Failure to empty
- Obstructive voiding symptoms
- Weak, slow and/or intermittent stream
- Post-void dribbling
- Urinary retention
Haematuria - must be carefully investigated.
Failure to empty
- 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
- 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
- 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
- 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
- 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
- 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 - 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
- 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
- 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