A 60 year old teacher complains of incomplete emptying, hesitancy,…
A 60 year old teacher complains of incomplete emptying, hesitancy, straining, which affects him while he is at work.
Lower urinary tract symptoms (LUTS)
Weak stream, hesitancy, and incomplete emptying or straining. Usually due to enlargement of prostate gland.
Benign prostatic enlargement/hyperplasia (BPE/BPH)
Leads to bladder outlet obstruction
Progressive symptoms ranging from nocturia to acute urinary retention and may include incomplete emptying, urinary hesitancy, weak stream, frequency and urgency. Long-term or chronic BOO may eventually lead to bladder/detrusor decompensation (overactive)
Bladder neck stenosis
Occurs in men after prostate surgery, leading to a bladder neck contracture or scar tissue can form at the junction of the bladder outlet and the prostate. Could be due to gaps in anastomosis causing bleeds and scar tissue or due to poor blood supply to the anastomosis
Narrowing of the urethra caused by straddle injury, instrumentation, infection (gonorrhoea) and certain non-infectious forms of urethritis, prior hypospadias surgery, less common cause include congenital urethral strictures and malignancy
Splaying of urinary stream, frequency, urgency, straining, dysuria, UTIs, prostatitis, inability to empty bladder
Poor detrusor contractility
Frequency, urgency and nocturia. May be due to detrusor overactivity.
Urinary tract infection
UTIs are infection of any part of urinary system, mostly the lower urinary tract. Bladder (cystitis), urethra (urethritis) and kidney (pyelonephritis), rarely the ureters. More common in women than men due to anatomical differences: shorter urethra and proximity to anus.
Causes include sexual intercourse, diabetes, poor hygiene, urinary catheter, bowel incontinence, blocked flow of urine, pregnancy, menopause, suppressed immune system, immobility, heavy use of ABx
Symptoms include urgency, frequency, cloudy or bloody or strong smelling urine, dysuria, nausea & vomiting, muscle aches and suprapubic & low back pains, presence of fever
Small mineral deposits that can form in the bladder, usually when urine becomes very concentrated or one becomes dehydrated, allowing minerals such as calcium or magnesium salts to crystallise and form stones.
Can also result from bladder outlet obstruction as this causes urine stasis. Can present as severe lower abdominal and back pain, dysuria, nocturia, straining and haematuria. Pain may also be associated with nausea, vomiting and chills.
Most common type of bladder cancer and cancer of the ureter, urethra, and urachus. Second most common type of kidney cancer. Arises from transitional epithelium, a tissue lining inner surface of hollow organs
Drugs such as cyclophosphamide, radiation exposure and somatic mutation (over expression of RAS and EGFR)
Haematuria, suprapubic pain, bladder spasms with abnormal voiding, history of tobacco abuse, exposure to toxins
Overactive bladder (OAB)
Involuntary contraction of detrusor muscle
Symptoms overlap with those attributed to bladder outlet obstruction secondary to BPH. Tissue ischemia appears to have a role in BOO-induced detrusor overactivity.
Genitourinary system: Exclude palpable bladder, phimosis and meatal stenosis
Digital rectal exam (DRE): estimate prostate size and to exclude obvious abnormalities suggestive of malignancy
International Prostate Symptom Score (IPSS)
Provides validated method for assessment of symptoms and quality of life. Based on American Urological Association Symptom Index with additional "bother" question.
Use to stratify older men with LUTS. High bother scores warrant early referral for specialist care and those with lower IPSS or bother scores, in the absence of complicated features outlined, can be managed in primary care setting.
Transabdominal ultrasound if suspicion of hydronephrosis, bladder stones, or chronic urinary retention. Measurement of prostate size here is generally inaccurate.
Urine cytology if suspicion of urothelial carcinoma.
Prostate specific antigen (PSA) may be checked to assess risk of prostate cancer
Indications for early referral to urologist include haematuria, recurrent infections, bladder stones, urinary retention and renal impairment.
T2DM, causes nocturia and polyuria, and is a risk for BPH
Neurologic disease would suggest neurogenic bladder
FMHx of BPH and prostate cancer
Hx of urethral trauma, urethritis, or urethral instrumentation that could lead to urethral stricture
Tx with drugs that impair bladder function (anticholinergic drugs) or increase outflow resistance (sympathomimetic drugs)