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CHAPTER13 Renal medicine and urology
Incontinence ofurine
Involuntary loss of urine which is demonstrable and a social or hygienic
problem. 1 in 3 with incontinence consult at outset, 1 in 3 consult later, 1 in
3 suer in silence. Opportunistic questioning can identify suerers.
History
• Frequency of complaint
• Volume passed
• Degree of incapacity
• Whether occurs with
standing/ coughing/ sneezing
Examination
• Abdominal including DRE— enlarged bladder, masses, loaded colon,
faecal impaction, anal tone
• Pelvic— prolapse, atrophy, neurological decit, retention of urine, and
pelvic masses
Investigation Intake/ output diary (at least 3d including working and
leisure days)— evaluates problem and benchmark for progress (record
drinks and passage of urine); Urine— RBCs, M,C&S; consider blood for
U&E, eGFR FBC, FBG/ HbA1c if renal impairment/ DM is suspected.
Drugs that exacerbate/ cause incontinence Diuretics, antihistamines,
anxiolytics, α- blockers, sedatives and hypnotics, anticholinergic drugs, TCAs.
GP management 0 30% have a mixed pattern. Treat according to
dominant symptom. Try general measures before referring to urology/ gynaecology or for further investigations.
Generalmeasures
• Manipulate uid intake:amount, type (avoid tea, coee, alcohol), timing
• Promote weight d
• Alter medication, e.g. timing of diuretics
• Treat UTI and chronic respiratory conditions
• Avoid constipation
• Consider HRT (topical or systemic) for oestrogen deciency
• Consider scheduled voiding if cognitive decit
• Referral— Table 13.8
Aids and appliances forincontinence E p. 426
Nocturnal enuresis inchildren E p. 893
Stressincontinence
• Symptoms Small losses of urine without warning throughout the day
related to coughing/ exercise
• Causes Prostatectomy; childbirth; deterioration of pelvic oor muscles/
nerves
• Treatment Pelvic oor exercises (E p. 821) continued >3mo help 60%
(taught by physiotherapists/ continence advisors; leaets available)—
may be assisted by vaginal cones and/ or electrical stimulation.
Mechanical devices (e.g. Contrelle Activguard®, FemSoft®) may help
• Urgency/ dysuria/ frequency of
micturition
• Past obstetric and medical history
• Medication
• Mobility and accessibility of toilets
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INCONTINENCE OFURINE
Table13.8 Referral forincontinence problems
Specialist continence
advisor/ DN
Urodynamic
studies
Gynaecology or
urology opinion
• Advice on aids or appliances
• Advice on primary care management
• Patient support
• If type of incontinence is uncertain
• Atypical features of incontinence
• After unsuccessful surgery
• If a neurological problem is suspected
• GP management has failed
• Severe symptoms and/ or pain
• Recurrent UTI
• Concomitant gynaecological problems (e.g. prolapse)
• Concomitant urological problems (e.g. chronic
retention, prostate abnormality on rectal examination)
• Failed incontinence surgery
• Pelvic radiotherapy
• Vesico- vaginal stula
• Haematuria— E p. 420
Urge incontinence (overactive bladder syndrome) Detrusor
instability or hyperreexia cause the bladder to contract unintentionally.
• Symptoms Frequency, overwhelming desire to void (often precipitated
by stressful event), large loss, nocturia
• Causes Idiopathic, neurological problems (stroke, MS, DM, spinal cord
injury, dementia, PD), local irritation (bladder stones, bladder cancer,
infection), obstruction (BPH), surgery (TURP)
Treatment Bladder training— resist the urge to pass urine for i periods.
Start with an achievable interval based on diary evidence and i slowly—
continue for >6wk. If bladder training is ineective, try oxybutynin rst lineN
(alternatives:solifenacin, tolterodine, trospium, duloxetine). Spontaneously
remits/ relapses; reassess every 3– 4 mo.
Overow Constant dribbling loss day and night. Causes:BPH, prostate cancer,
urethral stricture, faecal impaction, neurological (LMN lesions), side eect of
medication. Treatment is aimed at relieving the obstruction (E p. 428).
Urinary stula Communication between bladder and the outside—
normally through the vagina. Results in constant dribbling loss day and night.
Refer to gynaecology/ urology. Causes:congenital, malignancy, complication
of surgery.
Functional incontinence No urological problem. Caused by other
factors, e.g. inaccessible toilets/ immobility, behavioural problems, cognitive
decit. Treat the cause.
