Holding Urine for a Prolonged Period of Time and Acute Urinary Retension

Acute urine retention is a common condition affecting most of the elder males. There are several etiological factors for acute retention of urine. Holding urine for a prolonged period of time is one such etiology. How does holding urine for a long period of time cause acute urinary retention.

This can be explained by the LaPlace Law. When you hold urine for a long time, urine accumulate slowly and the bladder volume slowly increases. Finally, the bladder gets over-distended.  When the detrusor muscles are overstretched, they cannot contract. As a result, the bladder cannot empty itself by contracting. This process finally results in acute urinary retention.

Why Open Surgery Should not be done for Bladder Tumors?

Bladder tumors are very common. Most of them can be cured easily if identified early. Usually the superficial tumors of the bladder are treated with transurethral resection. They are not resected opening the bladder trans-abdominally. It is because there is a very high risk of tumor deposition along the tract if surgery is done trans-abdomonally.

Can You Get a Fistula Years After Radiotherapy for Cervical Cancer

Cervical cancer is one of the commonest gynecological malignancies all over the world. It can be cured if identified early. Most of the cervical cancers are squamous carcinomas. Squamous carcinomas are highly sensitive to radiotherapy. Therefore, radiotherapy for cervical carcinoma plays a major role in treating cervical cancers. As with any other treatment modality, radiotherapy also has its own set of complication. Fistula formation is one such complication.

A fistula can develop between the bladder and the perineal skin. This occurs as a result of avascular necrosis of the tissues surrounding the bladder. Unfortunately, the fistulas can occur several years after the radiotherapy. The cancer might have disappeared completely by then.  Sometimes ureterovaginal fistula (Between the ureter and the vagina) can coexist with viscicovaginal fistula (between the bladder and the vagina). Therefore, several investigations are done to differentiate one from another. Three swab test is one such investigation.

The three swab test is done by inserting a swab into the vagina and injecting a die through the urethra. The swab will stain with the die, if there is a viscicovaginal fistula. An intravenous urogram (IVU) should be performed to exclude a coexisting ureterovaginal fistula. 

How to Find Out the Cause for Red Colour Urine?

Red coloured urine can occur due to various reasons. Some of the causes of red coloured urine, for example blood in urine, can be very serious. Therefore, it is very important that you seek medical help, if you develop red coloured urine even once.

Red coloured urine does not always mean hematuria (blood in urine). haematuria, haemoglobinuria, myoglobinuria, some foods and some drugs can give rise to red coloured urine. The exact colour of the urine can be helpful to differentiate one from the other. When you say red coloured urine, it can vary from bright red to dark red colour. Dark red or coca cola colour urine indicates myoglobinuria which results from breakdown of muscles. Some drugs can also give a red colour to the urine. Some of these drugs are ethambutol, rifampicin and metronidasole. Some dietary ingredients can also give a red colour to the urine. These instances of red coloured urine are called pseudohaematuria.

The other way to find out the cause of red coloured urine is to know which part of the urine stream do you see the red coloured. Some people have red coloured urine only at the beginning of the stream and some have gross red coloured urine throughout the urine stream and some can complain of red coloured urine at the end of the urine flow.

Hematuria at the beginning of the urine flow is due to urethral strictures or urethral carcinoma. Terminal hematuria is due to a pathology in the bladder neck or the trigone. Even hematuria is often due to a renal pathology..

The commonest causes of hematuria are malignancy, stones and infections. Apart from these three most common causes there are other less common causes of hematuria such as glomerulonephritis, tuberculosis, poly cystic kidney disease, bleeding disorders, some drugs (warfarin, Heparin, Aspirin), benign prostatic hyperplasia and radiation cystitis.

As described above, we can find out the cause of red coloured urine only by describing the nature of it without the help of any investigations. We can always perform investigations to confirm the diagnosis.

What is Urine Cytology? How can it Detect Bladder Cancer?

There are several investigations that can confirm bladder carcinoma. urine cytology stays at the top of the list. It is a cery sensitive test to detect carcinoma insitu and high grade transitional cell carcinoma, but it is not sensitive for low grade transitional cell carcinoma.

