Clinical Practice Guideline On Difficulty in Urination

Oliver Leyson

Department Of Surgery

Ospital Ng Maynila Medical Center

What is an operational concept of difficulty In Urination?

Difficulty in urination is often reported as a sensation of pain or burning on urination, or dysuria, caused by anything that leads to inflammation of the urethral mucosa.

 Brendler CR. Evaluation of the urologic patient.

Campbell's Urology. 7th ed.131-57;1998.

Common Causes of dysuria

1. Infection  (60%)
2. Stone (35%)
3. Malignancy (5%)

What important points should be taken into consideration in evaluating a patient complaining of dysuria?

• Duration

•         Severity

•         Chronicity

•         Periodicity

•         Degree of disability

What are reliable signs and symptoms (more than 90% certainty) in the history of present illness of the patient infectious cause of dysuria?

•         FREQUENCY – voiding of more than six times per day, with a volume of more than 300 ml with each void.

•         NOCTURIA – nocturial frequency; voiding of more than two times at night

•         URGENCY – strong, sudden impulse to void

•         URETHRAL DISCHARGE 

What are reliable signs and symptoms (more than 90% certainty) in the history of present illness of the patient non-infectious cause of dysuria?

•         Dysuria

•         Fever

•         Hematuria

Infection

•         Dysuria is due to infection about 60 percent of the time.

•         All portions of the urinary tract are susceptible to infection, although the causative organisms vary by site.

•         Hollow, or tubular, structures in the urinary system, such as the kidney, renal pelvis, bladder, prostate and epididymis, are most vulnerable to infection by coliform bacteria.

•         bacteria are believed to gain access at the urethral meatus (through intercourse or local contamination) and then ascend to the affected organ

Causative Organism

•         Men with abnormalities in urinary anatomy or function are likely to have more unusual, recurrent or persistent infections with organisms such as Proteus, Klebsiella or Enterobacter species.

Abnormalities

•         bladder diverticula

•         renal cysts

•         urethral stricture

•         BPH

•         neurogenic bladder

–        multiple sclerosis,

–        Diabetes

–        stroke

–        spinal cord injury

Infection - discharge

•         Organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis preferentially infect the urethra.

•          Urethral discharge is the most frequent manifestation of infection with these organisms.

•         Discharge that is thick and discolored (yellow to gray) typifies gonococcal urethritis, whereas watery, scant or mucoid discharge is most common with nonspecific (nongonococcal) urethritis caused by infection with C. trachomatis or Ureaplasma urealyticum.

•         However, up to 18 percent of men with gonococcal infection do not have discharge, and up to 47 percent do not have dysuria.

Infection - Viruses

•         such as adenovirus, herpesvirus or mumps virus can also cause dysuria.

•         Hemorrhagic cystitis may result from adenovirus infection of the bladder.

•         Herpesvirus infection may disrupt meatal integrity, causing dysuria

•         Mumps infection of the epididymis and testicles can produce urethral inflammation and dysuria, although these complications have become infrequent since the introduction of the mumps vaccine.

Infection – Parasite

•         In developing countries, a common cause of bladder infection and dysuria is the parasite Schistosoma haematobium.

What are reliable(more than 90%) certainty of patient with dysuria have urinary calculi?

•         Long standing right flank pain that radiates to the right inguinal area

•         Dysuria

•         Frequency

•         (+) kidney punch on the right

Para-clinical Diagnostic Procedure

•         Yes

•         Plain abdominal x-ray and scout CT had 48% (22 of 46 cases) and 17% (8 of 46) sensitivity, respectively, for detecting the index stone.

Pathophysiology of Stone formation

•         There are various types of stones, calcium stones are very dense and are difficult to treat conservatively.  Uric acid stones, xanthine stones, and cysteine stones are less dense and some can be treated with success medically.

•         Stones can be lodged in different locations, but my manifest very similar clinical patterns like dysuria, hematuria, and renal colic.

Prevalence of Stones - Geography

Data for Philippines not available

Treatment Goals

•         Removal of the presently obstructing stone and its associated symptoms

•         Identification of the type of stone to prevention recurrence - medical

•         Size of the stone% of spontaneous passage4 mm90%4 – 6 mm50%More than 6 mm10%

CLINICAL PRESENTATION

1.Flank/loin pain, colicky + radiation

                        - haematuria

                        - nausea and vomiting

                        - chills/fever/frequency, if infected

            2.         Loin tenderness

            3.         Bilateral stones : renal failure

Obstruction

BPH is the most common cause of urinary complaints, including dysuria and obstruction.