Further information
European Association of Urology (2019) Urinary incontinence. M http://
uroweb.org/ guideline/ urinary- incontinence/
NICE (2019) Urinary incontinence and pelvic organ prolapse in
women:management. M www.nice.org.uk/ guidance/ ng123
Patient information and support
Bladder and Bowel Foundation F 01926 357220 M www.
bladderandbowel.org
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CHAPTER13 Renal medicine and urology
Aids and appliances forincontinence
Pads Many dierent types. DNs or continence advisors are best aware
of those available via the NHS locally. They are not available on FP10 and
supplied by local NHS Trusts on a ‘daily allowance’ basis. This varies across
the country.
Bed covers Absorb 1– 4L of urine. Good laundry facilities are needed. If
left wet can cause skin breakdown. Available via NHS Trusts.
External catheters or sheaths Can be prescribed on NHS prescrip-
tion. Approved appliances are listed in part IXB of the UK Drug Tari. Used
for men who have intractable incontinence and who are highly physically
dependent, do not have urine retention, and do not require an internal
catheter. Used in association with a drainage bag. Assessment and tting by
a DN or continence adviser is essential.
May be non- adhesive, self- adhesive, or attached with adhesive strips.
Adhesive sheaths can last several days but daily changing is recommended.
Replace non- adhesive sheaths 2– 3×/ d (some are reusable).
Problems Include i susceptibility to UTI, sores on penis, and skin irritation
due to the adhesive.
Catheters Can be prescribed on NHS prescription. Approved appli-
ances are listed in part IXA of the UK Drug Tari.
Indwelling catheters Only use catheters in patients who have:
• Urinary retention or neurogenic bladder dysfunction
• Severe pressure sores
• Inoperable obstructions that prevent the bladder emptying
• Terminal illness
• Housebound without adequate carer support
Types Only long- term Foley catheters are suitable for use in primary care.
They last 3– 12wk.
Catheter size Unless specied a 12 or 14Ch catheter is supplied. Use the
smallest diameter of catheter that drains urine eectively. Catheters >16Ch
are more likely to cause bypassing of urine around the catheter and urethral
strictures.
Catheter length Men require longer catheters than women. Specify ‘male’ or
‘female’ on the prescription.
Catheter balloon 10mL balloons are supplied unless specied otherwise.
Pre- lled catheters contain sterile water which inates the retaining balloon
with water. They are more expensive but quicker to insert and there are no
costs for syringes or sterile water.
Insertion E p. 429
Drainage Usually attached to a leg bag, although catheter valves are also
available allowing the patient to use his/ her bladder as a urine reservoir.
The valve must be released every 3– 4h to drain out the urine
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AIDS AND APPLIANCES FORINCONTINENCE
Commonproblems
• Leakage Check no constipation, check catheter not blocked, try smaller
gauge catheter
• Infection 90% develop bacteriuria <4wk after insertion. Always conrm
suspected UTI with MSU— only treat if symptomatic or Proteus species
grown. May prove dicult to eliminate. No good evidence bladder
instillations help
• Encrustation (50%) Deposition of minerals and other materials from the
urine onto the catheter. Worse if there is infection with Proteus species.
May cause catheter blockage or pain changing the catheter. Check pH
of urine regularly in patients with problems. Citric acid patency solutions
may help if pH >7.4 or a daily dose of vitamin C
• Inammation Results from physical presence of a catheter in the
urethra. Exacerbated by encrustation and infection. There is no easy
solution— try a dierent brand catheter (e.g. hydrogel catheter rather
than silicone)
• Blockage Change catheter. The interval of routine changes should be
altered if there is regular blockage towards the end of the life of a
catheter
Intermittent self- catheterization Patient inserts a catheter into
his/ her bladder 4– 5×/ d to drain urine. d problems of infection and
blockage. Useful for neurological bladder dysfunction. Types:
• Reusable silver or stainless steel
• Reusable PVC— washed and reused for 1 wk. Usually supply 5/ mo
• Single use— need 125– 150/ mo. Expensive. Only use on
consultant advice
Collecting bags Can be prescribed on NHS prescription. Approved ap-
pliances are listed in part IXB of the UK Drug Tari.
• Leg bags Drainable bags last 5– 7d. Usually 500/ 750mL. Larger capacity
bags are too heavy for mobile patients. Avariety of attachment systems
are available on prescription. Long tubes are needed to wear a bag on
the calf
• Night drainage bags Connect to night bag attachment of day bags. Single
use, disposable non- draining bags are recommended. Bag hangers are
not available on NHS prescription
Enuresis alarms Table23.13, E p. 893
Further information
NHSBSA Electronic drug tari. M www.nhsbsa.nhs.uk/ prescriptions
NICE (2015, updated 2017)Urinary tract infection (catheter- associated).
