Urinary bypass – this is when you have a catheter and OAB – the strength of contraction of the detrusor muscle is so strong that urine sprays past the catheter and can even spit out the catheter, balloon and all. Treatment options include botox.
TURP. Very common procedure for BPH. Involves removal of the adenomatous portion of the prostate. Complications are acute and late.
Acute complications are:
Failure to void
Urinary retention due to clots
TURP syndrome – occurs in 2% of patients. During TURP, about 900ml of fluid is used for irrigation, and this is absorbed into the extra/intravascular space through open venous sinuses in the prostatic capsule. This fluid is electrolyte-free. Usually the absorption is well tolerated, but occasionally patients can develop TURP syndrome – a hyponatraemic, hypochloraemic metabolic acidosis.
Local – work from top of system down. GN, RCC, pyelonephritis… stone…bladder tumour, UTI…
What investigations to do?
UA + microscopy (red cells, white cells, casts, crystals, bacteria), Bloods (FBC, U+E, coag), image proximal renal tract (renal US, +/- IVP) and distal tract (flexible cystoscopy)
RFs for UTI:
urinary tract obstruction
instrumentation of the urinary tract – eg catheter
UTI’s can be caused by an ascending infection (e.coli), or by haematogenous spread (IV drug users, TB, infective endocarditis)
RFs for pyelonephritis:
obstruction – congenital (PUJ obstruction) or acquired (stricture, stone)
anatomical – short urethra in females
Haematogenous spread from skin or GIT
Most common organism involved in acute pyelonephritis? – e.coli. Proteus mirabilis and Klebsiella also cause pyelonephritis. These are urease-splitting organisms that create an alkaline urine secondary to the release of ammonia, and this allows the precipitation of struvate stones in the renal pelvis and calyces.
Chronic pyelonephritis results in parenchymal scarring of the kidney. It is often the consequence of reflux and infections in childhood. Adults typically present with azotemia or hypertension. Do renal US, IVP. If a single kidney only is involved, the contralateral kidney will often show compensatory hypertrophy.
Acute bacterial prostatitis
Features include pyrexia, rigors, low back pain, perineal discomfort, dysuria, urinary frequency, urgency. Causes are e.coli in 80% of cases, other common causes are pseudomonas and enterococcus. O/E, prostate will be tender, swollen, warm and firm. Often accompanied by acute cystitis.
Chronic bacterial prostatitis is the most common cause of relapsing urinary tract infection in men. May be asymptomatic, or varying degrees of irritative urinary symptoms.
Symptoms of lower urinary tract obstruction:
weak stream – hows the flow?
Hesitancy do you ever have trouble starting the flow?
Intermittency ever have to start and stop?
Dribbling – any dribbling afterwards?
straining to void – ever have to strain a lot?
Frequency – how often do you go?
Nocturia – ever have to get up at night? How many times?
Dysuria – any burning or stinging or passing water?
urge incontinence – do you ever not make it to the loo?
DDx of lower urinary tract obstruction:
The problem can be structural or functional. Working from the top down…