Lower Urinary Tract Symptoms PDF

Lower Urinary Tract Symptoms Dr Loghmari Ahmed Urology Department Sahloul Hospital ♦ Characteristics of Normal urination: Voluntary Easy Painless Exclusively diurnal Complete ♦ The normal bladder has two phases: - a storage pha...

Lower Urinary Tract Symptoms Dr Loghmari Ahmed Urology Department Sahloul Hospital ♦ Characteristics of Normal urination: Voluntary Easy Painless Exclusively diurnal Complete ♦ The normal bladder has two phases: - a storage phase - an emptying phase Its average capacity is 500ml. ♦ Lower Urinary Tract Symptoms are a very common problem. They’re more common in men than women. They are symptoms not diseases. ♦Benign prostatic hypoplasia is the most common cause of LUTS. Voiding Disorders: ♦ According to the ICS, the correct terminology used to classify voiding disorders is storage symptoms, voiding symptoms and post voiding symptoms. Storage symptoms: Storage symptoms occur when the bladder should otherwise be storing urine - Frequency : (daytime) describes the number of times you go to the toilet during waking hours. > 7 times - Nocturia : means getting up at night to pass urine. - Urgency : a sudden strong feeling which tells to ‘go now or you might leak urine’. - incontinence Voiding symptoms: Voiding symptoms occur usually due to bladder outlet obstruction making it more difficult to pass urine - Hesitancy or straining in micturition: difficulty in initiating micturition resulting in a delay in the onset of voiding - Poor flow / Weak Stream - Interruption of the urinary stream - Dysuria - Pushing urination - Terminal dribbling Voiding symptoms: - Incomplete bladder emptying feeling - Late urinary drops The clinical Examination of a patient presenting with LUTS: 1) Medical History: ♦ We take interest in nature of the LUTS , duration , comorbid condition, sexual history, fluid intake, surgery/trauma and medication. ♦ Calculate the IPSS: International Prostatic Symptoms Score IPSS: used to measure the severity of lower urinary tract symptoms. Validated, reproducible scoring system to assess disease severity and response to therapy. Made up of 7 questions related to voiding symptoms. A score of 0 to 7 indicates mild symptoms, 8 to 19 indicates moderate symptoms And 20 to 35 indicates severe symptoms.  2) Physical Examination: Abdominal examination to exclude a pelvic mess or palpable bladder. Digital rectal examination: essential ! Simple neurological examination Pelvic examination in women to assess - oestrogen status - the presence of pelvic organ prolapse. 3) Investigations: Laboratory test: Urine Analysis: to Exclude - Blood in the urine urinary tract - Infection àUrine culture. - Glucose in the urine. Blood : blood creatinine, Psa Imaging techniques: Ultrasound: Measuring and visualizing the bladder Measuring and Visualizing the prostate Retrograde urethrogram: A procedure allowing the urethra to be x-rayed using a contrast dye Urodynamics : The study of urinary tract pressure flow: - Urofolow metry: A recording of urinary flow rates over time - Cystometry: a continuous recording of bladder pressure during gradual filling and voiding Note: LUTS are not specific to any lower tract pathology. Conclusion: LUTS are a common condition. The assessment of LUTS should be methodical and extensive enough to provide the basis for managing the patient’s symptoms. We should start by taking the history of the patient and performing a physical examination. IPSS can be a helpful tool. Complementary investigations may be required to finalize the diagnosis. Pain in Urology: Pain arising from the genito urinary tract may be quite severe and is usually associated with: - Obstruction : Ureteric stone / urinary retention - Inflammation / infection - Tumor of the GU tract Renal pain: Renal colic: Acute renal colic is a severe form of sudden flank pain that typically originates over the costovertebral angle and extends anteriorly and inferiorly towards the groin or testicle. It is often caused by acute obstruction of the urinary tract by a calculus and is frequently associated with nausea and vomiting. Lower Back pain: is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica, and is defined as chronic when it persists for 12 weeks or more. Acute Scrotum pain: is defined as “the constellation of new-onset pain, swelling, and/or tenderness of the intrascrotal contents.” Clinical examination is essential to determine the causes which are variable: - Inspection of the scrotal skin, - Palpation and appreciation of the size of the testicles, seat, ascent consistency, mobility, relief