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L ower U rinary T ract S ymptoms (LUTS)

L ower U rinary T ract S ymptoms (LUTS). Supervised by: Dr- Al Traifi Saad hamdan Faisal aldahash Meshal alsadhan. Objectives:. Why LUTS ? Common causes ? What are the symptoms ? Patient work up Details of the Common etiology BPH. INTRODUCTION .

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L ower U rinary T ract S ymptoms (LUTS)

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  1. Lower Urinary Tract Symptoms (LUTS) Supervised by: Dr- Al Traifi Saad hamdan Faisal aldahash Meshal alsadhan

  2. Objectives: Why LUTS? Common causes? What are the symptoms? Patient work up Details of the Common etiology BPH

  3. INTRODUCTION LUTS is the commonest presentation in urology . It’s a group of symptoms not a diseases It is due to many diseases

  4. Lower Urinary Tract Symptoms (LUTS) Causes • Benign prostatic hyperplasia (BPH) with obstruction • Detrusor muscle weakness and/or instability • Urinary Tract Infection (UTI) • Chronic prostatitis • Urinary stone • Malignancy: prostate or bladder • Neurological disease, e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome

  5. In males: Outflow obstruction BPH Meatal stenosis Impaired detrusor function NM dysfunction Detrusor instability Impaired detrusor contractility Psychogenic voiding dysfunction Infection Cystitis, prostatitis, prostatic abcess and urethral diverticulum. neoplastic Prostatic cancer, bladder cancer Others: Bladder diverticulum, stone and interstitial cystitis.

  6. In females : Mostly storage symptoms UTI Pregnancy Anxiety Overactive bladder Interstitial cystitis Postmenopausal urogenital atrophy Bladder tumor or stone Genital prolapses or pelvic mass Mostly voiding symptoms Age related detrusor muscle weakness Obstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis) Urethritis Drugs ( diuretics, alcohol, lithium, anticholinergics)

  7. Lower Urinary Tract Symptoms (LUTS) Voiding (Obstructive) • Hesitancy: delay in starting micturation • Poor stream. • Straining for voiding • Interruption of the urinary stream • Terminal dribbling.

  8. Storage (Irritaive) • Frequency. • Nocturia. • Urgency: sudden desire for urination that is difficult to postponed. • Urge incontinence. • dysuria

  9. Post void Symptoms • Post void Dribbling • Sense of incomplete emptying the bladder

  10. History of • DM • Urological intervention • CNS problems and symptoms • Hematuria • Previous urinary retention • Burning Micturation and Febrile UTI • Drugs intake • Constipation

  11. InternationalProstateSymptomsScore(IPSS) & Q of L

  12. Clinical Examination • Abdominal examination • Bladder palpation • Kidney palpation • PR examination.

  13. Per- rectal Examination

  14. Investigations • MSU (Mid-stream urine )& Urine culture • Urine Cytology (for presence of cancerous cells under microscope) • U&E • LFT • PSA (Prostate-specific antigen)

  15. US

  16. Ascending Urethrogram

  17. Urodynamics Voiding Diary Uroflometry Cystometry Pressure/Flow Study

  18. Voiding Diary

  19. Uroflometry

  20. Uroflometry

  21. Cystometry Over active Bladder Pdetmax

  22. Pressure/Flow Study

  23. Pressure/Flow Study

  24. Management • Watchful Waiting • Alpha Blockers: e.g. Prazosin • Alpha Reductase Inhibitors :e.g. Finasteride

  25. Benign Prostatic Hyperplasia BPH • It is the comments etiology of LUTS Disease of elderly men. • It is a histological diagnosis and represents as an increase in the number of epithelial and stromal elements of prostate

  26. Con. • The increase of the elements of prostate ,will result in the formation of large nodules in the periurethral region of the prostate. • the nodules compress the urethral canal to cause partial, or sometimes complete obstruction of the urethra, • which interferes with the normal flow of urine.

  27. Clinical manifestation: • Storage symptoms : • Frequency • Urgency • nocturia

  28. Voiding symptoms : • Hesitancy • Poor stream • Double voiding • Post void dribbling • Incomplete emptying • Pain and dysuria are usually not present

  29. PR examination • Normally, prostate is firm, smooth and with a palpable sulcus. • Signs of BPH: enlarged firm with palpable sulcus. • Sign of malignancy: hard nodular surface with impalpable sulcus.

  30. Investigation • Urinalysis • PSA (prostate specific antigen ) • Blood Urea Nitrogen and creatinine • US • Cystoscopy

  31. Treatment • Medical: • Tamsulosin: • It blocks adrenergic alpha-1 receptor of smooth muscle of prostate. • It decrease bladder neck and urethral resistance. • It is usually indicated in BPH.

  32. Tamsulosin ADVERSE EFFECT: 1- Headache . 2- Arthralgia . 3-Rhinitis . 4- Decrease libido . 5- back pain . Contraindications: 1- Liver disease . 2- Orthostatic hypotension . 3- Hypersensetivity .

  33. Finasteride • It is a 5-alpha reductase inhibitor. • It is an antiandrogenic drug . • It is used in case of BPH . • It is also indicated in case of alopecia in women .

  34. Finasteride ADVERSE EFFECT: 1- Breast enlargement 2- Impotence 3- Rash Contraindications: 1- Hypersensitivity 2- Pregnancy 3- Children

  35. BPH Indications for surgery • Renal impairment. • Hydronephrosis. • Recurrent UTI • secondary vesical stones • Recurrent Hematuria • Retention of urine • Significant symptoms not responding to medication.

  36. Surgery Transurethral • Minimal Invasive • Invasive, Transurethral Resection Prostatectomy ( TURP) Open Prostatectomy

  37. THE END

  38. Notes • BPH is the most common cause of urine obstruction in male . • Terminal voiding dripping: means dripping when the patient still in the bathroom (immediately after voiding). • Post voiding dripping: means dripping ,but when the patient outside the bathroom (after a period of time) . • negative PRtest doesn't exclude BPH. • Big BPH may lead to increase PSA.

  39. Cont. • > 100 ml is a significant residual volume after void. • The urodynamic is a very accurate diagnostic tool. • CHF patient came with nocturia. • In urine retention: • acute : the patient’s complain is pain  • chronic: the patient complaining of overflow incontinence. • Tamsulosin can cause retrograde ejaculation in males. 

  40. Cont. • Pus >>> culture • RBCs >>> cytology • When there is hypertrophy of the wall of bladder (>4cm ) >>urethral constriction. • Middle lobe enlargement doesn't respond to radiotherapy. • Urine flowmetry: • Voiding volume must be more than 150-200 ml. • in young male adult normal peak flow is 25ml /sec. • elderly is more than 15 ml /sec. • Female flow is stronger.

  41. Cystometry:- • Dertrouserpressure (normal is < 15 ml of water ??) • Pressure flow study • Increased pressure and decreased flow >>prostate • Decreased pressure and decreased flow >>Dertrouser

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