Urinary Symptoms

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Haematuria - 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 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.

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, 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 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.

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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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 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

• 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.

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.
• 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.

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 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 LFT's.
  • 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.

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Content by Dr Íomhar O' Sullivan 05/07/2004. Reviewed by Dr ÍOS 26/05/2006, 07/09/2007. Last review Dr IOS 7/01/11