of pain or not by lifting the testis, - Palpation of the epididymis and cord, rectal examination, examination must be obligatory bilateral and comparative, search for signs of accompaniment (fever,urethral discharge), - Examination of hernial orifices Bladder Pain Syndrome: Cystalgia ♦ Bladder pain syndrome has been adopted as a description of urinary tract symptoms that refer to: chronic (> 6 months) pelvic pain, pressure or discomfort that is perceived to be related to the urinary bladder and is accompanied by at least one other urinary symptom such as persistent urge to void or frequency. ♦ Evolution can be contained, paroxysmal relieved or not by urination Prostatodynia: It is mainly pain in the perineum (area between the anus and the genitals). Chronic pelvic pain may or may not be cyclical. ♦ In men, they manifest themselves in pain in the lower abdomen or in the genitals, during urination, defecation or during sexual intercourse and are often accentuated when sitting. The pain can radiate to the hypogastrium or the lumbar region. ♦ This pain is associated with sensations of burning of the urethra apart from urination, feelings of desire to urinate, irritation of the penis, digestive disorders, anxiety Hematuria Definition: Hematuria is defined as the presence of red blood cells in the urine. When visible to the naked eye, it is termed gross hematuria. When detected by the microscopic examination of the urinary sediment, it is termed microscopic hematuria Microscopic hematuria is defined as ≥ 10 red blood cells per mm3 / ≥ 103 per ml on a single specimen. The diagnosis of hematuria must always be confirmed by a quantitative urinary cytological examination There is no correlation between type of hematuria and severity of causal disease Differential diagnosis for hematuria: Neighborhood hemorrhage: urethrorrhagia, menstruation Drugs: rifampicin, metronidazole, vit B12, salazopyrine; food colouring: beets, blackberries; blood or biliary pigments: myoglobinuria, hemoglobinuria, bilirubinuria. Poisoning: lead, mercury The clinical assessment of a patient presenting with hematuria: 1) Medical History: Nature, duration, comorbid conditions Risk factors for malignancy in patients with hematuria : Older age Male gender History of cigarette smoking History of occupational chemical benzene or aromatic amines exposure History of cyclosphosphamide / ifosfamide chemotherapy  Pelvic radiation Irritative voiding symptoms ( urgency, frequency, dysuria) Family history of urothelial cancers 2) Physical Examination : - Hemodynamic state general exam - Urological exam - DRE 3) Investigations: - urianalysis - urine culture ♦ The chronology of haematuria has a localization value: (3 glasses test) the bladder is emptied by passing urine into a series of 3- ounce test tubes, and the contents of the first and the last are examined the first tube contains the washings from the anterior urethra the second, material from the bladder, and the last, material from the posterior urethra,prostate, and seminal vesicles The three-glass Test ➡️ 4) Urinary tract imagining: - Ultrasound - Cystoscopy:  CT Scan Etiologies of hematuria: The source of red blood cells in the urine can be from anywhere in the urinary tract between the kidney glomerulus and the urethral meatus. When considering the evaluation of hematuria, hematuria should be separated into glomerular or non-glomerular etiologies. Glomerular causes arise from the kidney itself. In general, glomerular hematuria is the purview of nephrologists Whereas urologists are concerned with structural and pathologic conditions that are visible on imaging and/or endoscopic examination. The presence of dysmorphic RBC, proteinuria, cellular casts, and/or renal insufficiency warrant concurrent nephrological and urologic evaluation. Conclusion: The source of RBC in the urine can be from anywhere in the urinary tract between the kidney glomerulus and the urethral meatus. Hematuria is categorized as either gross (visible to naked eye) or microscopic (diagnosed on microscopic urinalysis). A positive dipstick for hematuria requires confirmatory midstream microscopic urinalysis. The differential for hematuria is broad and includes glomerular and non-glomerular etiologies, the latter of which can be divided into upper and lower urinary tract origins. A through history and physical examination, which should include risk factors for urothelial carcinoma, are utilized for risk stratification. A complete urologic workup for hematuria includes cystoscopy and imaging of the upper urinary tract