Obstructive Voiding Symptoms

Ratin Adira
 Obstructive Voiding
• Benign Prostatic
Hyperplasia
– 70% male > 60 years.
– Increase to 90% in 80
years
 BPH Pathophysiology
Normal BPH

BLADDER

Hypertrophied
detrusor muscle
PROSTATE

URETHRA Obstructed
urinary flow

Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

 Voiding Symptoms
OBSTRUCTIVE IRRITATIVE
Hesitancy Frequency
Weak stream Nocturia
Intermittency Urgency
Incomplete emptying dysuria
Dribbling
 Hesitancy
• Difficulty a patient has with initiating the
urinary stream, often the patient has to push
or strain to begin micturition
 Weak Stream
• Decreased force during micturition
 Intermittency
• Stopped and started again several times
during urinate
 Incomplete Emptying
• A sensation of not emptying the bladder
completely after finished urinating
 Dribbling
• Small amount of urine dribbling at the end of
micturition
 Frequency
• Have to urinate again less than two hours
after finished urinating
 Urgency
• Difficult to postpone micturition
 Nocturia
• Get up to urinate from the time of night sleep untill
got up in the morning
• Do not confuse with polyuria caused by DM,,
excessive consumption of coffee, tea and alcohol,
especially before bedtime.
 Benign Prostatic Hyperplasia

• Leading to “symptom bother” and

worsened QOL
 AUA Symptom Score Sheet
More
Less Less
About than
than 1 than Almost Your
Not at all half the half
time half the always score
time the
in 5 time
time

Incomplete emptying
Over the past month, how often have you had a sensation of not emptying your 0 1 2 3 4 5
bladder completely after you finish urinating?

Frequency
Over the past month, how often have you had to urinate again less than two hours 0 1 2 3 4 5
after you finished urinating?

Intermittency
Over the past month, how often have you found you stopped and started again several 0 1 2 3 4 5
times when you urinated?

Urgency
Over the last month, how difficult have you found it to postpone urination?
0 1 2 3 4 5
Weak stream
Over the past month, how often have you had a weak urinary stream?
0 1 2 3 4 5
Straining
Over the past month, how often have you had to push or strain to begin urination?
0 1 2 3 4 5

5 times Your
None 1 time 2 times 3 times 4 times
or more score

Nocturia
Over the past month, many times did you most typically get up to urinate from the 0 1 2 3 4 5
time you went to bed until the time you got up in the morning?

Quality of life due to urinary symptoms Mixed – about equally Mostly

Delighted Pleased Mostly satisfied Unhappy Terrible
satisfied and dissatisfied dissatisfied

If you were to spend the rest of your life with your

urinary condition the way it is now, how would you 0 1 2 3 4 5 6
feel about that?

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.
 Complications
• Urinary retention
• UTI
• Sepsis secondary to UTI
• Residual urine
• Calculi
• Renal failure
• Hematuria
• Hernias, hemorroids, bowel habit change

9/17/2018 15
 Digital Rectal Examination (DRE)
• Performed for a number of clinical reasons
e.g. altered bowel habit, rectal bleeding,
urinary symptoms and is a skill surgeons
perform on all patients.
• It is commonly examined as it is an important
skill to know.
 Digital Rectal Examination (DRE)
• Ask for permission and
explain the procedure
• Position  litotomy or
patient turn to his left
side (for right handed
examiner)
• Equipment:
Gloves and
Jelly/lubricant, tissue
Position
 Steps DRE
1. Wash your hands, introduce yourself
2. Explain what you would like to do and obtain
consent  This is a slightly uncomfortable
procedure so you should warn the patient of
this.
3. A chaperone is required for this examination
4. Positioning the patient Ask them to lie on
their left hand side with their knees drawn up
towards their chest, their feet pushed forwards
and their anus exposed, or litotomy position
 Steps DRE
5. Having washed your
hands and put on your
gloves, separate the
buttocks and inspect
the area around the
anus. Look for any
abnormalities
including skin tags,
haemorrhoids and
fissures.
 Steps DRE
6. After inspecting,
lubricate your right
index finger.
7. Tell the patient you are
about to start the
procedure. Place your
finger on the anus so
that it points anteriorly
and apply pressure to
the midline of the
anus.
 Steps DRE
8. Maintain the pressure
so that your finger
enters the rectum.
Initially you need to
assess anal tone by
asking the patient to
squeeze your finger
 Steps DRE
9. Next you need to
systematically examine
each part of the rectum.
This is done by sweeping
the finger both clockwise
and anti-clockwise
around the entire
circumference. You
should be feeling for any
abnormalities such as
impacted faeces, masses
or ulcers.
 Steps DRE
10. One of the main reasons for performing a
rectal examination in males is to assess the
prostate gland. This lies anteriorly and should
always be felt. You should check the size,
consistency and presence of the midline
groove, surface.
 Steps DRE
11. Remove your finger
and examine the glove
for the colour of any
faeces as well as the
presence of any mucus
or blood.
 Steps DRE
12. Clean off any lubricant
left around the anus
and remove and
dispose of your gloves
in the clinical waste bin.
13. Allow the patient to
dress and thank them.
Wash your hands and
report your findings to
the examiner.
 Assesment DRE
1. Tonus Sphincter Anus Symphisis Pubis
2. Mucosa
3. Ampula Recti
4. Tenderness
5. Prostate
6. Mass
7. Glove: feses, bleeding
Coccygeus
Thank You