Polyuria

Urine output of >3 litres per day.  Note that it is usually accompanied by urinary frequency, but that frequency itself may not indicate polyuria (i.e. frequently passing small vs large volumes).

Pathophysiology

• In general, polyuria can be a result of anything that causes
  • Increased water intake (polydipsia)
  • Decreased ADH (antidiuretic hormone) secretion (central diabetes insipidus)
  • Decreased peripheral ADH sensitivity (nephrogenic diabetes insipidus)
    • ADH promotes water reabsorption in the renal collecting ducts
  • Solute diuresis (most commonly seen in uncontrolled diabetes mellitus- where high glucose concentrations cause a passive diuresis)

Assessment

• History
  • Define the extent of polyuria and distinguish between urinary frequency i.e. how much urine
  • If polyuria is present, explore this
    • Onset, Duration, Progression, Triggers, Exacerbating/Alleviating factors
    • Associated symptoms- specifically thirst/drinking (polydipsia); weight changes, (also night sweats)
  • Specific things to ask about include
    • Any recent IV fluids/tube feeds; recent catheterisation/urinary obstruction; recent head trauma/surgery or stroke
      • Note patients can be polyuric following urinary obstruction
  • PMHx
    • Diabetes mellitus
    • Psychiatric disorders – on lithium treatment
    • Sickle cell disease
    • Sarcoid/amyloidosis
    • Hyperparathyroidism
    • Hypertension – on diuretics
    • Alcohol and caffeine intake
    • Smoking history
• Examination
  • General examination of
    • Blood pressure/pulse
    • Weight
    • Mucous membranes (dry?)
    • Skin (dry, pigmented lesions, ulcers/nodules)
  • Neurological/psychiatric exam (doesn’t have to be extensive but may be further explored if there is any suspicion or positive findings
    • e.g. papilloedema; visual fields etc

Red Flags

• Abrupt onset or onset in children
• Night sweats, weight loss (particularly where there is a smoking history too)
• Psychiatric disorder

Investigations

• Serum or fingerprick (BM) glucose measurement and urinalysis to rule out diabetes mellitus
• Where hyperglycaemia is absent
  • U&Es including serum Calcium
    • Hypernatraemia suggests excess water loss due to diabetes insipidus
    • Hyponatraemia suggests excess free water intake (polydipsia)
  • Urine osmolarity
    • usually low with water diuresis and high with solute diuresis
• If a diagnosis is not yet clear, a water deprivation test can be done
  • (NB only to be done as an inpatient under supervision)
    • Typically a baseline set of weight, bloods and observations are performed in the morning.  The patient is then deprived of water.  Where possible, hourly samples of urine are tested for osmolarity and sodium concentrations.  Once the patient shows signs of deprivation (i.e. orthostatic hypotension; postural tachycardia; >=5% weight loss OR if the urinary concentration does not increase by >30mOsm/kg), baseline measurements are repeated and a bolus of exogenous ADH administered.  One hour later, measurements are repeated again.
  • Interpretation
    • Normal
      • Maximal urine osmolarity after dehydration (>700mOsm/kg), and osmolarity does NOT increase >5% following ADH injection
    • Central diabetes insipidus
      • Urine osmolarity unchanged during water deprivation but concentrates following ADH administration
    • Nephrogenic/peripheral diabetes insipidus
      • Urine osmolarity shows no significant change after either water deprivation or ADH administration
    • Psychogenic polydipsia
      • Initial urine osmolarity is low (<100mOsm/kg), but urine concentration will normalise with water deprivation (essentially normal response)
  • Other tests which may be appropriate include
    • Pituitary function tests
    • Serum lithium concentration
    • Autoantibody screen

Causes

• Other causes include
  • Cushing’s syndrome/disease
  • CKD
  • Hypercalcaemia
  • Fanconi’s syndrome

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Reflux Nephropathy/Chronic Pyelonephritis

