Urinary Symptoms



Failure to empty

Clinical

  • Obstructive voiding symptoms
    • Hesitancy
    • Straining
    • Weak, slow and/or intermittent stream
    • Post-void dribbling
    • Urinary retention

Failure to store

Clinical

  • Irritative voiding symptoms
    • Frequency
    • Urgency
    • Dysuria
    • Nocturia
    • Some will also be incontinent of urine

Haematuria - must be carefully investigated.


Failure to empty

BPH

  • BPH is a non-malignant growth of the prostate that occurs with age
  • It is not a precursor of prostate cancer
  • Cause of the enlargement is unknown (hormonal changes that occur with aging are thought to be involved)
  • First symptoms usually appear in 50's or 60's and are often progressive in nature.
    • Decreased force and calibre of their urinary stream
    • Difficulty starting their stream and may have to strain in order to empty their bladders
    • Flow may stop and start and they may dribble after they have finished voiding
    • Urge to void only minutes after they leave the washroom
    • If complete obstruction they present to the Emergency Department with severe supra pubic pain
    • Often also complain of irritative voiding symptoms in addition to the obstructive ones
  • Rectal exam usually reveals a symmetrically enlarged smooth prostate
  • If the prostate is hard and asymmetrical or if nodules are felt then malignancy must be considered
  • Check for a palpable / percussable bladder
  • Determination of the post void residual (ultrasound or catheter) is helpful. Any volume greater than 100 cc is significant
  • Alpha blockers such as Terazosin have been shown to be effective in some.
    • A 5-aplha reductase inhibitor (blocking the production of DHT) can shrink the prostate and relieve symptoms
  • Surgery (TURP) is the standard treatment

Prostate Cancer

  • Adenocarcinoma of the prostate has become the most common cancer in men. 
  • It is uncommon in men younger than 50 years of age
  • The cause is unknown
  • Most men with prostate cancer are asymptomatic but they can present with local or metastatic signs and symptoms.
    • Local symptoms include obstructive voiding, haematuria and perineal pain. 
    • Metastatic symptoms include bone pain, fatigue, weight loss and malaise. 
    • On physical exam one typically feels a hard discrete nodule on the prostate
  • PSA is a serum marker for prostate cancer however its specificity is poor (also raised in BPH and prostatitis )
    • A value under 4.0 makes prostate cancer unlikely while a value over 10.0 makes one quite suspicious
  • A transrectal ultrasound of the prostate - a TRUSP - can be booked through a urologist
  • Once Dx is confirmed pathologically, the extent of the disease must be ascertained.
    • Chest X-ray and bone scan will detect distant metastases
  • If tumour confined to the prostate then the patient is offered watchful waiting, radical prostatectomy, radical radiotherapy or brachytherapy (based on cancer and patient characteristics). 
  • If extended outside the prostate removing the prostate will be of no benefit, radiotherapy is an option
  • If distant spread - hormone therapy i(elimination of androgens)s needed

Urethral Strictures

  • Are fibrotic narrowing (scar tissue) within the urethra
  • Much more common in men than in women. Most are due to trauma or infection. 
  • Today most strictures are iatrogenic
  • Patients usually have a history of urethral instrumentation or STD's
  • Symptoms of progressively weakening stream with hesitancy, straining at urination, and post void dribbling It is not uncommon for them to develop a prostatitis
  • If the stricture is not too severe it can be manually dilated with male sounds (tapered metal rods). 
  • Restenosis is common

Hypotonic Bladder

  • Detrusor muscle is too weak to empty
  • Often secondary to chronic obstruction
  • A hypotonic bladder may be able to hold a few litres of urine without causing much discomfort
  • Often older men with a long-standing history of untreated BPH
  • If obstructions are treated, detrusor muscles may regain some contractility
  • Unfortunately, many of these patients require clean intermittent catheterisation - CIC - in order to empty their bladders

Detrusor Sphincter In-coordination

Normally, the urethral sphincter must relax just as the detrusor muscle of the bladder contracts. In-coordination occurs in patients who for one reason or another are not able to relax their sphincter at the appropriate time. 

