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Toronto Notes 2019
Lower Urinary Tract Symptoms (LUTS)
Urology U11
Dysuria
Definition
• painfulurination
Etiology
Table 6. Differential Diagnosis of Dysuria
Infectious
Neoplasm Calculi Inflammatory
Hormonal Trauma Psychogenic Other
Cystitis, urethritis, prostatitis, epididymitis/orchitis (if associated with lower tract inflammation), cervicitis, vulvovaginitis, perineal inflammation/infection, TB, vestibulitis
Kidney, bladder, prostate, penis, vagina/vulva, BPH Bladder stone, urethral stone, ureteral stone
Seronegative arthropathies (reactive arthritis: arthritis, uveitis, urethritis), drug side effects, autoimmune disorders, chronic pelvic pain syndrome (CPPS), interstitial cystitis
Endometriosis, hypoestrogenism
Catheter insertion, post-coital cystitis (honeymoon cystitis)
Somatization disorder, depression, stress/anxiety disorder
Contact sensitivity, foreign body, radiation/chemical cystitis, diverticulum
Investigations
• focusedHxandP/Etodeterminecause(fever,d/c,conjunctivitis,CVAtenderness,back/jointpain)
■ any d/c (urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing; wet mount if
vaginal d/c
■ U/AandurineC&S
■ if suspect infection, may start empiric ABx treatment (see Table 9, U16)
■ ± imaging of urinary tract (tumour, stones)
Hydronephrosis
• theupperurinarytractconsistsofthekidneysandureters
Definition
• dilationoftherenalpelvisandcalycescausedbytheimpairmentinantegradeurineflow(aka pelvicaliectasis)
Etiology
• mechanical
■ congenital: see Congenital Abnormalities, U37 ■ acquired
◆ intrinsic: trauma, inflammation and bleeding, calculi, urologic neoplasms, BPH, urethral stricture, phimosis, previous urological surgery
◆ extrinsic: trauma, neoplasms (uterine fibroid; colorectal, uterine, and cervical malignancies; lymphoma), aortic aneurysm, pregnancy (gravid uterus)
• functional
■ neuropathic: neurogenic bladder, diabetic neuropathy, spinal cord disease ■ hormonal: pregnancy (progesterone decreases ureteral tone)
Investigations
• focusedHx,inquiringaboutpain(flank,lowerabdomen,testes,labia),U/O,medicationuse,pregnancy, trauma, fever, Hx of UTIs, calculi, PID, and urological surgery
• CBC,electrolytes,Cr,BUN,U/A,urineC&S
• imagingstudies(U/Sis>90%sensitiveandspecific)
■ CT: helps delineate anatomy and potential causes (e.g. obstructing stone), but does not provide much functional information
■ MAG3 diuretic renogram: provides little anatomic structural information but evaluates differential renal function and demonstrates if functional obstruction exists
Treatment
• hydronephrosiscanbephysiologic(e.g.pregnancy)
• treatmentshouldbeguidedatimprovingsymptoms,treatinginfections,orimprovingrenalfunction • urgenttreatmentmayrequirepercutaneousnephrostomytubeorureteralstentingtorelievepressure