Background

• Specific type of chronic interstitial nephritis associated with vesico-ureteric reflux (VUR) in early life and the development of scarring of the kidney
• Due to chronic reflux of urine from the bladder into the ureters, in association with recurrent UTI in childhood (although ascending UTI/pyelonephritis is not necessarily a cause of scarring; reflux thought to be more important)
  • Factors other than these (e.g. genetic susceptibility) may also play a role
• VUR affects ~1% of neonates and 30-45% of children with a febrile UTI
  • Most children ‘grow out’ of this problem by age 5 (surgery is no longer routine)
• Incompetent UV valves or mechanical obstruction are the main causes

Presentation

• Renal scarring is usually asymptomatic (frequent UTIs as a child aside)
• Can present at any age of features of CKD e.g. hypertension, proteinuria, oedema (particularly in bilateral disease); lower urinary tract symptoms may also be present e.g. frequency, nocturia, dysuria

UTI in childhood

• A suspicion of VUR should be high in
  • UTI < 3 years
  • Febrile UTI <5 years
  • Recurrent UTIs in children

Investigations

• Renal USS may show renal scarring (can be difficult to visualise)
  • Radionuclide DMSA scans are particularly sensitive at showing scarring of the kidney
  • MRI/CT may also be useful
  • Micturating cystourethrogram may also be useful at detecting reflux
• Urinalysis
• FBC and U&Es
• (see also CKD)

Management

• Prophylactic antibiotics if there are recurrent infections
  • Men- Trimethoprim 200mg BD/Nitrofurantoin 50mg QDS or 100mg MR BD
  • Women- Trimethoprim 100mg nocte/post-coital +/- cranberry juice
• Manage CKD as appropriate
• Nephrectomy may be appropriate in unilateral disease

Urinary Incontinence

Background/Classifications

Involuntary leakage of urine

• Functional incontinence: e.g. due to poor mobility (unable to reach the toilet)
• Stress incontinence: involuntary leakage on effort/exertion e.g. sneezing/coughing.  Most commonly in women due to weakness of the pelvic floor muscles
• Urge incontinence: involuntary leakage immediately preceded by urgency, usually due to bladder dysfunction
• Overflow incontinence: usually due to chronic bladder outflow obstruction (e.g. prostatic disease in men) and can be accompanied by urinary retention
• Much more common in women than in men and the elderly (46% of women >80 and 34% of men >80)

Risk factors

• Women
  • Parity (more pregnancies and vaginal deliveries- more risk) – particularly of stress incontinence
  • BMI
  • Menopause

History

• Determine type of incontinence (stress, urge, mixed)
  • NB if mixed focus mainly on the predominant symptoms
• Ask about other urinary symptoms
  • Frequency, nocturia, dribbling/incomplete emptying, dysuria
  • Also ask about any sexual dysfunction, bowel habit
• Ask about previous medical history and current/past medications
  • In women, this should a full PMHx for Obs/Gynae (particularly parity, deliveries, surgery etc)
  • Ask about any neurological conditions (personal or family history)
• Ask about social circumstances, including functionality/mobility
  • e.g. access to the bathroom, family support
  • Also ask about caffeine, alcohol and diet/fluids
• Patients may also be asked to fill out a symptom scoring checklist to estimate the severity/impact of symptoms

Examination

• Women
  • Perform a full gynaecological examination including testing the tone of the pelvic floor
    • Assess also any prolapse
• Men
  • DRE: prostate examination
• Also examine the abdomen, pelvis and nervous system

Investigations

• Urinalysis/MSSU
  • Important to exclude treatable cause like UTI
• Residual volume scan (USS) or catheterisation
• Urinary (voiding) diaries
• NB Urodynamic testing is not often used first line but can be used in
  • patients with symptoms of over-active bladder/detrusor overactivity
  • symptoms suggestive of voiding dysfunction e.g. poor flow
  • patients who have had previous surgery for stress incontinence

