Luts, retention, anuria


Published on

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Luts, retention, anuria

  2. 2. Learning Objectives <ul><li>To understand the definitions & </li></ul><ul><li>Know causes of </li></ul><ul><li>Be able to take elaborate history </li></ul><ul><li>And conduct a relevant clinical exam </li></ul><ul><li>Be able to suggest relevant investigations </li></ul>
  3. 3. LUTS - OBSTRUCTIVE <ul><li>Static Obstruction (Mass related Increase in Urethral resistance). </li></ul><ul><ul><li>Poor flow / thin stream </li></ul></ul><ul><ul><li>Hesitancy </li></ul></ul><ul><ul><li>Intermittency of stream </li></ul></ul><ul><ul><li>Sense of incomplete evacuation of bladder </li></ul></ul><ul><ul><li>Terminal dribbling </li></ul></ul><ul><ul><li>Retention of urine Acute / chronic </li></ul></ul>
  4. 4. LUTS - I RRITATIVE <ul><li>Dynamic Obstruction (Increased adrenergic tone in prostate) </li></ul><ul><ul><li>Urgency </li></ul></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Day time / Night time (nocturia) </li></ul></ul><ul><ul><li>Urge incontinence </li></ul></ul>
  5. 5. Dysurea <ul><li>Pain associated with act of micturation </li></ul><ul><ul><li>Burninng, scalding </li></ul></ul>
  6. 6. Causes of Frequency – Dysuria <ul><li>Infections & inflammations </li></ul><ul><ul><li>nonspecific - Acute Cystitis, urethritis, prostatitis </li></ul></ul><ul><ul><li>specific - TB, schistosomiasis, Intersitial cystitis Abacterial cystitis /urethritis ( mycoplasma, herpes, chemical) Cystitis cystca and Alkaline encrustin cystitis </li></ul></ul><ul><li>BOO +/- sec. infection </li></ul><ul><ul><li>Phemosis / fused synichae, Ext. meatal stenosis </li></ul></ul><ul><ul><li>Urethral Stone / foreign body impaction, Enlarged prostate--------- benign / malignant / inflammatory/abscess </li></ul></ul><ul><ul><li>bladder neck stenosis, Post urethral,valve Urethral stricture </li></ul></ul><ul><ul><li>neoplasm of bladder, urethra, prostate and penis </li></ul></ul><ul><ul><li>vesical calculus, foreign body </li></ul></ul><ul><li>Neurogenic </li></ul><ul><li>Detrusor sphincter dyssynergia , </li></ul><ul><li>neurogenic bladder ,spine trauma, multiple seclerosis.DM </li></ul><ul><li>Stones , vesical , urethral, ureteric </li></ul><ul><li>Inncomplete bladder evacuation </li></ul><ul><ul><li>VUR, and vesical diverticulum </li></ul></ul><ul><ul><li>Cystocele / UV prolapse </li></ul></ul><ul><ul><li>decompensation of bladder / bladder atonia </li></ul></ul><ul><ul><li>BOO </li></ul></ul><ul><li>Malignancy </li></ul><ul><ul><li>CIS UB, bladder & prostatic CA </li></ul></ul><ul><li>Miscellaneous </li></ul><ul><ul><li>Drugs . Anticholinergic, </li></ul></ul><ul><ul><li>frequency – dysuria syndrome </li></ul></ul><ul><ul><li>Atrophic urethritis (senile) </li></ul></ul><ul><ul><li>Distal urethral syndrome </li></ul></ul><ul><ul><li>Pregnancy, diabetes, LVF, CCF, diuretics, polyuria </li></ul></ul>
  7. 7. Inability to Pass Urine <ul><li>Retention of Urine </li></ul><ul><ul><ul><li>When patient, despite an urge to void, is unable to push urine out of bladder due to either infravesical obstruction or inability to generate effective detrusor contractions. Correct catheterization yields urine relieving symptoms. </li></ul></ul></ul><ul><li>Anuria </li></ul><ul><ul><ul><li>A condition when either urine is not being produced ( pre-renal & renal) or is not reaching urinary bladder (post-renal / obstructive). No urge to void. No urine in bladder on USG, Even on correct catheterization, no urine is drained.. </li></ul></ul></ul><ul><ul><ul><li><100 cc urine / 24hrs </li></ul></ul></ul><ul><li>Extravasion </li></ul><ul><ul><ul><li>Leakage of urine into tissues / body cavity (peritoneum </li></ul></ul></ul><ul><ul><ul><ul><li>Bladder rupture / perforation </li></ul></ul></ul></ul>
