Urinary Symptoms

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Failure to empty BPH Prostate cancer Urethral strictures Hypotonic Bladder Detrusor Sphincter Incoordination

Failure to store Cystitis Interstitial Cystitis Prostatitis Bladder Cancer Stress Urinary Incontinence

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Lower urinary tract symptoms (LUTS) divided into those 

• Having trouble emptying their bladders and 
• Those having trouble storing urine in their bladders.

Patients unable to empty usually have obstructive voiding symptoms

• Hesitancy, straining, weak, slow and/or intermittent stream, post-void dribbling, and urinary retention.

Patients unable to properly store urine commonly present with irritative voiding symptoms

• Frequency, urgency, dysuria and nocturia. Some will also be incontinent of urine.

The presence of blood in the urine - hernaturia - must be carefully investigated.

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Failure to empty

BPH

• BPH is a nonmalignant 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 caliber 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 suprapubic 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 postvoid 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.

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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, hematuria 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.

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Urethral Strictures

• Are fibrotic narrowings (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.

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Hypotonic Bladder Detrusor muscle is too weak to empty. Often secondary to chronic obstruction. A hypotonic bladder may be able to hold a few liters 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 catheterization - CIC - in order to empty their bladders.

Detrusor Sphincter Incoordination Normally, the urethral sphincter must relax just as the detrusor muscle of the bladder contracts. Incoordination 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.

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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 bacteriuria, with occasional hematuria. 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 hematuria 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.
• Mircoscopic 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 fluroquinolone (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 hematuria.
• 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.
• Furter work up (eg cystoscopy) by urologist
• 85% of bladder tumors 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 LFT's.
  • Once the tumor 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.

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Content by Dr Íomhar O' Sullivan 05/07/2004.   Reviewed by Dr ÍOS 26/05/2006. Next review 26/05/2007.

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