Management

• 1st line
  • Lifestyle
    • Reduce caffeine intake
    • Consider altering fluid intake
    • Weight loss
  • Physiotherapy
    • pelvic floor muscle training for stress incontinence
    • bladder re-training for urge incontinence
• 2nd line
  • Drug treatment
    • Oxybutynin or tolterodine can be offered for urge incontinence
      • Review in 4 weeks (benefit) and 6 months (review)
    • The use of drugs in treating stress incontinence is limited although duloxetine may be used in conjunction with pelvic floor exercises (SIGN not NICE)
• 3rd line
  • Surgery/Invasive
    • Consider retropubic mid-urethral tape procedure with synthetic tape
    • Other procedures include open colposuspension and autologous rectus fascial sling procedures
  • Intramural bulking agents (rare)
• Others
  • Catheterisation can be considered (first line for relief in obstructive incontinence)

Oliguria/Anuria

There are various definitions:

Oliguria can generally be defined as <0.5ml/kg/hour or <300ml per day (whether catheterised or not).

Anuria <50ml/day.  Anuria is an emergency requiring rapid management.

Background/Physiology

• Urine volume is a difference of the amount of fluid filtered by the glomerulus and that reabsorbed by the renal tubules
  • It is not (directly) a measure of renal function (reduced GFR and reduced tubule reabsorption -> normal urine volume)
  • HOWEVER, it is commonly used as a physical measure of renal function in the acute setting, as reduced urine output is often one of the first physiological signs of hypovolaemia and/or shock
• Can be a result of reduced urine production
  • Acute kidney injury e.g. pre-renal AKI in diabetic ketoacidosis, dehydration or blood loss; or intra-renal AKI e.g. in glomerulonephritis
• Rarely a result of obstruction
  • Obstruction would have to be complete and below the level of the bladder neck; or bilateral; or unilateral on the side of a single-functioning kidney

Clinical Assessment

• Commonly, as a doctor you will be asked to review a patient with poor urine output as a sign of patient deterioration (whether this is associated with other physiological changes e.g. heart rate/BP etc or not)
  • ABCDE!
• THEN a History (if patient is able to give one)
  • Try and determine the timeline (onset; Any history of fluid loss e.g. diarrhoea, vomiting, bleeding, post operative)
  • Ask about PMHx and RHx
    • Stones, kidney problems in the past
    • Drugs e.g. Gentamicin, NSAIDs, ACEIs/ARBs, Antibiotics (and STOP these if renal function/U&Es are deteriorating also)
    • Diarrhoea (particularly E coli O157)
• Look for signs of hypotension, tachycardia, tachypnoea, fever (any suggestion of sepsis/shock) and fluid depletion 
• Palpate for bladder distension/tenderness
• In patients with a catheter, check catheter patency before further investigations, particularly if the patient is normotensive

Investigations

• Urinalysis
  • Prerenal causes can have normal urinalysis
  • In intrinsic (AKI cause by ATN)
    • Haematuria/Proteinuria
    • There may be red cell or granular casts
• FBC and U&Es (particularly sodium, potassium, urea, creatinine (and eGFR)
• If infection is suspected
  • FBC, CRP
• ABGs (metabolic acidosis)
• Kidney USS can be performed
• Urinary electrolytes can also be measured although this is not routine

Causes

• Any cause of acute kidney injury
  • Prerenal
    • e.g. volume depletion (bleeding, dehydration)
    • e.g. low cardiac output (MI, heart failure, PE)
    • e.g. decreased vascular resistance (shock, sepsis)
  • Renal e.g. acute tubular necrosis, glomerular disease
  • Post-renal e.g. blocked catheter; stone disease, BPH, sphincter dysfunction (anticholinergics, post operative)

Notes on management

• Treat reversible causes
  • Restore intravascular volume if necessary
• Monitor fluid balance closely
  • Do not prescribe any potassium as there is a risk of hyperkalaemia
• Dialysis may be used in patients where
  • Volume expansion that cannot be managed with diuretics
  • Refractory hyperkalaemia
  • Severe uraemia
    • NB No absolute indications- based on clinical judgement (duration, severity etc)