  8. 8. <ul><li>Oligurea </li></ul><ul><ul><li><300 ml urine / 24 hrs </li></ul></ul><ul><li>Renal failure </li></ul><ul><ul><li>When kidneys no longer able to maintain renal functions </li></ul></ul><ul><ul><li>Acute: sudden, potentiality reversible </li></ul></ul><ul><ul><li>Sudden rise of S creatinine by 1 </li></ul></ul><ul><ul><li>Chronic: insidious, progressive. nonreversible </li></ul></ul>
  9. 9. Types of Retention <ul><li>Acute Retention </li></ul><ul><ul><li>Agonizing painful condition with intense urge </li></ul></ul><ul><ul><li>Well defined palpable & tender bladder </li></ul></ul><ul><li>Chronic Retention </li></ul><ul><ul><li>Painless condition of incomplete bladder evacuation / high residual urine, (>250cc) </li></ul></ul><ul><ul><li>Bladder percussible but not well palpable/tender </li></ul></ul>
  10. 10. Causes of retention - boys <ul><li>Phemosis </li></ul><ul><li>Scab – meatal ulcer </li></ul><ul><li>External meatal stenosis </li></ul><ul><li>Urethritis </li></ul><ul><li>Urethral stricture </li></ul><ul><li>Urethral trauma </li></ul><ul><li>Post. & ant. Urethral valves </li></ul><ul><li>Vesical / urethral calculus </li></ul><ul><li>Blader neck stenosis </li></ul><ul><li>Neurogenic bladder </li></ul><ul><li>Constipation </li></ul><ul><li>Drugs </li></ul>
  11. 11. Causes of retention - girls <ul><li>Synechia vulvae Urethritis </li></ul><ul><ul><li>uncommon </li></ul></ul><ul><li>Urethral stricture / trauma </li></ul><ul><li>Vesical / urethral calculus </li></ul><ul><li>Blader neck stenosis </li></ul><ul><li>Neurogenic bladder </li></ul><ul><li>Constipation Drugs </li></ul>
  12. 12. Causes of retention – young males <ul><li>Meatal ulcer / stenosis </li></ul><ul><li>Urethral stricture / stone / abscess / trauma </li></ul><ul><li>Bladder stone </li></ul><ul><li>Drugs / anesthesia </li></ul><ul><li>Spinal shock / neurogenic bladder / DSD </li></ul><ul><li>Prostatitis / prostatic abscess </li></ul><ul><li>utrethritis </li></ul><ul><li># penis </li></ul><ul><li>Para phemosis / phemosis </li></ul>
  13. 13. Causes of retention – young females <ul><li>Hysterical conversion reaction </li></ul><ul><li>Drugs /anesthesia </li></ul><ul><li>Pain ( parturition, epi-, vaginal surgery) </li></ul><ul><li>Retroverted gravid uterus </li></ul><ul><li>MS </li></ul><ul><li>Cystocele / bladder stone </li></ul><ul><li>Neurogenic bladder </li></ul>
  14. 14. Causes of retention – elderly males <ul><li>BPH, CaP, abscess </li></ul><ul><li>Stone, Ca UB, clot retention </li></ul><ul><li>Stricture/stone/abscess /rupture –urethra </li></ul><ul><li>Meatal stenosis, Phemosis, para-phemosis </li></ul><ul><li>Drugs / anesthesia, </li></ul><ul><li>Disc prolapse / cauda equina syndrome </li></ul><ul><li>spinal shock , neurogenic bladder </li></ul><ul><li>Ca penis </li></ul><ul><li>Bladder neck stenosis / hypertrophy </li></ul><ul><li>Diabetic sensory neuropathy </li></ul><ul><li>Pelvic surgery, anal fissure, hemorrhoids </li></ul><ul><li>Obstructed hernia </li></ul>
  15. 15. Causes of retention – elderly females <ul><li>Atrophic urethritis </li></ul><ul><li>Meatal stenosis </li></ul><ul><li>Ca UB, clot retention </li></ul><ul><li>Neurogenic blader, </li></ul><ul><li>Carancle </li></ul><ul><li>Stricture / stone/rupture –urethra </li></ul><ul><li>Cystocele/ prolapse </li></ul><ul><li>Drugs / anesthesia, </li></ul><ul><li>Disc prolapse / cauda equina syndrome </li></ul><ul><li>spinal shock </li></ul><ul><li>Bladder neck stenosis / hypertrophy </li></ul><ul><li>Diabetic sensory neuropathy </li></ul><ul><li>Pelvic surgery, anal fissure, hemorrhoids </li></ul><ul><li>Obstructed hernia </li></ul><ul><li>Urethral diverticulum </li></ul>