It is performed in clean catch urine. You should first clean the external genitalia with soap (not with an aniseptic solution). Then you should start pass urine. About 80-100 ml of urine should be collected fron the middle of the urine stream (midstream urine). Then the sample is sent to the laboratory. If there is any delay in transporting the urine sample to the laboratory, it should be stored in a refrigerator. 

The malignant cells can be identified from this urine sample. This test is not recommended for screening purposes, but if it becomes positive , it is a strong marker of bladder carcinoma.

When to Suspect Bladder Cancer?

Bladder cancer is one of the commonest genitourinary tract malignancies. It can be treated and sometimes be cured, if you identify it early. The symptoms of bladder cancer can sometimes be very non specific. Therefore, there should be a high degree of clinical suspicion to identify this disease condition. So, what are the features of bladder cancer?

The most common and highly suspicious clinical presentation of bladder cancer is hematuria. Even a single episode of hematuria is highly indicative of bladder cancer. The other clinical presentations of bladder cancer include,

• Storage symptoms - Storage symptoms include, frequency, urgency, urge incontinence, nocturia and nocturnal enuresis. These symptoms are very non specific and can be the result of other benign conditions of the urinary tract, such as benign prostatic hyperplasia, but urologist always suspect bladder cancer because it is very common and can be cured completely if identified early.
• Dysuria without evidence of infection - Some people with bladder cancer can present with dysuria without evidence of any infection. Evidence of infection include fever with chills and rigors. They complain of pain or burning sensation when passing urine. 
• Recurrent urinary tract infections is another feature of bladder cancer. 
• Microscopic hematuria - Many people with bladder cancer pass red cells with their urine, but the number of red cells in the urine is not enough to give red colour to the urine to be seen in naked eye. These people are sed to have microscopic hematuria. These people are usually detected when a urine full report is performed when they present with any other urinary tract symptom. 
• Pathological fracture - Some people can stay un-noticed for years without developing any symptoms. These people can have advanced bladder carcinoma. The cancer may have spread to distal organs. Bones are a very common site of bladder cancer metastasis. Such people can first present with pathological fractures. The radiographs will show a metastatic lesion and a bladder tumor can be found when looked for a primary site.  
• Obstructive uropathy - Obstructive uropathy is the outcome of obstruction of the urinary tract. One of both ureters can be obstructed due to the tumor. As a result the hydronephroreters develops and the post-renal renal failure can occur. The patient can present with features of renal failure such as generalised body swelling, especially peri-orbital swelling in the morning. 
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Are You at Higher Risk of Developing Bladder Cancer?

There are risk factors for most of the diseases in this world. Similarly, bladder cancer also has a list of its own risk factors. They are,

• Cigarette smoking - 25 -50 %
• Industrial toxins 

Bladder cancer has a very good relationship with industrial toxins such as rubber, leather and textile. Hair colouring agents also makes people more prone to get bladder carcinoma.

•  Radiation 

If you have a history of exposure to radiation, it puts you in danger of developing bladder cancer.

• Chronic inflammation of the bladder

Chronic inflammation of the bladder is another well known risk factor for developing bladder cancer.  if you have past history of recurrent episodes of urinary tract infections or a past history of bladder stones, your bladder has been under chronic inflammatory process.

• High fat diet, fried meat animal fats
• Age - as with many cancers, your chances of getting a bladder tumor increases with advancing age. As you grow old, the cells accumulate mutations and finally can become malignant.
• White race
• Male gender - men are at three times more risk of developing bladder cancer than females
• Lynch syndrome

If you have any of above risk factors, you have chance of developing bladder carcinoma. It doesn't mean that every one exposed to above agents can develop bladder cancer. It also doesn't mean that you will not get bladder cancer if you don't have any of those risk factors. Therefore, there is no need to panic. But, you should be aware of symptoms of bladder cancer to identify it early.

The most common feature of bladder cancer is gross hematuria. Therefore, if you ever develop hematuria, even once in your life, you should immediately seek medical help. 