Acute Pyelonephritis/Urosepsis

Background

• The kidneys may become infected in a minority of patients with UTIs
• As with UTI, pyelonephritis is more common in young women and the most common causative organisms are
  • E coli, Klebsiella pneumoniae, Proteus spp, Pseudomonas spp, Enterococcus spp

Risk factors

• Structural renal abnormalities
• Calculi
• Urinary catheterisation
• Stents or other urological procedures
• Pregnancy
• Diabetes
• Primary Biliary Cirrhosis
• Immunocompromise
• Neuropathic bladder

Presentation

• Classic triad of loin pain, fever and tenderness over the costophrenic angle (kidneys)
  • Onset is often acute
  • Suprapubic pain is also often present.  Other features of lower UTI may be present e.g. frequency, dysuria etc
  • Fever can often be high enough to cause rigors
  • Other systemic features may also be present e.g. nausea/vomiting, anorexia, malaise and occasionally diarrhoea

Investigations

• Urinalysis for leucocytes and nitrites to confirm a UTI.  Urine microscopy and culture/sensitivities should also be sent
• Blood tests
  • FBC (raised WCC); raised CRP and PV
  • Blood cultures
• Imaging may be performed but isn’t necessary for management/diagnosis (may help in cases of uncertainty or if there is a chance of anatomical abnormality)

Management

• Hospital
  • IV Amoxicillin and Gentamicin (Aztreonam can be an alternative to gentamicin)
    • IV Co-trimoxazole if penicillin allergic
    • Step down to oral co-trimoxazole
    • Total 14 days if pyelonephritis (28 days for urosepsis)
• Community
  • Consider admission
  • Co-amoxiclav 625mg TDS or cotrimoxazole 960mg BD for 14 days

Urinary Tract Infection (lower)

Usually describes acute urethritis and cystitis caused by a microorganism.

Background/Epidemiology

• Common- accounts for around 1-3% of consultations in GP; affects around 3% of women at age 20 and increasing by ~1% every decade.
  • In men, UTI is uncommon except in neonates/infants and in men >60 with LUTS.

Risk

• More common in women because, the urethra is shorter and there is closer proximity between the urethra and the vagina and anus.
• Patients with catheters (or other instrumentation or foreign bodies- technically including renal stones) are also much higher risk
• Bladder outflow obstruction e.g. BPH, Prostate Cancer, urethral stricture
• Uterine prolapse
• Neurological conditions e.g. MS, diabetic neuropathy
• Diabetes mellitus
• NB Have a high clinical suspicion in elderly people (particularly females) who have acute onset fever or delirium of unknown cause, as this is the most common cause.

Pathophysiology

• The most common organisms to cause UTIs are
  • E coli (from the GI tract- account for ~75%)
  • Proteus spp
  • Staphylococcus saprophyticus
  • Other organisms include
    • Pseudomonas spp, streptococci and staph epidermidis
    • In hospital, Klebsiella and streptococci are more common (E coli still most common)
• Entry of the organisms may be retrograde (via the urethra), via the bloodstream (particularly in immunosuppressed) or direct (via instrumentation)

Clinical Presentation

• abrupt onset frequency and urgency of micturition
• scalding/burning pain (dysuria) in the urethra during micturition
• suprapubic pain during and after voiding
• feeling of incomplete emptying (due to spasm of the inflamed bladder wall)
• cloudy urine which may have an offensive smell
• there may also be haematuria
• Systemic symptoms e.g. fever, rigors, nausea/vomiting, confusion etc are usually only mild in simple UTI.  If these signs are present, suspect pyelonephritis and/or bacteraemia.
• Make sure to ask about previous UTIs and PMHx

Investigations

• NB UTI in females is a clinical diagnosis and investigations aren’t completely necessary.  UTI in males should be investigated with culture (male UTI is often immediately classed as complicated)
• Urinalysis
  • Leucocytes and nitrites are suggestive of UTI
• Urine microscopy/culture & sensitivity
• In some cases, particularly if the patient is having recurrent episodes or if there is a history suspicious of renal stones, USS imaging may be of benefit.