M www.nice.org.uk/ guidance/ ng113
Patient advice and support
Bladder and Bowel Foundation F 01926 357220 M www.
bladderandbowel.org
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CHAPTER13 Renal medicine and urology
Urinary tractobstruction
Causes of obstruction Figure 13.2. Obstruction may be unilateral
(kidney, pelvi- ureteric junction, or ureter), or bilateral (bladder, urethra,
prostate). Unilateral obstruction may present late if the other kidney remains functioning. Suspect if loin ache worsened by drinking. Conrm with
USS and refer to urology. Obstructing lesions may be in the lumen, e.g.
stones; in the wall, e.g. tumours; or impinging from outside, e.g. retroperitoneal brosis.
Acute retention of urine Sudden inability to pass urine l lower
abdominal discomfort with inability to keep still. Dierentiate from AKI.
♂ > ♀. Risk factors: age >70y; symptoms of prostatism/ poor urinary
stream.
Causes Prostatic obstruction (82%); constipation; alcohol; drugs (anticholinergics, diuretics); UTI; operation (e.g. hernia repair). Rarer causes:urethral stricture; clot retention; spinal cord compression; bladder stone.
Examination Abdomen— palpable bladder; DRE— enlarged ± irregular
prostate; perineal sensation to exclude neurological cause.
Investigation MSU to exclude infection. Blood for U&E, Cr, and eGFR. Only
investigate if catheterizing in the community.
Management Catheterize (record initial volume drained) or refer to urology for catheterization— local policies vary. Treat infection. Refer to DN
for instruction on management of the catheter. Refer to urology for further
assessment and treatment.
Chronic retention ofurine Insidious onset. Causes:benign prostatic
hypertrophy; pelvic malignancy; CNS disease. May present as:
• Nocturnal enuresis
• Overow incontinence
Examination and investigation As for acute retention. Bladder is enlarged
(may contain >1.5L) but usually non- tender.
Management Refer to urology for further assessment and treatment.
Refer urgently or acutely if pain, UTI, or renal failure (eGFR <60mL/ min/
1.73m3). Do not catheterize in the community.
Retroperitoneal brosis Ureters become embedded in dense brous
plaques in the retroperitoneal space. Associations:
• Drugs, e.g. methysergide
• Carcinoma
• Crohn’s disease
Presentation and management Typically middle- aged men presenting with
fever, malaise, sweating, leg oedema, i BP, palpable mass, and acute/
chronic renal failure. Refer for specialist care. Options include steroids and
nephrostomies.
Horseshoe kidney Congenital abnormality. Kidneys are fused in the
midline to form a horseshoe- shaped mass. The kidney may function normally or may present with obstructive nephropathy or UTIs.
• Acute on chronic retention
• Lower abdominal mass
• Connective tissue disease
• Raynaud’s syndrome
• Fibrotic diseases, e.g. alveolitis
• UTI
• Renal failure
Pelvi-ureteric junction
Ureter
Bladde
• Tumour
• Calculus
• Calculus
• Tumour
• Impacted sloughed papilla
• Retroperitoneal brosi
• Compression by LNs
• Tumour
• Clot
• Pelvic malignancy
• Calculus
y
Unilateral:
Bilateral:
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s
r
Figure13.2 Causes of urinary tract obstruction
Passing a urethral catheter 0 Technique learned through
supervised experience. Only attempt alone if you are competent
to do so.