  • These patients complain of painful voiding with stop and go stream. 
  • They may also may the subjective feeling of being unable to completely empty their bladders
  • The diagnosis is made with urodynamics

Failure to store

Cystitis

  • Acute cystitis is an infection of the bladder
  • Coliform bacteria including E. coli are the commonest cause (Staph saprophyticus and enterocci less common)
  • Patients typically present with irritative voiding symptoms.
    • Frequency, dysuria, urgency, nocturia
  • Fever is rare. There are usually no specific physical findings
  • Microscopy reveals pyuria and bacteruria, with occasional haematuria The WBC is usually normal
  • Urine should be sent for culture and sensitivity
  • Patients with a typical history should be started on antibiotics empirically.
    • Nitrofuratoin, TMP-SMX or fluoroquinolones (Cipro, Noroxin). Treatment should be at least 3 days
  • Follow up cultures are not necessary unless symptoms persist or recur or the patient is pregnant

Interstitial Cystitis

  • Interstitial cystitis - I.C. - is a term used to describe a chronically painful and irritated bladder. 
  • Almost exclusive women (average age of 43 years)
  • Classic irritative voiding symptoms associated with cystitis.
    • Also suprapubic pain or pressure that gets worse as the bladder fills and is relieved when the bladder is emptied
    • Dyspareunia is quite common
    • They usually have been treated with several courses of antibiotics with no significant improvement in their symptoms
  • The only physical finding may be some suprapubic tenderness
  • Urinalysis reveals microscopic haematuria in 20 - 30% but urine cultures are negative
  • A trial of antibiotics is worthwhile. If the patient does not respond then a referral to a urologist is appropriate
  • The diagnosis is based on the exclusion of other irritative bladder diseases, including carcinoma in situ. 
  • On cystoscopy the bladder is usually of low capacity (350 cc or less) with significant pain on filling
  • There is no standard therapy but a popular regimen involves intravesical instillation of DMSO and heparin on a weekly basis. DMSO acts as an analgesic, anti-inflammatory and muscle relaxant. Heparin is believed to act as an exogenous glycosaminoglycan (GAG) layer to help protect the bladder mucosa. 
  • Other oral treatment options include Elmiron, and anti-histamines

Prostatitis

  • Acute bacterial prostatitis is an infection of the prostate (usually urinary pathogens, most commonly E. coli)
  • Typically presents with an acute febrile illness with chills with low back and perineal pain. 
  • Secondary cystitis and or bladder outlet obstruction and urinary retention
  • On physical exam the prostate is warm, swollen, boggy and exquisitely tender. 
  • FBC shows an elevated white count
  • Microscopic examination of the urine demonstrates a significant number of WBC and bacteria
  • Treat ABCs - particularly if patient ill and toxic ± IV antibiotics
  • Urine should be sent for culture and sensitivity and the patient started on antibiotics empirically. 
  • A six week course of a fluoroquinolone (Ofloxacin 400 mg po bid or Ciprofloxacin 500 mg po bid) is recommended

Bladder Cancer

  • Most commonly, is a transitional cell carcinoma - TCC
  • Second most common genitourinary malignancy
  • Cigarette smoking responsible 50% of cases, exposure to industrial chemicals account for another 25%
  • Almost all patients are over the age of 40 with the average age being 65
  • M:F = 2:1
  • Most present with irritative voiding symptoms and/or haematuria
  • Usually nothing specific to find on physical exam. 
  • Urinalysis with culture should be done to rule out infection. 
    • Malignant cells can sometimes be picked up with urine cytology. 
  • Upper tract imaging (ultrasound or IVP) is also helpful as it will rule out the kidneys and ureters as a source of bleeding and disease
  • Further work up (e.g. cystoscopy) by urologist
  • 85% of bladder tumours are superficial and can be completely resected transurethrally.
    • But up to 80% recurrence rate with a 30% rate of increased invasiveness with recurrences
    • If multiple recurrences or if carcinoma in situ is reported intravesical BCG is recommended
  • For more invasive cases - radical cystectomy
    • Metastatic work-up includes a CXR, bone scan, CT scan of the abdomen and pelvis, and LFTs
    • Once the tumour is outside the bladder, chemotherapy is the only option
    • Radiotherapy can be given but this is usually only for relief of bladder symptoms in palliative patients

Stress Urinary Incontinence

  • Occurs with increased intra-abdominal pressure is referred to as stress urinary incontinence - SUI
  • Because of pelvic floor weakness the position of the bladder neck and proximal urethra in SUI patients is poorly supported
  • The physical exam should include a pelvic. 
  • The position and hypermobility of the bladder neck can be verified. 
  • The diagnosis can usually be-made from the history and physical exam alone but urinalysis and urine culture should also be done to rule out other causes. 
  • Urodynamics may be helpful
  • Treatment may be difficult. 
    • Some have found pelvic floor - Kegel's - exercises useful
    • Bladder drill - can also help
    • Weight loss can be a significant factor in treatment
    • Success rates for suspension surgery vary with the surgeon's experience with the procedure

Content by Dr Íomhar O' Sullivan 05/07/2004. Reviewed by Dr ÍOS 26/05/2006, 07/09/2007. Last review Dr IOS 13/12/21.