Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
.pdf
438
INCONTINENCE
The GP overview
Incontinence is involuntary mictu rition. It is not a common presenting symptom, embarrassment
tending to inhibit patients, but it is oen mentioned as a ‘while I’m here’ or noted by the doctor,
typically because of the characteristic odour when visiting an elderly patient. It may present more
frequently in the future as the problem receives more publicity and patients realise that help is
available. e population prevalence in women is around 10%, but is probably much higher in
older age groups.
Differential diagnosis
COMMON
stress incontinence (with or without prolapse)
infective cystitis
overactive bladder syndrome: idiopathic or secondary to other problems (e.g. CVA, dementia,
Parkinson’s disease)
chronic outow obstruction (e.g. prostatic enlargement, bladder neck stenosis, urethral
stenosis)
aer prostatectomy (usually temporary)
OCCASIONAL
interstitial cystitis
bladder stone or tumour
aer abdomino-pelvic surgery and radiotherapy
stula: vesicovaginal/uterine, ureterovaginal (surgery and malignancy)
polyuria (any cause, e.g. diabetes, diuretics – particularly if compounded by immobility in
the elderly)
RARE
aer pelvic fracture (direct sphincter damage with or without neurological damage)
congenital abnormalities: short urethra, wide urethra, epispadias, ectopic ureter
sensory neuropathy (e.g. diabetes and syphilis)
multiple sclerosis, syringomyelia
paraplegia, cauda equina lesion
psychogenic
ketamine-associated ulcerative cystitis
https://t.me/med1917
INCONTINENCE 439
Ready reckoner
Stress
incontinence
Infective
cystitis
Overactive bladder
syndrome
Outow
obstruction
Prostatectomy
Stress pattern Ye s No No Possible Possible
Urge pattern No Ye s Ye s No Ye s
Overow pattern No No No Yes No
Dysuria No Ye s No No Possible
Palpable bladder No No No Ye s No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: PSA, U&E, ultrasound, urodynamic studies, uroowmetry.
SMALL PRINT: Fasting sugar or HbA1c blood sugar, syphilis serology, cystoscopy, neurological
investigations.
Urinalysis: To test for infection and diabetes.
MSU: To conrm infection and guide antibiotic treatment.
Fasting sugar or HbA1c and syphilis serology: If diabetes or syphilis a possible cause of
neuropathy.
PSA: Consider this if LUTS or prostatic enlargement on examination.
U&E: To assess renal function in chronic outow obstruction.
Ultrasound: May suggest outow obstruction or chronic infection.
Specialist investigations may include: Urodynamic studies (helpful to distinguish between
urge and stress incontinence), uroowmetry (prostatic enlargement), cystoscopy (may reveal
cause of outow obstruction, stone or tumour) and neurological investigations (e.g. imaging
of spinal cord).
TOP TIPS
Incontinence has many causes, but can oen be broadly categorised into one of three
groups– stress incontinence (e.g. with coughing), urge incontinence (‘when I’ve got to go,
I’ve got to go’) and continuous, like water over the edge of a dam (e.g. through a vesicovaginal
stula, or in overow from a chronically distended bladder).
e aetiology may be multifactorial, particularly in the elderly. Mobility, vision, distance to
the toilet and ongoing medication may all be relevant.
Overactive bladder syndrome and stress incontinence can be dicult to distinguish. e
latter rarely causes nocturnal incontinence, while it may be a feature of overactive bladder
syndrome. If in doubt, refer for urodynamic studies.
Adopt a sympathetic approach. Incontinence can have a devastating impact on self-esteem
and seriously aect a patient’s social and sexual functioning.
https://t.me/med1917
440 SYMPTOM SORTER
Incontinence with saddle anaesthesia and leg weakness suggests a cauda equina lesion. is
is a neurological emergency – refer urgently.
Continuous incontinence suggests signicant pathology, such as a stula, chronic outow
obstruction or a neurological problem.
Never empty the huge bladder of chronic retention in one go. is can cause bleeding and
renal complications. Admit for catheterisation and controlled release.
Adult-onset nocturnal enuresis suggests chronic retention.
Remember the possibility of chronic ketamine abuse in young people.
NOTES:
https://t.me/med1917
441
NOCTURIA
The GP overview
Nocturia may present in isolation or it may be a manifestation of other urinary disturbances
such as polyuria or frequency. Surprisingly, in older age groups, it is as common in women as
men. Occasional nocturia is, of course, quite normal – the symptom should only be viewed as
pathological when it causes disruption or distress.