Prepare theequipmentneeded
• Sterile rubber gloves, plastic sheet to prevent spills, paper sheet to
provide sterile eld, cleansing materials— cotton swabs, cleansing uid
• Local anaesthetic/ lubricating gel, e.g. 1% lidocaine + 0.25% chlorhexidine
• Catheter— usually 12Ch or 14Ch— ensure the catheter is long if
catheterizing a man (E p. 426)— and if the catheter is not pre- lled—
sterile syringe + 10mL of sterile water
• Kidney dish/ other receptacle to catch the urine before connecting the
drainage bag; drainage tube and bag
Inserting thecatheter
• Ensure the patient is comfortable; protect against spills with a plastic
sheet; cover area with a sterile paper sheet
• Ensure strict aseptic technique. Cleanse the penis/ vulva and squeeze
lubricant/ local anaesthetic gel into the urethra— allow it to work
• Gently but rmly, push the catheter into the urethra. Ensure the end
of the catheter is over the receptacle. When the catheter enters the
bladder, urine ows into the receptacle. Inate the balloon with sterile
water (if needed) once the catheter is inside the bladder. Connect the
catheter to the collecting tube and bag
• If male, pull the foreskin over the glans again to prevent paraphimosis
0 If you are unable to pass a catheter, refer to urology.
URINARY TRACTOBSTRUCTION
Both ureters
• Retroperitoneal brosis
Bladder
• Tumour
• Clot
• Pelvic malignancy
• Calculus
Prostate
• Benign prostatic hypertroph
• Prostate cancer
Urethra
• Urethral stricture
• Urethral valves
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CHAPTER13 Renal medicine and urology
Benign prostatichypertrophy
10– 30% of men in their early 70s have symptomatic benign prostatic hypertrophy (BPH). There is no relation between size of the prostate and symptoms. Assessment— Table 13.9.
Symptoms ofprostatism
• Obstructive d and intermittent urinary stream, double micturition,
hesitancy, terminal dribbling, feeling of incomplete emptying, and
straining to void. Dierential diagnosis:prostatic enlargement, strictures,
tumours, urethral valves, bladder neck contracture
• Irritative (due to detrusor muscle hypertrophy)— urinary frequency,
urgency, dysuria and nocturia. Dierential diagnosis:enlarged prostate,
UTI, polydipsia, detrusor instability, hypercalcaemia, uraemia
Complications 10% at presentation
• Recurrent UTI • Chronic obstruction— E p. 428
• Bladder stones • Overow incontinence— E p. 425
• Haematuria • Obstructive nephropathy
• Acute retention of urine ± prior obstructive symptoms— E p. 428
GP management Symptoms can improve spontaneously but overall
progress slowly. 1– 2%/ y develop urinary retention. Options:
Watchful waiting Patients with mild to moderate symptoms at presenta-
tion with no complications of BPH and who are not severely troubled by
their symptoms. Self- help includes:d evening uid intake, d caeine intake,
bladder retraining and prevention of constipation.
Drug therapy Those with mild/ moderate symptoms who are troubled by
their symptoms. Consider:
• α- adrenoceptor agonists, e.g. prazosin, doxazosin— watch for postural
hypotension. d symptomatic worsening
• 5α- reductase inhibitors, e.g. nasteride— best for patients with bulky
prostates— takes up to 6mo to work. d risk of urinary retention
• Combination therapy— α- adrenoceptor agonist and 5α- reductase
inhibitor d progression by 66%— more than either agent alone
Referral to a urologist E=Emergency admission; U=Urgent;
S=Soon; R=Routine
• Complicated BPH (e.g. acute retention)— E/ U
• Nodular/ rm prostate on DRE— U
• Failure to respond to drug therapy after 3– 12mo (α- blocker) or 6– 12
mo (5α- reductase inhibitor)— R
Bacterial prostatitis Consider in men presenting with suspected
UTI. Other features:fever; arthralgia/ myalgia; low back, perineal, penile, ±
rectal pain. DRE reveals swollen, tender prostate. If suspected, check MSU
and treat with paracetamol/ ibuprofen ± codeine and 4wk course of oral
antibiotic which penetrates prostatic tissue, e.g. ciprooxacin 500mg bd,
ooxacin 200mg bd. Refer for specialist advice if not settling. Complications
include:acute retention of urine, chronic bacterial prostatitis, and prostate
abscess.
• i PSA (E p. 433)— U
• Severe symptoms— S
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BENIGN PROSTATICHYPERTROPHY
Table13.9 Assessment ofBPH
Assessment Comments
History • General well- being
Frequency– volume
chart
Symptom score
(IPSS— E p. 432)
Abdominal
examination
Digital rectal
examination
Serum urea,
creatinine, and eGFR
MSU Dipstick for blood and glucose. M,C&S
Ultrasound measurement of post- micturition residual
Maximum voiding ow
ratea
Serum PSA High values can indicate prostate cancer (E p. 433)
a
May be available through open- access prostate assessment clinics.
• Obstructive symptoms
• Irritative symptoms
• Haematuria
Assess pattern and type of uid consumption (e.g. alcohol/
caeine at night i nocturia)
Objectively grade symptoms giving measure of severity. IPSS
scores:0– 7 mild; 8– 19 moderate; 20– 35 severe
A general quality of life measurement can be used to assess
impact of symptoms
Look for distended bladder, palpable kidneys. Examine
external genitalia
Anal tone, size, shape, and consistency of prostate (normal
prostate— size of a chestnut with smooth, rubbery consistency)
Renal function assessment
<15mL/ s for voided volume. >100mL is abnormal
• Pain
• Polyuria and polydipsia
• Neurological symptoms
• Past history of urological
instrumentation or STIs
Chronic prostatitis (chronic pelvic pain syndrome) 2– 14% lifetime prevalence.