Management

• In uncatheterised patients
  • 1st line- Trimethoprim 200mg BD for 3 days (female- unless pregnancy is suspected/known) or 7 days (male) OR Nitrofurantoin MR 100mg BD or 50mg QDS for 3 or 7 days.
  • 2nd line- culture sample and treat as sensitivities

Special cases

• Patients with chronic kidney disease
  • In patients with CKD 3B/4/5, consider pivmecillinam (400mg stat then 200mg TDS for 3 days)
• UTI in pregnancy
  • 1st line nitrofurantoin MR 100mg BD or 50mg QDS for 7 days in the 1st and 2nd trimester
    • In the 3rd trimester, trimethoprim 200mg BD for 7 days
  • 2nd line cefalexin 500mg every 8 hours for a minimum of 7 days or as per sensitivities
• Recurrent UTIs in women (≥2/month or ≥3/year)
  • Treat for 6 months then review
  • 100mg trimethoprim at night/post-coital OR nitrofurantoin 50-100mg at night/post-coital
    • (Cranberry juice/extract also has evidence)
• Catheterised patients
  • In the presence of a catheter, antibiotics will NOT eradicate bacteria
  • Change catheter prior to treatment
  • Send sample
  • Treat only if symptomatic/systemically unwell
  • If in the community
    • Co-amoxiclav 625mg TDS for 14 days or cotrimoxazole 960mg BD for 14 days
      • 2nd line, base on sensitivities
  • If in hospital
    • IV Amoxicillin and Gentamicin (cotrimoxazole + gentamicin)
      • Aztreonam can be used as an alternative to gentamicin in patients with kidney failure (AKI/CKD)
      • Step down to co-trimoxazole or adjust as sensitivities suggest for 14 days total

Dysuria

Pain, burning or discomfort on urination.

Background

• More common in younger women
• Most commonly, but not always, a sign of cystitis/urethritis secondary to a UTI
  • Furthermore, the diagnosis of UTI may be secondary to an underlying predisposition e.g. prostatic enlargement in men; anatomical abnormality in children etc

History

• Ask about timing/onset (including when in relation to urination), frequency (how often does it happen), severity, location
  • e.g. Pain on initiation suggests urethritis whereas suprapubic pain after micturition is more suggestive of cystitis
• Ask about associated symptoms
  • Haematuria
  • Urinary frequency, urgency, hesitancy (LUTS); volumes/flow
  • Appearance of the urine (e.g. bloody, cloudy; malodourous)
  • Discharge
  • Flank/abdominal pain/colic
  • Fever, rigors, malaise
• Ask about past medical history (particularly any recent urological procedures/conditions; and if they have had this before) and drug history, sexual history (including unprotected sex), social history
  • ?possible pregnancy

Examination

• Vital observations
  • Temperature; pulse rate
• Abdominal examination
  • Looking particularly for any tenderness, specifically suprapubic or loin tenderness
• Examination of the external genitalia
  • Any inflammation of the genitals, any discharge, any trauma
• PR exam may be appropriate in men who give a history suggestive of prostatic conditions

Investigations

• Urinalysis and mid-stream urine microscopy/culture & sensitivity are often useful first line tests.
  • This may provide enough information to diagnose UTI and warrant the prescription of antibiotics
• First pass urine or high vaginal swabs/endocervical swabs may be useful if sexually transmitted infections are suspected
• Imaging (CT KUB or Renal/Pelvic USS) could be performed if there is suspicion of bladder (or other urological) stones