More than 50 percent of men over 70 years of age have the clinical syndrome of BPH, and nearly 90 percent have microscopic evidence of prostatic hyperplasia

What is benign prostatic hyperplasia?

•         a noncancerous enlargement of the prostate gland that occurs in almost all men as they age.

•         Enlargement is usually harmless, but it often results in problems urinating.

•         About half of all men over 50 experience some symptoms.

•         Significant portion of the symptoms are due to obstruction and age induced detrusor dysfunction

What are the risks of BPH?

•         BPH can be inconvenient, but it is usually not a serious problem.

•         Quality of life may be affected if frequent nighttime urination disrupts sleep.

•         In a small number of cases, BPH may cause bladder outlet obstruction (BOO), making it impossible or extremely difficult to urinate.

•         This may result in backed-up urine (urinary retention), leading to bladder infections or stones, or kidney damage.

•         BPH does not cause prostate cancer and does not affect a man's ability to father children, nor does it usually result in erection problems

•         BPH-induced dysuria may be caused by urinary infection resulting from obstruction and stasis. It may also be caused by inflammation of the distended urethral mucosa. Over time, chronic obstruction of urinary outflow as a result of BPH can cause bladder hyperplasia, trabeculation and, eventually, decompensation.23

Obstruction - The syndrome of BPH

•         Manifestation of a static component, a dynamic component, or both.

•         The static component results from hyperplastic enlargement of the gland, which occludes the prostatic urethra. Blocking the conversion of testosterone to dihydrotestosterone using a 5-alpha reductase inhibitor such as finasteride (Proscar) can shrink the gland.

•         The dynamic component is due to increased tone of the fibromuscular stroma of the prostate, resulting in compression of the

When is a prostate biopsy indicated?

•         Although an abnormal DRE or an elevated PSA may suggest the presence of prostate cancer, cancer can only be confirmed by the pathologic examination of prostate tissue. A urologist should be consulted for a prostate biopsy when any of the following findings are present:

                        PSA is 4.0 ng/mL or more;

                        A significant PSA rise from one test to another

                        DRE is abnormal.

•         Prostate tissue can be obtained in several ways. The most common method is by means of a transrectal, ultrasound-guided prostate biopsy, which is usually performed as an outpatient procedure without anesthesia.

•         Such biopsies are rarely complicated by rectal bleeding, hematuria, or prostatic infection. After biopsy, blood in the stool or urine usually disappears after a few days. Blood in the semen can be seen for up to several weeks after biopsy.

Goals of Treatment:

To relieve urinary obstruction

Pharmacologic medications:

The most frequently performed surgeries are:

•         Open Prostatectomy - operation of choice when the prostate is so large (more than 80 to 100 g) that TURP cannot be performed safely.

•         Suprapubic prostatectomy -involves opening the bladder and removing the inner portion of the prostate through the bladder.

•         Retropubic prostatectomy, the bladder is pushed aside and the inner prostate tissue is removed without entering the bladder.

•         Transurethral resection of the prostate (TURP) - where an instrument is inserted up the urethra to remove the section of prostate tissue that is blocking urine flow.

•         Transurethral incision of the prostate (TUIP) - where an instrument is inserted up the urethra and an electric current or a laser beam is used to make incisions in the prostate where the prostate meets the bladder.

•         This relaxes the opening to the bladder, decreasing resistance to the flow of urine out of the bladder. No tissue is removed.

The decision whether to use medications for BPH:

•         The American Urological Association (AUA) symptom index is used to help men determine the severity of their urinary symptoms and can also be used to measure the effectiveness of treatment.

•         However, the most important factor in deciding whether to get treatment is not your AUA rating, but how much the symptoms bother the patient and affect the quality of life.

REFERENCES

1. Brendler CR. Evaluation of the urologic patient. Campbell's Urology. 7th ed.131-57;1998.
2. Tanagho EA, McAninch JW. Smith’s General Urology, 13th ed,378-392:1992.
3. Goldman DR, Brown FH, Guarneiri DM.  Perioperative Medicine The Medical Care of the Surgical Patient, 2nd ed.;121-122, 175-194:1994.
4. Walsh PC, Retik AB, Vaughan ED Jr, Wein, AJ. Campbell’s Urology, 7th ed. WB Saunder’s Company; 1998;1429-1472