Urinary disorders

A happy man at the doctor

Dr. Alain Sermier & Dr. Laurent Vaucher

Urologists, Urology, Clinique de Genolier, Genolier

May 5, 2021

Urinary disorders occur when there’s something wrong with the bladder or the urethra. Voiding disorders in men between 50-80 years of age are extremely common. Around 90% of men in that age range have some sort of a voiding disorder. They can happen because of prostatic hypertrophy, instability of the detrusor muscle, urinary tract or prostate infection, bladder stones, and more. Urinary symptoms can be divided into filling, draining, and post micturition. Medication is prescribed in case of mictional disorders and failure of simple measures. There’s also the surgical approach, but that’s reserved for more severe symptoms.

Want to learn more? Keep reading the article by Dr. Alain Sermier & Dr. Laurent Vaucher.

The lower urinary tract consists of the bladder and urethra and should be considered a single functional unit for storing and emptying urine. Dysfunction occurs when there is a problem with either of these basic functions, in both men and women. Voiding disorders can be separated into three separate groups of symptoms, depending on whether they are related to storage, emptying or completion of voiding.

Annoying and very frequent disorders

Urinary disorders can considerably interfere with the quality of life of those affected. They are the telltale signs of the pathology of the urogenital system. The origin of these urinary disorders is multiple, and can sometimes correspond to one or more diagnoses, such as prostate hypertrophy in men, nocturia (abnormally high frequency of nocturnal urination), or instability of the detrusor muscle (the muscle responsible for bladder contraction).

Voiding disorders are extremely common, especially in men. 90% of men aged between 50 and 80 years suffer from varying degrees of voiding symptoms. The prevalence of storage-related symptoms increases significantly with age, from 3% in men aged 40 to 42% in men aged over 75. Once symptoms appear, their progression is variable, with one-third of patients experiencing improvement over time, one-third The prevalence of nocturia is also related to age, with 69% of men over 85 having to get up to urinate at night, compared to 49% of women. The prevalence of nocturia is also related to age, with 69% of men over 85 having to get up to urinate at night, compared to 49% of women.

The main problem in diagnosing the cause of these symptoms is that they are not specific to a particular organ or disease, and can be seen in a wide range of diseases. Therefore, these symptoms in themselves do not allow the diagnosis of the underlying dysfunction or even the assessment of the severity of the disease in terms of the severity of the functional disorder. Thus, voiding disorders can be attributed to conditions as varied as:

– prostatic hypertrophy leading to obstruction

– instability of the detrusor muscle

– urinary tract infection or prostate infection

– bladder stones

– bladder or prostate neoplasia

– neurological disease (multiple sclerosis, spinal cord disease…)

The search for possible causes and associated comorbidities is an essential step in the management of patients with voiding disorders. The presence of blood in the urine, a history of urinary tract infections and the list of treatments are all elements to be taken into account. A simple test that anyone can do is the voiding calendar. It is sufficient to note the frequency and quantity of urination, as well as the volume of drinks taken during the day. Evaluated over a period of 3-4 days, this examination allows the average volume of micturition and the frequency of micturition to be determined objectively, as well as revealing a possible reversal of the micturition cycle.

Essential complementary examinations…

Because of the non-specificity of clinical signs, para-clinical examinations are particularly important in the search for the pathologies underlying emotional disorders. A urine dipstick test for blood, glucose, leukocytes, or protein is essential, as is a bacteriological examination of the urine for urinary tract infection. Assessment of renal function by measuring serum creatinine may be necessary if renal failure is suspected.

Depending on the nature of the presenting symptoms, the specialist may perform post-void residual urine measurement, cystoscopy, ultrasound examination of the upper urinary tract, or urodynamics. Urodynamic testing involves studying the bladder’s reactions in real-time, using sensors on probes, as the bladder is filled and emptied. This examination, performed in In this case, the patient is given an outpatient examination to identify any obstruction or overactivity of the bladder (uncontrolled contractions of the bladder muscle). In the case of mildly disabling symptoms, simple measures such as avoiding caffeinated or alcoholic beverages and medication that may influence urinary function can already bring about a significant improvement.

Urinary symptoms

Filling:
– Emergency
– Frequency
– Nocturia
– Urgent Incontinence

Drain:
– Decreased jet
– Intermittence
– Effort
– Pain

Post micturition:
– Incomplete voiding
– Loss of urine after voiding

A targeted therapeutic approach…

In case of embarrassing mictional disorders and failure of simple measures, prescription of medication is indicated, guided by the type of symptoms presented. Many molecules exist on the market and it is often necessary to try several different drugs before finding the right treatment.

A surgical approach will be chosen if the urinary symptoms are severe or if the medication does not have a sufficient effect. In case of enlargement of the prostate (benign prostatic hyperplasia), endoscopic removal of the prostate gland through the natural route is indicated. There are several techniques: mono- or bipolar resection (TURP), plasma or laser vaporization (TUVP), and Holmium laser enucleation (HoLEP). Complications such as urinary tract infection, bleeding, or urine loss after deobstruction are rare but may occur. In all cases, ejaculation will disappear because the decreased resistance at the bladder neck and prostatic urethra will cause retrograde ejaculation into the bladder. For this reason, this type of operation will not be performed in cases of paternity desire. Erectile dysfunction may rarely occur after the surgery. —If the prostate gland is small, i.e. less than 30 grams, a cervical-prostatic incision (incision with a coagulation hook from a groove in the bladder neck to the end of the prostatic urethra) can also be offered. This option is less invasive, with a lower risk of bleeding, but the recurrence rate is higher.

In the case of large prostatic hyperplasia (prostate volume > 80 ml), an open operation (adenomectomy) is proposed, as such a volume can hardly be resected by transurethral endoscopy. In the very elderly patient or if the patient’s condition does not allow for surgery, endoscopic stenting of the prostatic urethra is also a possibility.

In the case of bladder function disorders (e.g. hyperactivity of the detrusor muscle causing a feeling of urgency or sudden urine loss after a certain volume of filling), there are several alternatives if anticholinergic drugs are insufficient. An injection of botulinum toxin into the detrusor muscle reduces or eliminates the symptoms in the vast majority of cases. The effect of these injections lasts for an average of six months and the treatment must be repeated as soon as the symptoms reappear. The main risk is urinary retention (inability to empty the bladder) if the effect is too strong.

In the case of stress incontinence (loss of urine when coughing, sneezing, or any other effort that increases intra-abdominal pressure), an artificial sphincter or suspension of the urethra by a prosthetic implant (mesh) may be proposed. The risk is also urinary retention after the operation.

A minority of patients develop significant post-void residual urine, which can lead to bladder stone formation or renal failure due to overpressure in the bladder causing urine to flow back to the kidneys. Worsening symptoms or increased post-void residue are thus warning signs that a surgical approach is needed, especially if the prostate gland is large.

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