Renal Failure: An Overview

How do they present

1.     Acumilation of fluid

2.     Reduction in Normal Renal Functions

Accumulation of fluid

 

• Generalized edema

o   Periorbital edema

o   Ascites

o   Ankle edema

• Pulmonary edema

 

Reduction in Normal Renal Functions

·        Uremic Symptoms

o   Nausea

o   Vomiting

o   Loss of apetite

·        In chronic renal failure

o   Anemia

o   Tiredness

o   Tachycardia

·        Hypertensive features

 

Differential Diagnosis

·        Renal Failure

·        Hypovoluemia

 

Immediate Management

·        Maintain an input output chart.

·        Take blood for,

o   Blood urea

o   Serum creatinine

o   Electrolytes

o   Full Blood Count

·        Do a fluid challenge.

·        Give 10 units of insulin along with 50 cc dextrose.

·        Take an ECG – Tall tempted T wawes

 

 How to find out the etiology of Renal Failure?

·        Investigations

   USS Abdomen

   X- Ray KUB

   Renal Biopsy

 

 Renal Failure is of two Types

·        Acute renal failure

·        Chronic renal failure

 

 Causes of Acute Renal Failure

o       Poisoning

• Snake Bites

§     Cobra

§     Viper

§     Hump nosed viper

o         Wasp Bites

o         Leptospirosis

o         Pyelonephritis

o         Bilateral Ureteric Obstruction

o         Heavy Metal Poisoning

o         Organic  compounds – Break Oil

o         Crush Injuries

 

Causes of Chronic Renal Failure

·        Diabetic Nephropathy

·        Persistent Long standing Hypertension

·        Recurrent Pyelonephritis

·        Renal Calculi

 

 

Treatment

·        Dialysis

·        Renal Transplant

·        Dugs

   Erythropoietin

   1 alpha Cholecalciferole

   Phosphate Binders

   Iron Supplements

   Folic acid

·        Management of the underlying Disease/s

 

 

Urine Culture Positive, But no Urinary Symptom?

This is common finding during elderly, when a urine culture is performed. The report may say that there are bacterial growths in the urine, but the patient may not have any urinary symptom.

In such instances, the best thing to do is DO NOTHING!

UNLESS

·         The patient is pregnant

·         The organism is proteus

·         The patient have severe diabetic mellitus

·         The patient is awaiting any urological procedure  

Symptoms of Urinary Tract Diseases 

Complications of Urinary tract obstruction 

Complications of Urinary tract obstruction

Urinary tract obstruction leads to retention of urine, which leads to following complications.

1. 1.       Acute retention of urine

1. 2.       Chronic retention of urine

1. 3.       Urinary tract infections

1. 4.       Stone Formation

1. 5.       Chronic renal failure.

Symptoms of Urinary Tract Diseases 

Urine culture positive, but no urinary symptoms? 

Symptoms of Urinary Tract Diseases

Do you have the following symptoms? May be you are having a urinary tract disease.

There are many diseases that can affect the urinary tract, but many of them can be identified by the urinary symptoms you have. The disease can be guessed by checking the kind of symptoms you have. I will briefly explain what are those symptoms are.

We divide urinary tract symptoms in to two categories. They are,

1. 1.      Obstructive features

1. 2.      Storage/ irritative features

This categorization is very helpful because some diseases cause obstruction, and thereby lead to urinary retention and some reduce the ability of the bladder to store urine.

The obstructive features are,

1.      

• Poor stream

This means that the projectile nature of the urine flow is low.

• 2.      Intermittent stream

This means that the urine is voided little by little intermittently.  You cannot maintain a steady continues flow of urine.

• 3.      Terminal dribbling

In terminal dribbling you may find some drops of urine flowing drop by drop even after you have finished urination.

• 4.      Hesitancy

In hesitancy you find it difficult to start urination. You really want to pass urine, but find it difficult to initiate urination.

The storage/ irritative features are,

• 1.      Precipitancy

Passing urine without knowing.

• 2.      Recent onset nocturnal enuresis

• 3.      Urgency

The patient cannot hold urination when he feels like wanting to pass urine.

• 4.      Nocturia

Passing urine several times in the night.

• 5.      Frequency

Increased number of times you pass urine.

You may have symptoms from either one of the above two categories or symptoms from both.

Urinary tract obstruction?  What are the Complications? 

Urine culture positive, but no urinary symptoms?