Causes

• UTI or other infections
  • Pyelonephritis
  • Cystitis
• STIs: Chlamydia, gonorrhoea, non-gonococcal urethritis; genital herpes simplex;
  • Vaginitis
  • Prostatitis, epididymitis/epididymo-orchitis
• Kidney/Bladder stones in the urethra
• Obstruction (prostate enlargement)
• Trauma
• Drugs
  • Cyclophosphamide, allopurinol, danazol,

Scrotal Swellings and Examination

Scrotal swellings are not an uncommon presentation, and it is crucial to be able to differentiate the cause of swelling, as some are a lot more serious than others.  Common and important causes include:

• Testicular cancer
• Testicular torsion
• Torsion of a testicular/epididymal appendage
• Varicocele
• Hydrocele
• Haematocele
• Epididymal cyst (spermatocele)

History

• Ask about pain- duration, severity etc
  • usually severe and acute onset in testicular torsion
  • more gradual pain/swelling in epididymo-orchitis
  • episodic pain can be an atypical feature of testicular torsion
• Ask about any associated symptoms
  • e.g. features of UTI/STI (e.g. discharge, pyuria) which might suggest epididymo-orchitis
  • parotid swelling (mumps orchitis)
  • nausea/vomiting (torsion, rarely in epididymo-orchitis)
• Any history of trauma (haematocele, rarely in torsion)
• Also ask about any relevant past medical history: in particular- undescended testes

NB consider the age of the patient: torsion is generally more common in young men, whereas cancer may be more common in older men

Examination

• YOU SHOULD ALWAYS EXAMINE THE SCROTUM IN THE STANDING POSITION
• If there is a normal side, always examine this first to a) make sure it is normal and b) compare to abnormal
• Inspect for
  • Lie (is one testis higher than other?); appearance; scars; oedema; sebaceous cysts, ulcers or swellings; erythema
• Palpate
  • Does the patient have 2 testes? If not, feel the inguinal canal and perineum for an undescended testis.
    • The scrotum should be freely mobile from the testes
  • Feeling the normal side first, palpate the body and poles of the testicle, checking the patient’s face for any pain/tenderness (ask this too)
    • Compare size, shape and consistency (they should be roughly equal, smooth, rubbery and firm)
    • Are there any lumps, changes in consistency, tenderness, swelling etc?
  • Palpate the epididymis along the posterolateral border of the testis, again noting any tenderness or abnormality
  • Palpate up each spermatic cord, whilst gently pulling the respective testis downwards
    • It should feel regular and smooth
• Special tests
  • Cremasteric reflex
    • can be elicited by stroking the superficial aspect of the medial thigh near the testes and the testis should rise on the respective side.
      • may not do so in torsion
  • Prehn’s sign
    • If the patient has pain which is relieved by raising the testes- the pain is suggestive more of epididymitis.
• Assessing scrotal swellings
  • 

Differential Diagnosis

Haematuria

Macroscopic Haematuria- visible blood in the urine

Microscopic Haematuria- not visible but identified by urine microscopy or dipstick test.  This may be symptomatic or asymptomatic.  Defined as >3 red blood cells in the urine.

NB Be wary that dipsticks actually detect haem, and can (in some uncommon situations) be false negative/positive.  Also recognise that it can be normal to have asymptomatic microscopic haematuria, which usually doesn’t require investigation.

• In children and young people, glomerular causes are more predominant.  In older people, this decreases and cancer and stone disease become more common.

Assessment and Investigation

What is significant haematuria?

• Any single episode of macroscopic haematuria
• Any single episode of symptomatic microscopic haematuria in the absence of UTI and other transient causes
• Persistent asymptomatic microscopic haematuria (2 out of 3 separate urinalysis) in the absence of UTI and other transient causes
  • NB the presence of haematuria should NOT be attributed to anti-coagulant/anti-platelet therapy, unless trauma (e.g. traumatic catheterisation) is present.