  16. 16. Work up
  17. 17. ASSESSMENT - Essential information from patient <ul><li>LUTS (including QoL Score) </li></ul><ul><li>Other Urinary symptoms (eg hematuria) </li></ul><ul><li>Previous pelvic surgery (eg Ant Resection) </li></ul><ul><li>Neuropathy (eg Parkinsonis, MS,CVA) </li></ul><ul><li>Cardiac Problems </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Fluid Intake & out put chart. </li></ul>
  18. 18. History <ul><li>Duration of retention </li></ul><ul><li>Painfull? </li></ul><ul><li>Precipitating factors </li></ul><ul><li>Preceding LUTS </li></ul><ul><li>Other urinary complaints </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Stage of disease </li></ul><ul><li>Medical illnesses - co-morbidity </li></ul>
  19. 19. History <ul><li>Catheterization </li></ul><ul><ul><li>Easy </li></ul></ul><ul><ul><li>Caliber </li></ul></ul><ul><ul><li>Urine quantity / color </li></ul></ul><ul><ul><li>Where / by whom </li></ul></ul><ul><ul><li>TWOC </li></ul></ul>
  20. 20. <ul><li>EVALUATION </li></ul><ul><ul><li>BPH symptom scoring </li></ul></ul><ul><ul><ul><li>AUA scoring (scoring chart) </li></ul></ul></ul>
  21. 21. AUA SOURCE Urinary Symptoms (Symptom Score Criteria) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost Always 1. Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0 1 2 3 4 5 2. Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5 3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinate? 0 1 2 3 4 5 4. Urgency Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5
  22. 22. AUA SCORE Urinary Symptoms (Symptom Score Criteria) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost Always 5. Weak Stream Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5 6. Straining Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5 None 1 time 2 times 3 times 4 times 5 or more times 7. Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got in the morning? 0 1 2 3 4 5
  23. 23. AUA Symptom Score QUALITY OF LIFE DUE TO URINARY PROBLEMS Delighted Pleased Mostly Satisfied Mixed-about equally satisfied and un-satisfied Mostly dis-satisfied Unhappy Terrible If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0 1 2 3 4 5 6
  25. 25. Examination <ul><li>Meatus </li></ul><ul><li>Urethra </li></ul><ul><li>Bladder Ac / Ch </li></ul><ul><li>DRE </li></ul><ul><li>Hernia </li></ul><ul><li>Neurological ex </li></ul><ul><ul><ul><li>Higer mental functions </li></ul></ul></ul><ul><ul><ul><li>Cranial nerves </li></ul></ul></ul><ul><ul><ul><li>Lower limb </li></ul></ul></ul><ul><ul><ul><li>perineum - sensations </li></ul></ul></ul>
  26. 26. ASSESSMENT Lab & Other tests <ul><li>URINALYSIS / CS </li></ul><ul><li>CBE </li></ul><ul><li>BLOOD UREA & SERUM CREATININE </li></ul><ul><li>U.S.G. RENAL TRACT (POST VOID URINE) </li></ul><ul><li>CXR, ECG, RBS. </li></ul>
  27. 27. <ul><ul><ul><li>PSA </li></ul></ul></ul><ul><ul><ul><li>? Role of IVU </li></ul></ul></ul><ul><ul><ul><li>? Role of Urodynamics UROFLOWMETRY,PRESSURE FLOW STUDIES. </li></ul></ul></ul>
  28. 28. Investigations <ul><li>Cystoscopy </li></ul>
  29. 29. Retention Treatment <ul><li>Urethral catheterization </li></ul><ul><ul><li>Technique </li></ul></ul><ul><ul><ul><li>Explain / consent ( need / discomfort) </li></ul></ul></ul><ul><ul><ul><li>Keep Items ready </li></ul></ul></ul><ul><ul><ul><li>Theatre / dressing room / bed </li></ul></ul></ul><ul><ul><ul><li>Supine posture legs separated </li></ul></ul></ul><ul><ul><ul><li>Female – knee bent & separated, feet together </li></ul></ul></ul><ul><ul><ul><li>Gloves </li></ul></ul></ul>