Differential diagnosis
COMMON
age related (in part caused by a reduction in bladder capacity)
excess uid intake at bed time (especially alcohol)
any cause of swollen ankles (the recumbent posture redistributes the uid load at night) – see
‘Swollen ankles’
cystitis
LUTS in men, secondary to benign prostatic enlargement
OCCASIONAL
overactive bladder syndrome
lower urinary tract obstruction (other than prostate problems)
any other cause of urinary frequency (see ‘Frequency’)
diabetes mellitus
any other cause of polyuria (see ‘Excessive urination’)
sleep apnoea (causes overproduction of urine)
RARE
anxiety
drug side eect (rare because drugs likely to cause diuresis are usually taken in the morning)
diabetes insipidus
https://t.me/med1917
442 SYMPTOM SORTER
Ready reckoner
Age related Excess uid intake Swollen ankles Cystitis LUTS
Daytime ankle oedema Possible No Ye s No No
Daytime frequency Possible No No Ye s Possible
Poor urinary ow No No No No Ye s
Long-term problem Ye s Possible Yes No Ye s
Polyuria No Ye s Ye s No No
Possible investigations
NOTE: Urinar y frequency, polyuria, or swollen a nkles as ‘causes’ of nocturi a will need investigati ng
in their own right – see the relevant sections for more details on each of these topics.
LI KE LY: Urinalysis, MSU, urinary frequency volume chart.
POSSIBLE: Blood sugar/HbA1c, PSA.
SMALL PRINT: Cystoscopy, urodynamic studies, ultrasound, water deprivation test.
Urinalysis: Protein, nitrites, leucocytes and possible haematuria in infection; glucose in
diabetes; specic gravity very low in diabetes insipidus.
MSU: To conrm infection and identify pathogen.
Urinary frequency volume chart: To help distinguish nocturnal polyuria (increased urine
production at night) from reduced bladder storage capacity.
Blood sugar/HbA1c: To conrm diabetes mellitus.
PSA: Pros and cons of this test may be discussed if assessment raises the possibility of prostate
cancer.
Specialist tests include: Cystoscopy and ultrasound (for lower urinary tract obstruction),
urodynamic studies (for unstable bladder) and water deprivation test (for diabetes insipidus).
TOP TIPS
In the elderly, the cause is oen multifactorial.
e eects: Such as disturbed sleep, a disrupted household, exhaustion and occasional
incontinence – may be more important to the patient than the specic diagnosis.
Swollen ankles: Of any aetiology – are frequently overlooked as an underlying cause.
Nocturia may just be a manifestation (albeit the most distressing) of polyuria or urinary
frequency. Focus your approach on the underlying problem.
https://t.me/med1917
NOCTURIA 443
Exclude diabetes – but remember that it is not the only cause of polyuria, nocturia and thirst.
A habitual ‘nightcap’ may be the cause of nocturia – and may be a pointer to an underlying
alcohol problem, especially in solitary elderly males.
NOTES:
https://t.me/med1917
444
RETENTION
The GP overview
Retention is failure to empty the bladder completely. e acute form characteristically aects
men, presents urgently and requires immediate catheterisation or hospitalisation. Chronic
retention may produce few symptoms and may only be discovered during palpation of the
abdomen.
Differential diagnosis
COMMON
prostatic hypertrophy: benign, rarely carcinoma
anticholinergic drugs: bladder stabilisers and tricyclic antidepressants
constipation
bladder neck obstruction/urethral stricture
UTI (including prostatitis and prostatic abscess)
OCCASIONAL
urethral calculus
‘holding on’ (leads to prostatic congestion)
pelvic mass: retroverted, gravid uterus or broid uterus
acute genital herpes (via local inammation and interference with neurological control of
detrusor reex arc)
clot retention (e.g. aer bleed from tumour or post-TURP bleed)
balanoposthitis in children (if very painful)
RARE
neurological: MS, syphilis, spinal cord compression
pedunculated bladder tumour
traumatic rupture of urethra
foreign body inserted into anterior urethra
phimosis
psychological
https://t.me/med1917
RETENTION 445
Ready reckoner
Prostatic
hypertrophy
Drugs Constipation Bladder neck UTI
Enlarged prostate PR Ye s No No No Possible
Acute Possible Yes Possible No Yes
Young patient No Possible No Possible Possible
Abnormal urinalysis Possible No No No Ye s
Palpable colon No No Yes No No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: U&E, PSA, ultrasound, cystoscopy.
