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60yo male teacher complains of difficulty emptying bladder. Voiding…
60yo male teacher complains of difficulty emptying bladder. Voiding symptoms -
Hesitancy, weak stream, straining, incomplete emptying.
Chronic LUTS - Voiding Symptoms
(Hesitancy, Poor stream, Intermittent flow, Straining to void, Incomplete emptying, Terminal dribbling, Dysuria, Overflow incontinence
Poor detrusor contractility
Neurologenic
Hx:
Acute urinary retention (cauda equina syndrome & cord compression (back pain, sciatica; Hx of trauma, mets), stroke (relevant signs), chronic LUTS (Hx of neurological dz; DM, MS)
PE:
PMHx of neurological disease, lax anal tone, abnormal lower limb neurological examination.
Drugs-Induced
Anti-cholinergic (antihistamines, antipsychotics, TCAs, hyoscine), Opioids, Alpha agonists (e.g. pseudoephedrine)
BPH
Hx:
↑Urinary Freq, Urgency, Hesitancy, Incomplete bladder emptying, Straining, ↓Force of stream, Dribbling. Typically appear slowly & progress gradually over a period of years. May cause urinary retention. Risk factor: Type II DM, FHx of BPH.
PE:
DRE (Enlarged prostate that is symmetric & smooth, palpable median sulcus, mobile rectal mucosa over prostate).
Urethral Stricture
Hx:
↓Force of stream, Incomplete bladder emptying. Spraying of urinary stream. Dysuria (Painful urination). Recurrent UTI. Sexual dysfunction. Hx of prior instrumentation, injury, or infection (STI).
PE:
Enlarged bladder, Enlarged or tender lymph nodes in groin.
Bladder Neck Stenosis
(Prostate, Cancer,
Bladder Neck Cancer)
PE:
DRE (Enlarged prostate that is asymmetric/firm/nodular, loss of median sulcus, non-mobile overlying rectal mucosa). Inguinal lymphadenopathy.
Hx:
↑Urinary Freq, Urgency, Nocturia, Hesitancy. Weight loss. Painless Hematuria, Hematospermia
Risk factors: FHx of prostate cancer, >60yo, Smoking, Diet (↑Animal fat, ↓Vege)
Penile causes
Phimosis, Paraphimosis
PE:
Edema & tenderness of glans penis, painful swelling of retracted foreskin, constricting band of tissue at head of penis
Hx:
Hx of balanitis; DM, piercings, mishandled prepuce (e.g. urinary catheter)
Chronic LUTS - Storage Symptoms
Frequency, Nocturia, Urgency, Urgency incontinence
Urothelial carcinoma
Hx
: Painless hematuria, voiding, pain (advanced), FMHx
PE:
usually unremarkable, solid pelvic mass (advanced), induration/ fixation of prostate & bladder
Bladder Calculi/Stones
Hx:
usually storage Sx but acute urinary retention
possible. sudden termination of voiding. Hx of stones (hematuria, renal colic), referred pain (tip of penis, scrotum, back, hip)
PE:
suprapubic tenderness, fullness & palpable, distended bladder (acute urinary retention)
Overactive bladder
Frequent urge to urinate with possible incontinence & nocturia.
Infections
UTI
Acute onset. Dysuria. Storage Symptoms with pyuria (Cloudy/Foul-smelling urine). May have hematuria, Suprapubic/Low back pain
Lower - Cystitis (Mild fever)
Upper - Pyelonephritis (Fever, Hypotension, Flank pain, Positive renal punch)
Prostatitis
Fever, Perineal pain or backache. Irritative urinary symptoms (dysuria, frequency, urgency). Unlike UTI, there is pain on ejaculation and a tender, enlarged prostate on rectal exam, ± suprapubic tenderness.
Urethritis
Dysuria + non-bloody urethral discharge
may be a sign of STD (e.g. gonorrhoea, chlamydia). Inspect genitals for discharge and STD lesions (ulcers, vesicles, crusting).
Hydronephrosis
Hx:
Pain (usu. Acute - Upper ureteral/renal pelvic lesions: Flank; Lower ureteral:Radiate to ipsilateral testicle/labia). Change in urine output, Hematuria.
PE:
Percussion (Enlarged bladder). Distended lower abdomen. Might have HTN, Abdominal mass.