  30. 30. Urethral catheterization Technique <ul><ul><ul><li>Cleaning = aniseptics </li></ul></ul></ul><ul><ul><ul><li>Females – separate labia – clean from before backwards, hold till cath complete </li></ul></ul></ul><ul><ul><ul><li>Prepuse – retract & clean </li></ul></ul></ul><ul><ul><ul><li>Drape </li></ul></ul></ul><ul><ul><ul><li>instill gel – hold 2 min / clamp </li></ul></ul></ul><ul><ul><ul><li>Hold penis with non-dominent hand glans towards head end == Curve “S” ---  “U” </li></ul></ul></ul><ul><ul><ul><li>Use dominant hand for cath </li></ul></ul></ul><ul><ul><ul><li>Gently push cath - non touch technique </li></ul></ul></ul><ul><ul><ul><li>Deep / slow breathing </li></ul></ul></ul>
  31. 31. Urethral catheterization Technique <ul><li>Relax ---------- valium </li></ul><ul><li>Push whole length in – till bifercation </li></ul><ul><li>Don’t inflate till clear urine drained </li></ul><ul><ul><li>gel, misplaced, anuria, extravasion </li></ul></ul><ul><ul><li>Inflate while full length inside / pull afterwards </li></ul></ul><ul><ul><li>Use water = not saline </li></ul></ul><ul><ul><li>Don’t inflate = blood, not sure of position </li></ul></ul><ul><li>Note color amount of urine </li></ul><ul><li>C/S </li></ul><ul><li>Post cath heamaturia - slow/ intermitant / high </li></ul>
  32. 32. Urethral catheterization Technique <ul><li>Resistance -- look for help </li></ul><ul><ul><li>refer </li></ul></ul><ul><ul><li>Suprapubic puncture abscess </li></ul></ul><ul><ul><li>Marryfield introducer </li></ul></ul><ul><ul><li>coude tip cath </li></ul></ul><ul><ul><li>trocar cath == ingram / bard </li></ul></ul><ul><ul><li>Open s/p </li></ul></ul><ul><ul><li>urethral instrumentation = bougies / optical </li></ul></ul><ul><li>Retract prepuse back </li></ul><ul><li>Documentation of procedure </li></ul><ul><li>Exam abdomen </li></ul>
  33. 33. <ul><li>Closed drainage system </li></ul><ul><li>Antibiotecs </li></ul><ul><li>Size of cath </li></ul><ul><li>Leakage blocked / spasm </li></ul>
  34. 34. Chronic Retention <ul><li>High residual volume urine , >250cc </li></ul><ul><li>Longstanding, painless, not precisely palpable, dull to percussion </li></ul><ul><li>High / low pressure ch. Retention </li></ul><ul><li>Upper tract dilatation / deterioration </li></ul><ul><li>Causes </li></ul><ul><ul><li>Long standing BOO </li></ul></ul><ul><ul><li>LMNL </li></ul></ul>
  35. 35. Chronic Retention <ul><li>Treatment </li></ul><ul><ul><li>INTERNAL CATHETERIZATION </li></ul></ul><ul><ul><li>NOT EXTERNAL CATH </li></ul></ul><ul><ul><li>CATH IS NOT A RISK FOR INFECTION, IT RATHER CURES INFECTION </li></ul></ul><ul><ul><li>CURE OF PYO-CYSTITIS IS DAINAGE LIKE I/D FOR ABSCESS </li></ul></ul>
  36. 36. Chronic Retention <ul><li>Complications </li></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><ul><li>slow decompression </li></ul></ul></ul><ul><ul><ul><ul><li>clamp / non-gravity dependant / elevate </li></ul></ul></ul></ul><ul><ul><li>Crit >200 mmole = post obst diuresis </li></ul></ul><ul><ul><ul><li>Concentration ability </li></ul></ul></ul><ul><ul><ul><li>Fluid overload / backlog </li></ul></ul></ul><ul><ul><ul><li>Osmotic diuresis </li></ul></ul></ul><ul><ul><li>Dehydration / ellectrolyte disturbances </li></ul></ul><ul><ul><ul><li>Replacement of fluid / Na </li></ul></ul></ul><ul><ul><ul><ul><li>ml to ml replacement on hourly basis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Later -- one litre less then prvious days output </li></ul></ul></ul></ul><ul><ul><ul><ul><li>oral / intravenous saline. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Potassium only if low ---- renal failure </li></ul></ul></ul></ul><ul><li>Infection </li></ul>
  37. 37. RETENTION WITH OVERFLOW / PARADOXICAL INCONTENANCE <ul><li>Incontinence associated with a full bladder </li></ul><ul><li>Almost same as ch. retention </li></ul>