SM A L L PR I N T: Neurological investigations, prostatic biopsy, urethrography (all hospital-based
investigations).
Urinalysis of any urine available may conrm a UTI as the cause; may also reveal microscopic
haematuria if a stone or bladder tumour.
MSU: Will conrm infective agent in UTI.
U&E: Renal failure may follow chronic retention.
PSA may be worth considering if preceding symptoms of prostatism or abnormal prostate
on examination.
Specialist tests may include: Renal ultrasound (reveals obstruction and pelvic masses),
cystoscopy (may be diagnostic and therapeutic for stones, stricture, bladder outow
obstruction and bladder tumour), neurological investigations (e.g. spinal cord imag ing if cord
lesion suspected), prostatic biopsy (if suspicious area of prostate palpable) and urethrography
(for stricture).
TOP TIPS
Do not overlook faecal impaction in the elderly patient as a cause of urinary retention.
‘First-aid’ relief of retention when the cause is a painful perineal condition (e.g.
balanoposthitis, herpes simplex or UTI) may be achieved by encouraging the patient to
urinate while immersed in a warm bath.
Anuria can be mistaken for retention. A straightforward clinical assessment should
dierentiate the two conditions.
https://t.me/med1917
446 SYMPTOM SORTER
A history suggesting a disc prolapse with urinary retention indicates possible cord
compression – admit immediately.
Sudden stoppage of urine with a pain like a blow to the bladder and passage of a few drops
of blood is pathognomic of urethral calculus.
Beware of any drugs with anticholinergic side eects in patients with a history of outow
obstruction – they may precipitate acute retention.
Avoid catheterisation when sepsis is likely (e.g. possible UTI) – instrumentation may result
in septicaemia. Instead, admit to hospital for catheterisation under appropriate antibiotic
cover.
Do not catheterise the patient with chronic retention; admit for controlled drainage. Sudden
decompression can result in haematuria and renal complications.
NOTES:
https://t.me/med1917
447
INDEX
abbreviations, ix–xi
abdominal aortic aneurysm
epigastric pain, 30
loin pain, 33
abdominal carcinoma
abdominal pain, 9
abdominal swelling, 6
constipation, 21–3
diarrhoea, 25
epigastric pain, 30–2
abdominal migraine, abdominal pain, 36–7
abdominal pain
abdominal migraine, 36–7
acute, 9–11
in children, 12–14
in pregnancy, 15 –17
chronic/recurrent
in adults, 18–20
in childhood, 36–9
constipation, 23
limp in child, 309, 311
abdominal swelling, 6–8
vomiting in infants, 47
weight gain, 238
abdomino-pelvic surgery, urinary incontinence,
438
abnormal gait in adults, 179–81
abnormal movements, 182–4
abnormal nails, 276–8
abscess
breast enlargement in men, 67
constipation, 21–2
cough, 115
facial pain, 16 4–5
febrile child, 200
groin swelling, 382–3
prolonged fever, 221–2
tremor, 233
acanthosis nigricans
papules, 411–12
skinfold rash, 421, 423
ACE inhibitors
blisters, 400
cough, 115–17
diarrhoea, 26
thirst/dry mouth, 229
achalasia, swallowing diculties, 332
Achilles tendon, ruptured
calf pain, 294–
5
swollen calf, 327
achilles tendonitis, foot pain, 297
acne
facial rash, 167–8
nodulocystic, 408, 410
papules, 411–12
pustules, 416 –17
acne excoriée
facial rash, 167, 169
facial ulcers and blisters, 173
acoustic neuroma
deafness, 128–30
tinnitus, 137, 139
tremor, 233
vertigo, 101, 103
acquired megacolon, constipation, 22
acromegaly
breast enlargement in men, 66
excess body hair, 279
excessive sweating, 194
ACTH-secreting tumours
excessive urination, 434
ushing, 206
actinomycosis
facial ulcers and blisters, 173
neck lumps, 338
nodules, 408
prolonged fever, 221
acute pyelonephritis, dysuria, 429
acute surgical abdomen, vomiting in infants, 45
acute vestibular neuronitis, vomiting, 39–40
Addison’s disease
abdominal pain, 18–19
absent periods, 386
dizziness, 83–4
mouth lumps, 366
sex-drive, loss of, 95
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана