Lower Urinary Tract Disorders

37. Lower Urinary Tract Disorders 657

Case 2

A 17-year-old boy is brought to the emergency department after sustaining a bicycle accident. He is noted to have gross blood at the penile meatus. He has not voided since the time of his accident.

Case 3

A 22-year-old college student complains of burning with urination. He has a clear urethral discharge and recently has engaged in unprotected intercourse.

Introduction

Lower urinary tract disorders are intended to include those complaints related to the function of voiding that prompt a patient to seek the care of a physician. Such complaints may be a result of a primary urinary tract etiology (i.e., urinary tract infection) or of a secondary urinary tract etiology (i.e., bladder hyperreflexia following cerebral vascular accident). Hence, a complete and accurate history and a complete and accurate physical examination remain of the utmost importance in the evaluation of such patients.

This chapter discusses the presentation, workup, and treatment of common lower urinary tract disorders, including benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), urinary incontinence, hematuria, cystitis, dysuria, and pneumaturia.

Benign Prostatic Hyperplasia (BPH) and Lower Urinary

Tract Symptoms (LUTS)

It is estimated that there are approximately 6 million patient visits annually among U.S. males for the evaluation of symptoms attributable to enlargement of the prostate gland. It is incumbent upon the evaluating physician to have a consistent approach to this disorder, to identify patients at increased risk of adverse event (i.e., acute urinary retention), and to initiate appropriate therapy in those patients in whom it is required. It also is important to detect disease states that can mimic the symptoms of BPH. The Agency for Health Care Policy and Research recommends that all males with lower urinary complaints be administered a Prostate Symptom Questionnaire (Table 37.1). This scoring system addresses six areas of voiding dysfunction that are scored from 0 (no symptoms) to 5 (severe symptoms), for a composite score ranging from 0 to 30.

Differential Diagnosis

It is important to rule out other etiologies of urinary symptoms in making the diagnosis of benign prostatic hyperplasia. The presence of prostate cancer must be ruled out since treatment of benign disease would be ineffective and would result in further disease

658 M. Perrotti

Table 37.1. American Urologic Association Prostate Symptom Index.

progression. This can be accomplished with a well-performed digital rectal examination (DRE), a serum prostate-specific antigen (PSA) test, and reference to normal value ranges. It generally is recognized that a prostate biopsy is indicated in those men with either elevated serum PSA level (>4 ng/mL) or a suspicious DRE finding before embarking upon a BPH treatment regimen (see Algorithm 37.1, Table 37.2).

Irritative symptoms such as urinary frequency may be due to underlying urinary tract infection, bladder malignancy, primary bladder disorder (i.e., radiation cystitis), or neurologic disease such as history of cerebral vascular accident, multiple sclerosis, or Parkinson’s disease (Table 37.3). Similarly, poor bladder emptying may be seen in primary neurologic disease and in the neuropathy associated with diabetes. In cases that are not diagnostically clear, urodynamic testing is performed to assess bladder function quantitatively. During this office procedure, the bladder is drained after voiding to measure postvoid residual, and then the bladder is filled at a determined rate and bladder pressure is

Initial evaluation

Hx, PE, DRE

Urinalysis

Serum PSA

Algorithm 37.1. Algorithm for the evaluation and treatment of benign prostate hyperplasia. AUA-SI, American Urologic Association Prostate Symptom Index; DRE, digital rectal exam; Hx, history; PE, physical examination; PSA, prostate-specific antigen; R/O, rule out; US, ultrasound.

37. Lower Urinary Tract Disorders 659

Table 37.2. Results of watchful waiting series for prostate cancer.

a Johansson J-E, Adami H-O, Andersson S-O, et al. High 10-year survival rate in patients with early, untreated prostatic cancer. JAMA 1992;267:2191–2196.

b Whitmore WF, Warner JA, Thompson IM. Expectant management of localized prostatic cancer. Cancer (Phila) 1991;67:1091–1096.

c Hanash KA, Utz DC, Cook EN, et al. Carcinoma of the prostate: a 15-year follow-up. J Urol 1972;107:450–453.

d George NJR. Natural history of localized prostatic cancer managed by conservative therapy alone. Lancet 1988;494–497.

e Madsen PO, Graverson PH, Gasser TC, et al. Treatment of localized prostatic cancer: radical prostatectomy versus placebo: a 15-year follow-up. Scand J Urol Nephrol Suppl 1988;110:95–100.

Source: Reprinted from Presti JC Jr. Urology. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

measured. While performing this study, record is made of the bladder’s response to filling (i.e., sensation, compliance, stability, capacity) and the peak strength of bladder pressure generation during voiding. The peak bladder voiding pressure is correlated with the electronically measured voiding urine flow measurement.

Cases of mixed disease states pose a management challenge. A patient may have poor bladder contractility secondary to diabetic nephropathy aggravated by bladder obstruction secondary to BPH. In such patients, results of BPH management often are suboptimal. In men with Parkinson’s disease and bladder outlet obstruction secondary to BPH, transurethral resection of the prostate (TURP) is associated with a high rate of incontinence and is avoided, and maximal medical management is utilized.

Treatment

It generally is recommended that a discussion of treatment options be initiated in those men with moderate (8 to 19) or severe (≥20) symptom scores (Table 37.4). Treatment may include surveillance alone, medical management, or surgical intervention, the gold standard being electrosurgical TURP. After hearing a discussion of the potential risks and benefits of available therapies, most patients want medical management in an attempt to avoid a surgical procedure if possible.

Medical Management

Medical management consists primarily of a-receptor blockade or 5a- reductase inhibition (Table 37.5). Alpha-blocker agents (i.e., Cardura, Hytrin, Flomax) have been shown to decrease the tone of the a- innervated muscle of the prostatic stroma and bladder neck regions. These agents decrease the symptom score and improve urinary flow rates. As a result, the alpha-blockers are Food and Drug Administration

660 M. Perrotti

Table 37.3. Urodynamic findings in selected neurologic disorders.

abnl, abnormal; DH, detrusor hyperreflexia; DA, detrusor areflexia; DSD, detrusor sphincter dyssynergia; ISD, intrinsic sphincter deficiency; nl, normal.

37. Lower Urinary Tract Disorders 661

Table 37.4. American Urologic Association

Prostate Symptom Index (AUA-SI).

(FDA) approved for reduction of symptoms attributable to BPH. The other arm of medical therapy is the use of a 5a-reductase inhibitor. Currently, there is only one 5a-reductase inhibitor—Proscar—available for use in the U.S. This agent reduces intraprostatic 5-hydroxy-testos- terone, results in regression of the glandular component of BPH, and has been shown to reduce prostate volume by up to 20%. Similar to alpha-blockers, 5a-reductase blockade reduces the symptom score, improves urinary flow rates, and is approved for this indication in men with BPH. Additionally, however, 5a-reductase inhibition has been shown to reduce the risk of acute urinary retention in men with moderate to severe symptoms of BPH in a well-conducted randomized prospective study and is approved for long-term use in men with BPH to prevent urinary retention. There are data to indicate that risk reduction improves with increasing prostate size and advancing patient age at baseline, the very patients who are at the highest risk of urinary retention if not treated. It is tempting to use both an alphablocker and 5a-reductase inhibitor simultaneously, given their differing mode of action. This is sometimes done in men with symptoms of BPH who are deemed not to be good surgical candidates secondary to significant comorbidities (i.e., recent myocardial infarction).

Surgical Management

Men who experience progression of symptoms despite medical management often are advised to undergo transurethral electrosurgical resection of the obstructing prostate tissue. This procedure is most effective in relieving the obstructive symptoms of BPH, allowing for markedly improved urinary flow and bladder emptying. Some men prefer surgical intervention to medical management due to severity of bladder outlet obstruction, medication adverse reaction, or cost-related issues. Newer thermal therapies are available that may provide symptom reduction with less attendant procedural risk compared to traditional electrosurgical resection.

Table 37.5. Agents used in the medical management of benign prostatic hyperplasia (BPH).

662 M. Perrotti

Urinary Incontinence

Urinary incontinence is the involuntary loss of urine. This condition is seen in men and women and can have a variety of etiologies. It is important to obtain a full medical history and to conduct a full physical examination, with special attention to urologic history, obstetrical and gynecologic history, and neurologic history (Table 37.3). It often is helpful to approach the incontinent patient with the aim of classification based on a simplified approach that describes the bladder disorder (i.e., failure to store, as in a patient with stress incontinence) (Table 37.6).

Female Patient

In evaluating the female patient, as in Case 1, it is helpful first to determine whether the incontinence follows a pattern consis-

Table 37.6. Functional classification of urinary incontinence.

Failure to store

Because of the bladder

Detrusor hyperactivity

Involuntary contractions

Suprasacral neurologic disease

Idiopathic

Decreased compliance

Fibrosis

Idiopathic

Sensory urgency

Inflammation

Infectious

Neurologic

Psychological

Idiopathic

Because of the outlet

Stress incontinence

Nonfunctional bladder neck/proximal urethra

Failure to empty

Because of the bladder

Neurologic

Myogenic

Psychogenic

Idiopathic

Because of the outlet

Anatomic

Prostatic obstruction

Bladder neck contracture

Urethral stricture

Functional

Smooth sphincter dyssynergia

Striated sphincter dyssynergia

37. Lower Urinary Tract Disorders 663

Table 37.7. Agents used in the medical management of detrusor hyperreflexia/overactive bladder.

tent with stress urinary incontinence (i.e., leakage at bladder outlet with increases in intraabdominal pressure) or urgency urinary incontinence (i.e., leakage associated with the urge to void). Classically, a patient with stress urinary incontinence reports leakage of urine with sneeze, cough, or activities such as lifting, jogging, or brisk walking. The patient with urgency incontinence commonly reports accompanying urinary frequency and often is classified as having an “overactive” bladder. It is important to be aware that there may be overlap of these two broad categories, an example of which is illustrated by Case 1. Though this patient leaks urine with cough and sneeze, it is the urgency and urge incontinence following stroke that is interfering most with her activities of daily life. Detrusor hyperreflexia commonly is seen in cases of suprapontine cerebral disorders such as cerebrovascular accident (Table 37.3). Though bladder neck suspension would address the stress component of this patient’s incontinence, what she really needs is anticholinergic therapy to control her detrusor hyperreflexia. In patients with stress urinary incontinence, options for management include Kegel exercises, biofeedback, and operative suspension of the bladder neck. There are a variety of techniques for bladder neck suspension, and, in most cases, a pubovaginal sling procedure is performed.

Male Patient

In the male patient with incontinence, it is important to rule out retention with urinary overflow incontinence. Retention may be due to BPH, primary bladder dysfunction as in diabetes, other neurologic etiology (i.e., multiple sclerosis), or a combination of factors. Retention of urine can be ruled out by measuring the postvoid bladder urine residual volume either with ultrasound or, more commonly, with bladder catheterization. Incontinent male patients may suffer from detrusor hyperreflexia with resultant urgency incontinence. Men with injury to the urinary sphincter show failure to store urine and a stress incontinence pattern.

Treatment of hyperreflexia consists of anticholinergic therapy (Table 37.7). One must be cautious in the male patient not to induce urinary retention iatrogenically by weakening the detrusor too much. Risk of retention is due to the higher detrusor voiding pressure required in men to overcome the resistance of the prostatic urethra. In men with

664 M. Perrotti

stress incontinence, treatment may be conservative (i.e., Kegel, biofeedback) or may be operative. Operative interventions include bladder neck injection with bulking agents such as collagen or implantation of artificial urinary sphincter.

Hematuria

Hematuria may be gross (visible to the naked eye), as in Case 2, or microscopic and can present alone or in combination with other symptoms. Etiologies include infection, urinary calculi, malignancy, and trauma. In Case 2, the patient experienced a traumatic event, resulting in gross hematuria. In this situation, urethral injury is likely. When pain is present, its location may point to the source of bleeding, indicating the importance of the patient history. Malignancy of the urinary tract is most common in smokers and in those over 40 years of age. It generally is recommended that, after the physical examination is performed, the patient provide urine for analysis and bacterial culture as well as for cytology testing for cancer cells. Results will direct further evaluation and treatment. (See Chapter 38, Evaluation of Flank Pain.)

Upper urinary tract imaging is required to rule out a renal etiology for hematuria, and renal ultrasound assesses for mass lesion, calculus, or other abnormality, such as hydronephrosis. Renal ultrasound is desirable given its safety and lack of need for contrast injection. It is limited, however, by its lack of ability to visualize the ureter wall. Intravenous pyelogram (IVP) provides anatomic imaging of the ureter’s entire length, but it has been supplanted in most institutions by computed tomography (CT) scanning. Though CT lacks the fine ureteral lumen detail of IVP, it is far superior to IVP in imaging the kidneys, bladder, prostate, and surrounding structures.

