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Urological Symptoms

August 2016
Scope
Introduction

Hematuria

Incontinence

Acute Urinary Retention

Uremia

Summary
Introduction
Urinary Symptoms 14% of referrals with symptoms
to palliative care services

Symptoms in 400 patients referred to palliative care services: prevalence and patterns.
Potter et al Pall Med 2003
Introduction
Conditions that may lead to urological symptoms
Cancers prostate, bladder, ureter, kidneys,
gynaecological
Infections upper/lower tract
Neurological Spinal cord lesions, MND
Drugs anti-cholinergics
Organ failure renal failure
Iatrogenic Post-radiation (radiation cystitis)
Hematuria
Defintion (American Urological Association)
Hematuria is defined as the presence of red
blood cells in the urine. When visible to the
patient, it is termed gross hematuria and is
usually alarming to patients. Microscopic
hematuria is that detected by the dipstick
method or microscopic examination of the
urinary sediment
Hematuria
Intervention Response Indication Remarks
Arterial 90% All causes May be combined
Occlusion with urinary
diversion
Formalin 90% Radiation Cystitis High complication
Instillation Recurrence after rate
combined approach
Alum 80% Sloughing Tumor Avoid in renal
Instillation Mass, impairment
Radiation Cystitis, Cheap
Cyclophosphamide
Induced
Hemorrhagic Cystitis
(CIHC)

Hyperbaric 85% Radiation Cystitis Expensive


Oxygen CIHC At least 20
Therapy sessions

Palliative Treatment of Intractable Hematuria in Context of Advanced Bladder


Cancer A systematic review. Seyeed GM & Naseer M Urology Journal 2009
Hematuria
Intervention Respons Indication Remarks
e
Intravesical 90% CIHC Mixed response
Carboprost Not
Instillation recommended
Urinary Diversion 87% Radiation Cystitis Treats associated
CIHC azotemia
Chemoradiation Good May change
inoperable cancer
to surgically
resectable
Palliative Last resort
Cystectomy

Palliative Treatment of Intractable Hematuria in Context of Advanced Bladder


Cancer A systematic review. Seyeed GM & Naseer M Urology Journal 2009
Hematuria
Incontinence
Definition (International Continence Society)
Any complaint of involuntary leakage of urine or
faeces
Types of Urinary Incontinence
Stress associated with coughing, sneezing
Urge associated with sudden desire to void
Mixed mix of Stress and Urge Incontinence
Prevalence increases with age
More prevalent in long term care institutions
Incontinence
Stress Urinary Incontinence
Avoid coffee
Bladder Training
Scheduled voiding
Restrict fluids if appropriate
Pelvic Floor Muscles Training (PFMT)
Drugs antimuscarinics e.g. Oxybutinin ,
Tolterodine
Incontinence
Urge Urinary Incontinence
Lifestyle advice
Caffeine reduction
Weight loss if obese
Scheduled voiding
Physical Therapy (PFMT)
Behavioral Therapy
Medications
Surgical Intervention
Incontinence
Mixed Urinary Incontinence
Management focused on predominant
component urge or stress
Incontinence
Acute Retention of Urine
Definition (International Continence Society)
This is defined as a generally (but certainly not
always) painful, palpable or percussable
bladder, when the patient is unable to pass any
urine when the bladder is full

Percussible bladder 150 mls

Palpable bladder 200 mls


Acute Retention of Urine
Causes
Drugs
Infection
Constipation
Clot retention
Neurological cauda equine
Diabetes
Pelvic mass
Prostate
Acute Retention of Urine
Treat reversible causes
Bladder Catheterisation
Indwelling vs intermittent
Long term vs short term
Urethral vs Suprapubic
Uremia
Definition
uremia is used loosely to describe the illness
accompanying kidney failure that cannot be
explained by derangements in extracellular volume,
inorganic ion concentrations, or lack of known renal
synthetic products.
We now assume that uremic illness is due largely to
the accumulation of organic waste products, not all
identified as yet, that are normally cleared by the
kidneys.

Uremia. Meyer & Hostetter. NEJM 2007


Uremia
Signs and Symptoms
Neuro/Muscular
Fatigue, Peripheral neuropathy, Cramps,
Anorexia/nausea, Restless legs, Altered mental
state, Sleep disturbances, Seizures, Coma
Endocrine/Metabolic
Amenorrhea, Sexual dysfunction, Bone disease,
Reduced resting energy expenditure, Insulin
resistance, Increased protein-muscle catabolism
Others
Serositis, Pericarditis, Hiccups, Itch, Anemia,
Platelet Dysfunction

Uremia. Meyer & Hostetter. NEJM 2007


Uremia
Pruritus/Itch
Emolients
Limited role for anti-histamines
Paroxetine or Mirtazapine
Hiccups
Chlorpromazine, haloperidol
Seizures
Benzodiazepines
Summary
Important to look for reversible causes
Consider common causes for symptoms
Relief of symptoms may improve QoL