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A 60 year old teacher comes in complaining of difficulty emptying his…
A 60 year old teacher comes in complaining of difficulty emptying his bladder (retention). He has had to wait before the urinary stream starts, and also to strain to keep the stream going (voiding). He sometimes has the sensation of incomplete emptying (voiding), and this has interfered with his work in the classroom.
Acute
Urinary infection picture: acute onset of dysuria (pain on pee) and storage symptoms (urgency, frequency), associated with pyuria (cloudy or foul-smelling urine) ± hematuria ± suprapubic pain.
UTI: may be lower (cystitis), in which patients are very well (at most mild fever), or upper (pyelonephritis), which can cause sepsis (fever, even hypotension), flank pain, and +ve renal punch.
Prostatitis: a febrile and ill pt with perineal pain or backache, and irritative urinary symptoms (dysuria, frequency, urgency). Unlike UTI, there is pain on ejaculation and a tender, boggy prostate on rectal exam, ± suprapubic tenderness.
Urethritis: dysuria + non-bloody urethral discharge may be a sign of STD (e.g. gonorrhoea, chlamydia). Inspect the genitals for discharge and STD lesions (ulcers, vesicles, crusting).
Epididymo-orchitis: another STD-associated dx but it tends to present as an acute testis rather than with dysuria. Palpate for tender testes, epididymitis, and spermatic cords.
Other infection: viral (adenoviral cystitis, herpes, mumps orhchitis) and parasitic (in developing countries, schistosoma hematobium).
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Chronic
Storage (urgency ± urge incontinence, frequency (but not ↑ urine volume, unlike polyuria), nocturia.
Urinary tract infection: ask abt dysuria (see approach to dysuria), but this may be absent
Overactive bladder (OAB), due to uncontrolled spontaneous contractions of the detrusor muscle during the filling phase. Pts complain of urgency, ± urge incontinence, small-volume frequent
voiding, and nocturia.
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Neurogenic: usually a UMN lesion causing ↓
cortical inhibition and a hyperexcitable micturition
reflex. Causes e.g. stroke, spinal trauma, cervical
myelopathy, Parkinson’s, multiple sclerosis. Check
past med hx and do neuro exam.
Irritation: by bladder cancer, calculi.
Voiding (hesitancy, slow stream, intermittancy, straining to void, terminal dribble. Strangury refers to dropwise expulsion of urine with straining, pain, and urgency. Postmicturition symptom include incomplete emptying and dribble.)
Neurogenic bladder: any past medical history of
neurological disease, lax anal tone, or abnormal
lower limb neurological examination.
Penile causes: e.g. phimosis, paraphimosis (in uncircumcised penis). This will be obvious on genitalia examination.
Benign prostatic hyperplasia (BPH): Rectal exam
should reveal a smooth enlarged non-tender prostate,
with a palpable median sulcus, and mobile rectal mucosa
over the prostate
Urethral stricture: a patient with previous urinary
instrumentation or sexually transmitted disease
(STD)
Drugs: anticholinergic side-effect (antihistamines,
antipsychotics, tricyclic antidepressants, hyoscine),
opoids, alpha agonists (e.g. pseudoephedrine). Take
a drug hx esp for recently started drugs.
Prostate or bladder neck cancer: The presence of any painless
hematuria, loss of weight, or suspicious rectal exam (hard, irregularly nodular prostate with loss of median sulcus and non-mobile overlying rectal mucosa) should prompt suspicion.