Cause is unknown. Presents with >3mo history of:
• Urological pain— lower abdomen, pelvis/ perineum, penis (especially tip
± on ejaculation), testicles, rectum, low back ±
• Irritative/ obstructive symptoms and/ or ejaculatory disturbance
Diagnosis is based on history with exclusion of other causes. Suitable investigations include DRE, MSU, urine cytology, sexually transmitted infection screen, PSA, ± urodynamic studies. Treatment is dicult— provide
information and support; try α- blockers (e.g. doxazosin 4mg od for 6mo).
Spontaneous improvement/ remission often occurs.
Further information
Rees J, etal. (2015) Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/ chronic pelvic pain syndrome:a consensus
guideline. BJU Int 116:509– 25. M https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC5008168/pdf/BJU-116-509.pdf
Patient support
The Urology Foundation M https://www.theurologyfoundation.org/
urologyhealth/prostate/prostatitis
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CHAPTER13 Renal medicine and urology
The International Prostate SymptomScore
Not at all
Less than 1
timein 5
Less than half
the time
About half the
time
More than half
the time
Almost always
Your score
Over the past month, how often
have you had a sensation of not
emptying your bladder completely
after you nish urinating?
Over the past month, how often
have you had to urinate again <2h
hours after you nished urinating?
Over the past month, how often
have you stopped and started
several times when you urinated?
Over the past month, how often
have you found it dicult to
postpone urinating?
Over the past month, how often
have you had a weak urinary
stream?
Over the past month, how often
have you had to push or strain to
begin urinating?
Over the past month, typically from
the time you went to bed to the
time you got up in the morning,
how many times did you get up to
urinate?
Total IPSS score
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5+
If you were to live the rest of your
life with your urinary condition the
way it is now, how would you feel
about it?
0– 7=mildly symptomatic; 20– 35=severely symptomatic; 8– 19=moderately symptomatic .
The International Prostate Symptom Score is reproduced with permission from the American
Urological Association.
Delighted
Pleased
Mostly satised
Equally satised/
dissatised
Mostly
dissatised
Unhappy
0 1 2 3 4 5 6
Terrible
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BENIGN PROSTATICHYPERTROPHY
Prostate- specic antigen (PSA) testing There is no prostate
screening programme in the UK but men can request a PSA test. The
Government has introduced a PSA Informed Choice Programme. Warn
patients about the poor specicity of the test before performing the test
and provide information about the pros and cons of testing.
In addition, PSA is routinely measured in men with urological symptoms.
Abnormal PSA is a common reason for referral to an urologist. Its sensitivity and specicity are poor.
Pros and cons ofPSAtesting
Benets of PSA testing Downside of PSA testing
• It may provide reassurance
if the test result is normal
• It may nd cancer before
symptoms develop and
at an early stage when
treatments could be
benecial
• If treatment is successful,
the consequences of
more advanced cancer are
avoided
Reasons foriPSA
• Prostate cancer
• Benign prostatic hypertrophy
• Acute or chronic prostatitis
• Physical exercise
• Acute urinary retention
0 PSA may be normal when early prostate cancer is present.
Performing a PSA test Digital rectal examination may cause a transient i in
PSA levels (M), so do the PSA test before doing a digital rectal examination. If that is not possible, delay the test for 1wk after the examination.
Exclude urinary infection before PSA testing. Do NOT do a PSA test if
the man has:
• Aproven UTI— treat the UTI and postpone the PSA test for ≥1mo
• Ejaculated within the previous 48h
• Exercised vigorously in the previous 48h
• Had a prostate biopsy <6wk ago
PSA cut os that should prompt referral
Age (y) Refer to urology if PSA (ng/ mL)
50– 59
60– 69
≥70
0 Finasteride and dutasteride d PSA by ~50%.
• It can miss cancer, and provide false
reassurance
• It may lead to unnecessary anxiety and
medical tests when no cancer is present
• It might detect slow- growing cancer
that may never cause any symptoms or
shortened lifespan
• The main treatments of prostate cancer
have signicant side eects, and there
is no certainty that treatment will be
successful
• Prostate instrumentation
(includes prostate biopsy and
urinary catheterization)
• Old age
≥3.0
≥4.0
>5.0
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