Characteristics 

• A renal cause such as glomerulonephritis will generally cause persistent microscopic haematuria with or without periods of gross haematuria
• Gross haematuria associated with renal causes will usually be present throughout the stream
  • if haematuria is only present at the start of stream- it is suggestive of a distal urethral cause e.g. urethritis
  • if only present at the end- it is suggestive of upper urethral/prostatic/trigonal cause
    • this said, bladder cancer and other bladder causes can often present as gross haematuria throughout the stream

Associated symptoms

• Pain- usually associated with stone disease or infection
• Rash, arthralgia, fatigue- may be associated with an inflammatory/immune mediated cause
• Fatigue, night sweats and weight loss may be present with neoplastic causes

Investigations

• EXCLUDE UTI- Urine dipstick should always be done first
  • Nitrites and leucocyte markers suggest UTI
  • Protein suggests nephrological cause e.g. glomerulonephritis
  • MSSU should follow any abnormal dipstick to further evaluate findings
• Symptomatic microscopic haematuria and asymptomatic persistent microscopic haematuria should be further investigated:
  • Blood pressure
  • Creatinine/eGFR (renal function)
  • Urine sample for protein/creatinine ratio (normally <50) or albumin/creatinine ratio (normally (<30)
• All macroscopic haematuria should be investigated by urology with some form of imaging
  • Usually Cystoscopy + USS or CT KUB
• All patients with symptomatic haematuria (inc macroscopic haematuria) and all patients >40 years old with any significant haematuria should be referred to urology.  Referal to renal medicine should be made if eGFR/creatinine or PCR/ACR are abnormal and/or a renal cause is suspected.

Potential Causes

• Cancer:
  • Bladder (TCC, Squamous cell carcinoma); Kidney (Renal cell adenocarcinoma); Renal pelvis/ureter (TCC); prostate
• Stones (kidney/ureteric/bladder)
• Infection
  • bacterial, mycobacterial (TB), parasitic (schistosomiasis), infective urethritis
• Inflammation
  • Cyclophosphamide cystitis, interstitial cystitis
• Trauma
  • In particular catheterisation and pelvic fractures
• Renal Cystic disease
• Nephrological causes (consider particularly in children/young adults; or with accompanying significant proteinuria; blood often takes form of red cell casts)-
  • IgA Nephropathy, post-infective glomerulonephritis, membrano-proliferative glomerulonephritis, Henoch-Schonlein purpura, vasculitis, Alport’s syndrome, thin basement membrane disease, Fabry’s disease etc
• Other causes
  • Anticoagulation therapy; sickle cell/hemophilia; renal papillary necrosis

Lower Urinary Tract Symptoms

A collection of symptoms that commonly co-exist.  Most commonly due to prostatic enlargement in men, but this cause is not exclusive and others should be considered where appropriate e.g. with haematuria- consider bladder cancer; chronic retention; rarely due to neurological dysfunction (cauda equina syndrome/spinal tumours.

Symptomology

• Storage
  • Urgency- sudden urge for micturition
  • Frequency
  • Nocturia
  • Urinary incontinence
• Voiding
  • Hesitancy
  • Straining
  • Slow stream
  • Splitting/spraying
  • Intermittency
  • Terminal dribble
• Post-micturition
  • Dribble
  • Feeling of incomplete emptying

Investigation 

• For men with bothersome LUTS, urinary frequency volume chart
• Urine dipstick analysis
• Bloods for U&Es (renal function) plus PSA in men
  • Do a PSA if symptoms suggest bladder outlet obstruction secondary to BPH or if the patient is concerned about prostate cancer
  • Bloods for PSA should be done before a PR exam (although there is little evidence to suggest that PR exam has a significantly large effect on PSE, many doctors practice this way to be safe)
• Flow-rate measurements and residual volume scans are not recommended by NICE but may be carried out depending on local guidelines
• Serum creatinine may be measured if there is any suspicion of associated renal impairment

Differential Diagnosis

• Benign Prostatic Hypertrophy
• Prostate Cancer
• Bladder Cancer
• Chronic retention/overactive bladder
• Neurological deficit