In the nonacute setting, office fiberoptic cystoscopy is performed to inspect, under direct vision, the urethra, including the posterior prostatic urethra, and the bladder. Urine effluent from the left and right ureteral orifices is assessed for evidence of bleeding. Cystoscopy in the operating room under anesthesia is reserved for those with an abnormal finding on office fiberoptic cystoscopy and for those with gross bleeding requiring clot evacuation and fulguration. At the time of cystoscopy in the operating room, bladder biopsy, endoscopic tumor removal, retrograde pyelogram of the upper tracts, and ureteroscopy to evaluate the ureter and renal pelvis may be performed. Patients with gross hematuria may require hospitalization, prompt evaluation, and treatment for hemodynamic instability, significant drop in blood count, or inability to evacuate urinary tract (i.e., clot retention).

The evaluation of the trauma patient is coordinated with the trauma team. The finding of gross blood at the penile meatus, as in our case study, requires evaluation of the urethra with retrograde urethrogram to rule out the presence of a urethral disruption. In the event that a urethral disruption is documented, urethral catheterization of

37. Lower Urinary Tract Disorders 665

Table 37.8. Urinalysis and intravenous urography in the diagnosis of ureteral injuries.

N/A, not available.

a Number of patients in study.

b Microscopic (>5 red cells/high-power field) or gross hematuria on initial urinalysis. c Intravenous urography demonstrating ureteral injury.

d Peterson NE, Pitts JC. Penetrating injuries of the ureter. J Urol 1981;126:587–590.

e Liroff SA, Pontes JES, Pierce JM Jr. Gunshot wounds of the ureter: 5 years of experience. J Urol 1977;118:551–553.

f Lankford R, Block NL, Politano VA. Gunshot wounds of the ureter: a review of ten cases. J Trauma 1974;14:848–852.

trauma: diagnosis and management. J Trauma 1989;29:370–374.

j Steers WD, Corriere JN Jr, Benson GS, et al. The use of indwelling ureteral stents in managing ureteral injuries due to external violence. J Trauma 1985;25:1001–1003.

k Rober PE, Smith JB, Pierce JM. Gunshot injuries of the ureter. J Trauma 1990;30:83–86. l Campbell EW, Filderman PS, Jacobs SC. Ureteral injury due to blunt and penetrating trauma. Urology 1992;40:216–220.

Source: Reprinted from Presti JC Jr. Urology. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

the bladder is avoided to prevent further urethral damage, and a suprapubic cystostomy tube is placed. In performing retrograde urethrogram, contrast is injected into the penile urethra under fluoroscopic guidance via a catheter placed in the fossa navicularis; 3 cc of saline placed in the retention balloon of the catheter provides an adequate seal. In the absence of contrast extravasation indicating that the urethra is intact, a Foley catheter may be passed into the bladder.

To rule out bladder perforation as a source of hematuria, a cystogram is performed. Contrast is instilled into the bladder under gravity via a Foley catheter, and a maximum of 400 cc is instilled. Imaging is achieved with either fluoroscopy or CT (i.e., CT cystogram). Extravasation of instilled contrast from the bladder indicates bladder perforation. The kidneys and ureters are evaluated most commonly with CT following intravenous contrast injection (Table 37.8). The

666 M. Perrotti

kidneys are assessed to confirm blood flow and rule out renal parenchymal fracture. The integrity of each ureter is assessed from renal pelvis to bladder.

Cystitis

Cystitis denotes an inflammation of the urinary tract. By far the most common is bacterial cystitis, representing an inflammation in the bladder secondary to a bacterial infection. Bacterial cystitis may be accompanied by urinary frequency, dysuria, urgency, and foulsmelling or cloudy urine. There may be associated suprapubic discomfort, lower back pain, and low grade (i.e., <101°F) temperature elevation. Some patients present with hematuria due to marked bladder mucosal inflammation. It is preferable to obtain urine analysis and culture at the time of antibiotic initiation, though many patients are treated empirically. Commonly used first-line agents are Macrodantin and Bactrim, and success rates are approximately 60% and 75%, respectively. Though required length of therapy remains poorly defined, it generally is agreed that 3 days is too short and 10 days probably unnecessary and associated with complications such as yeast vaginal overgrowth. Most patients are treated with 5 to 7 days of therapy. In patients with persistent symptoms following antibiotic therapy, careful reevaluation of the urinary tract is required, starting with urinalysis and culture. Subsequent treatment and further evaluation are based on these results.