  38. 38. RENAL FAILURE <ul><li>PRE-RENAL (hypotention) </li></ul><ul><ul><li>Hypovolumia, hemmorhage,sepsis, cardiogenic shock, aneasthesia, hypoxiaa </li></ul></ul><ul><li>RENAL </li></ul><ul><ul><li>Drugs, poisons, contrast media, eclampsia, myoglobinuria, incompatible blood transfusion, DIC </li></ul></ul><ul><li>POST RENAL </li></ul>
  39. 39. Causes of post renal anuria <ul><li>Bilateral PUJ obstruction by stone </li></ul><ul><li>Unilateral PUJ obstruction by stone with contralateral ureteric obstruction </li></ul><ul><li>BILATERAL Ureteric Obstruction </li></ul><ul><ul><li>Extramural </li></ul></ul><ul><ul><ul><ul><li>Tumors of cervix, ovary, uterous, vagina, urinary bladder, prostate, rectum, colon, caecum & lymphomas </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Idiopathic retroperitoneal fibrosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Retrocaval ureter </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pararenal cysts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Aberent vessels </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LIGATURES </li></ul></ul></ul></ul><ul><ul><li>Intraluminal </li></ul></ul><ul><ul><ul><ul><li>Calculus, sloughed papilla, clot, ureteric malignancy, CRYSTALURIA </li></ul></ul></ul></ul><ul><ul><li>Intramural </li></ul></ul><ul><ul><ul><li>Congenital PUJ obstruction or stenosis </li></ul></ul></ul><ul><ul><ul><li>Ureterocele and congenital small ureteric orifice </li></ul></ul></ul><ul><ul><ul><li>Strictures ( stone, repair, tuberculosis, schistosomiasis) </li></ul></ul></ul><ul><ul><ul><li>Ureteric / vecsical malignanncy </li></ul></ul></ul><ul><ul><ul><li>Kenks & adhesions ( sec to VUR) </li></ul></ul></ul><ul><li>Unilateral PUJ or ureteric obstruction in case of </li></ul><ul><ul><li>Contralateral nephrectomy </li></ul></ul><ul><ul><li>Already obstructed or nonfunctional </li></ul></ul><ul><ul><li>Congenitally absent </li></ul></ul>
  40. 40. History taking <ul><li>Urge to void </li></ul><ul><li>Duration </li></ul><ul><li>Pain, hemaaturia, stone passage </li></ul><ul><li>Symptoms of uremia </li></ul><ul><li>Any precipitating event </li></ul>
  41. 41. Clinical exam <ul><li>Bladder not palpable </li></ul><ul><li>Confirmed by cath </li></ul><ul><li>Signs of uremia </li></ul>
  42. 42. Workup <ul><li>Urine usually not available for testing </li></ul><ul><ul><li>If ==urine osmolality, Na </li></ul></ul><ul><li>Urea, critinine </li></ul><ul><li>Serum ellectrolite </li></ul><ul><li>Arterial Blood gases </li></ul><ul><li>Hb </li></ul><ul><li>Xray and ultrasound KUB </li></ul><ul><li>IUV usually contraindicated </li></ul><ul><li>Retrograde Urography </li></ul><ul><li>CT scan (contrast ???????) </li></ul><ul><li>RENAL SCAN </li></ul>
  43. 43. Management <ul><li>SUPPORTIVE </li></ul><ul><ul><li>Renal support - dialysis </li></ul></ul><ul><ul><li>Infection control </li></ul></ul><ul><ul><li>Nutritional support </li></ul></ul><ul><ul><li>Nursinng care </li></ul></ul><ul><ul><li>Fluid balance </li></ul></ul><ul><li>BYPASS PROCEDURES </li></ul><ul><ul><li>Ureteric catheterization / stenting </li></ul></ul><ul><ul><li>Nephrostomy </li></ul></ul><ul><ul><ul><li>PCN – percutaneous nephrostomy </li></ul></ul></ul><ul><ul><ul><li>Open </li></ul></ul></ul><ul><li>DEFINATIVE PROCEDURESSS </li></ul>
  44. 44. Dialysis <ul><li>Diffusion across semipermiable memb </li></ul><ul><li>Dialyysis fluids </li></ul><ul><li>Peritonneal </li></ul><ul><li>Hemodialysis </li></ul><ul><li>Indications </li></ul><ul><ul><li>A acidosis </li></ul></ul><ul><ul><li>I intoxication </li></ul></ul><ul><ul><li>O overload (fluid) </li></ul></ul><ul><ul><li>U uremia </li></ul></ul><ul><ul><li>P pericarditis </li></ul></ul><ul><ul><li>P polyneuroathy </li></ul></ul>