Материал: Oxford American Handbook of Urology ( PDFDrive )

12 CHAPTER 1 Preliminary investigation

neoplastic conditions of the bladder, prostate, or urethra. While LUTS are, in general, relatively nonspecific for a particular disease, the associated symptoms can indicate their cause.

For example, LUTS in association with hematuria suggests a possibility of bladder cancer. This is more likely if irritative symptoms (urinary frequency, urgency), and bladder (suprapubic) pain are prominent. Carcinoma in situ of the bladder, a superficial, noninvasive, and potentially very aggressive form of bladder cancer, which very often progresses to muscle invasive or metastatic cancer, classically presents in this way.

Recent onset of bed wetting in an elderly man is often due to highpressure chronic retention. Visual inspection of the abdomen may show marked distension due to a grossly enlarged bladder. The diagnosis of chronic retention is confirmed by palpating the enlarged, tense bladder, which is dull to percussion; ultrasound measurement; and drainage of a large volume following catheterization.

Rarely, LUTS can be due to neurological disease.

Multiple sclerosis can cause urgency and urge incontinence.

Parkinson disease is associated with urinary symptoms and incontinence. Many patients also have detrusor overactivity and impaired contractility.

Spinal cord or cauda equina compression due to pelvic or sacral tumors can cause urinary symptoms. Associated symptoms include back pain, sciatica, ejaculatory disturbances, and sensory disturbances in the legs, feet, and perineum. In these rare cases, loss of pericoccygeal or perineal sensation (sacral nerve roots 2–4) indicates an interruption to the sensory innervation of the bladder, and an MRI scan often confirms the clinical suspicion that there is a neurological problem.

Further reading

Abrams P, et al. (2002). Lower urinary tract function. Neurourol Urodyn 21:167–178.

Gravas S, Melekos MD (2009). Male lower urinary tract symptoms: how do symptoms guide our choice of treatment? Curr Opin Urol. 19(1):49–54.

Vishwajit S, Anderson KE (2009). Terminology of lower urinary tract symptoms. Helpful or confusing? Sci World J 18;9:17–22.

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14 CHAPTER 1 Preliminary investigation

Nocturia and nocturnal polyuria

Nocturia is the frequent need to get up and urinate at night. It is differentiated from enuresis (bed wetting) in that the person does not wake and the bladder empties.

Nocturnal polyuria (NP) refers to a condition in which the rate of urine output is excessive only at night and total 24-hour output is within normal limits.

Nocturia 2 is fairly common and is a bothersome cause of sleep disturbance.

Prevalence of nocturia 2: men—40% age 60–70 years, 55% age >70 years; women—10% age 20–40 years, 50% age >80 years.1,2 Nocturia 2 is associated with a 2-fold increased risk of falls and injury in the active elderly.

Men who void more than twice at night have a 2-fold increased risk of death, possibly due to the associations of nocturia with endocrine and cardiovascular disease.3

Diagnostic approach to the patient with nocturia

Nocturia can be due to urological disease, but more often than not it is nonurological in origin. Most awakenings from sleep attributed by patients pressured to urinate were instead a result of sleep disorders—even in those patients with well-known medical reasons for noctruria Therefore, “approach the lower urinary tract last” (Neil Resnick,4 Professor of Gerontology, Pittsburgh).5,6

Causes of nocturia

•Urological: benign prostatic obstruction, overactive bladder, incomplete bladder emptying

•Nonurological: renal failure, idiopathic nocturnal polyuria, diabetes mellitus, central diabetes insipidus, nephrogenic diabetes insipidus, primary polydipsia, hypercalcemia, drugs, autonomic failure, obstructive sleep apnea

Assessment of the nocturic patient

Ask the patient to complete a voiding diary that records time and volume of each void over a 24-hour period for 7 days. This establishes

•If the patient is polyuric or nonpolyuric

•If polyuric, is the polyuria present throughout 24 hours or is it confined to nighttime (nocturnal polyuria)?

1 Coyne KS, et al. (2003). The prevalence of nocturia and its effect on health-related quality of life and sleep in a community sample in the USA. Br J Urol Int 92:948–954.

2 Jackson S (199). Lower urinary tract symptoms and nocturia in women: prevalence, aetiology and diagnosis. Br J Urol Int 84:5–8.

3 McKeigue P, Reynard J (2000). Relation of nocturnal polyuria of the elderly to essential hypertension. Lancet 355:486–488.

4 Resnick NM (2002). Geriatric incontinence and voiding dysfunction. In Walsh PC, Retik AB, Vaughan ED, Wein AJ (Eds.), Campbell’s Urology, 8th ed. Philadelphia: W.B. Saunders.