In the evaluation of patients with recurrent urinary tract infection (see Algorithm 37.2), it is important to differentiate between persistent and recurrent infection, to confirm that prior documented infection has been treated appropriately (i.e., appropriate antibiotic for sufficient duration), and to rule out predisposing factors such as structural abnormalities (i.e., bladder diverticulum, bladder outlet obstruction), potential nidus of infection (i.e., renal calculus), or host factors (i.e., postmenopausal state, immunosuppression). In patients with no discernible etiology, some success has been seen when bowel dysfunction (i.e., constipation) and voiding dysfunction (i.e., incomplete emptying; incontinence) are addressed. Complicated infections are those associated with temperature elevation above 101°F, structural abnormalities of the urinary tract, resistant organisms, or renal insufficiency. They pose a treatment challenge and often require advanced therapies.

Some patients have lingering bladder discomfort after infection has been treated appropriately. In these patients, the urinalysis is acellular, and culture results are negative. Often, such patients are treated with repetitive courses of antibiotics. However, in such patients, antispasmotic agents alone are effective (Table 37.7) for symptom relief.

668 M. Perrotti

and urinary tract. Most commonly, in cases of diverticular disease, a communication is seen between the colon and bladder. Less commonly, the etiology is colon cancer. The study of choice is a CT scan of the abdomen and pelvis to inspect the bladder for air. If the bladder has not been instrumented (i.e., cystoscopy, catheterization), no air should be within the bladder, and this finding on CT scan denotes presence of fistula until proven otherwise. Patients with enteric-vesical fistula have positive urine cultures refractory to antibiotic therapy, often with multiple organisms. In the absence of enteric-vesical fistula, pneumaturia may be due to urinary tract infection with a gasproducing organism. Other patients simply have “frothy” urine and need only to be reassured.

Treatment depends on etiology. In the case of urinary tract infection alone, appropriate antibiotic therapy is administered. In patients with enteric-vesical fistula, formal evaluation of the gastrointestinal tract is required, often with barium enema and colonoscopy. Malignancy must be ruled out, and colonic biopsy of any suspicious regions performed. Cystoscopy reveals a region of reddened, raised mucosa that may be biopsied. Repair is surgical, with primary treatment of the primary gastrointestinal process and simultaneous formal bladder repair.

Summary

Lower urinary tract symptoms result from abnormalities of the bladder and urethra. In males, benign hyperplasia is most common and may present with urinary frequency, urgency, or retention. In females, obstruction is uncommon; however, incontinence due to relaxation of the pelvic floor musculature is seen more often. The bladder and urethra are vulnerable to trauma and should be evaluated when blood is seen at the urethral meatus during trauma. Infection and tumor also can produce lower urinary tract symptoms, and cystoscopy is often needed to exclude the latter.

Selected Readings

Benign prostatic hyperplasia: diagnosis and treatment clinical practice guideline No. 8. AHCPR Publication No. 94-0582. February 1994.

Cohn DE, Rader JS. Gynecology. In: Norton JA, Bollinger RR, Chang AE, et al., eds. Surgery: Basic Science and Clinical Evidence. New York: SpringerVerlag, 2001.

Perrotti M, Fair WR. Prostate cancer: patient evaluation. In: Resnick MI, Thompson IM, eds. Surgery of the Prostate. New York: Churchill Livingstone, 1998:1–20.

Presti JC Jr. Urology. In: Norton JA, Bollinger RR, Chang AE, et al., eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001.

Steers WD, Barrett DM, Wein AJ. Voiding function and dysfunction. B. Voiding dysfunction: diagnosis, classification and management. In: Gillenwater JY,

37. Lower Urinary Tract Disorders 669

Grayhack JT, Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis: Mosby-Year Book, Inc., 1996:1220–1325.

Zderic SA, Levin R, Wein AJ. Voiding function and dysfunction. A. Voiding function: relevant anatomy, physiology, pharmacology and molecular aspects. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis: Mosby-Year Book, 1996:1159–1219.