5 Pressman MR, Figueroa WG, Kendrick-Mohamed J, et al. (1996). Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders. Arch Intern Med 156:545.

6 Fitzgerald MP, Litman HJ, Link CL; McKinlay JB, et al. (2007). The association of nocturia with cardiac disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 177:1385–1389.

NOCTURIA AND NOCTURNAL POLYURIA 15

Polyuria (24-hour polyuria) is defined as >3 L of urine output per 24 hours (standardization).

Nocturnal polyuria is defined as the production of more than one-third of 24-hour urine output between midnight and 8 a.m. (It is a normal physiological mechanism to reduce urine output at night. Urine output between midnight and 8 a.m.—one-third of the 24-hour clock—should certainly be no more than one-third of 24-hour total urine output and, in most people, will be considerably less than one-third.)

Polyuria (urine output of >3 L/24 hours) is due to either a solute diuresis or water diuresis.

Measure urine osmolality: <250 mosm/kg = water diuresis, >300 mosm/ kg = solute diuresis.

Excess levels of various solutes in the urine, such as glucose in the poorly controlled diabetic, lead to a solute diuresis. A water diuresis occurs in patients with primary polydipsia (an appropriate physiological response to high water intake) and diabetes insipidus (DI) (antidiuretic hormone [ADH] deficiency or resistance). Patients on lithium have renal resistance to ADH (nephrogenic DI).

Further reading

Guite HF, et al. (1988). Hypothesis: posture is one of the determinants of the circadian rhythm of urine flow and electrolyte excretion in elderly female patients. Age Ageing 17:241–248.

Matthiesen TB, Rittig S, Norgaard JP, Pedersen EB, Djurhuus JC (1996). Nocturnal polyuria and natriuresis in male patients with nocturia and lower urinary tract symptoms. J Urol 156:1292–1299.

van Kerrebroeck P, Abrams P, Chaikin D, et al. (2002). The standardisation of terminology in nocturia: Report from the Standardisation Sub-committee of the International Continence Society.

Neurourol Urodyn 21:179–183.

16 CHAPTER 1 Preliminary investigation

Flank pain

Sometimes referred to as loin pain, flank pain is pain or discomfort in the side of the abdomen between the last rib and the hip. It can present suddenly with the severity reaching a peak within minutes or hours (acute flank pain). Alternatively, it may have a slower course of onset (chronic flank pain), developing over weeks or months.

Traditionally, flank pain is presumed to be urological in origin, based on the anatomic position of the kidney and ureters. However, other structures in this region and pathology within these structures, and pain arising from extra-abdominal organs may radiate to the flank as a referred pain. While flank pain may be urological, other possibilities must be considered in the differential diagnosis.

The speed of onset of flank pain gives some, though not an absolute, indication of the cause of urological flank pain. Acute flank pain is more likely to be due to something obstructing the ureter, such as a stone. Flank pain of more chronic onset suggests disease within the kidney or renal pelvis.

Acute flank pain

The most common cause of sudden onset of severe pain in the flank is the passage of a stone formed in the kidney that is passing down through the ureter. Ureteric stone pain characteristically starts very suddenly (within minutes), is colicky in nature (waves of increasing severity are followed by a reduction in severity, though seldom going away completely), and radiates to the groin as the stone passes into the lower ureter.

The pain may change in location, from flank to groin, but its location does not provide a good indication of the position of the stone, except when the patient has pain or discomfort in the penis and a strong desire to void, which suggests that the stone has moved into the intramural part of the ureter (the segment within the bladder) or bladder. The patient cannot get comfortable and often changes position frequently without relief.

Half of patients with these classic symptoms of ureteric colic do not have a stone confirmed on subsequent imaging studies or have no documentation of passing a stone.1,2 They have some other cause for their pain (see next page).

A ureteric stone is only very rarely life threatening, but many of the differential diagnoses may be life threatening. Acute flank pain is less likely to be due to a ureteric stone in women and in patients at the extremes of age. Urolithiasis tends to be a disease of men (less common in women) between the ages of ~20 and 60 years, though it can occur in younger and older individuals.

1 Smith RC (1996). Diagnosis of acute flank pain: value of unenhanced helical CT. AJR Am J Roentgen 166:97–100.

2 Thomson JM (2001). Computed tomography versus intravenous urography in diagnosis of acute flank pain from urolithiasis: a randomized study comparing imaging costs and radiation dose.

Australas Radiol 45:291–297.