Departemen Bedah RSMH/FK Unsri

Pendidikan Dokter Spesialis-1 Ilmu Bedah

Lower Urinary Tract Symptoms

Dr. Dendy Riansyah

 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Obstructive
Irritative Symptoms
Symptoms
• Nocturia, • Urinary hesitancy,
• Dysuria • Intermittency,
• Postvoid dribbling,
• Straining

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Irritative symptoms
• Frequency is one of the most common urologic symptoms. The normal adult
voids 5-6 times/day, with a volume of approximately 300 mL with each void.
• Urinary frequency is due to either increased urinary output (polyuria) or
decreased bladder capacity.
• If the patient has polyuria and should be evaluated for diabetes mellitus,
diabetes insipidus, or excessive fluid ingestion.
• Decreased bladder capacity; bladder outlet obstruction with decreased
compliance, increased residual urine, and/or decreased functional capacity
due to irritation, neurogenic bladder with increased sensitivity and decreased
compliance, pressure from extrinsic sources, or anxiety.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Nocturia is nocturnal frequency. It may be secondary to increased urine output or

decreased bladder capacity.
• Frequency during the day without nocturia is usually of psychogenic origin and
related to anxiety.
• Nocturia without frequency may occur in the patient with congestive heart
failure and peripheral edema in whom the intravascular volume and urine
output increase when the patient is supine.
• Renal concentrating ability decreases with age; therefore urine production in
the geriatric patient is increased at night, when renal blood flow is increased as
a result of recumbency.
• Nocturia also occur in people who drink large amounts of liquid in the evening,
particularly caffeinated and alcoholic beverages strong diuretic effects.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Dysuria is painful urination that is usually caused by inflammation.

• This pain is usually not felt over the bladder but is commonly
referred to the urethral meatus.
• Pain occurring at the start of urination may indicate urethral
pathology, whereas pain occurring at the end of micturition
(strangury) is usually of bladder origin.
• Dysuria is frequently accompanied by frequency and urgency.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Obstructive Symptoms
• Decreased force of urination is usually secondary to bladder outlet obstruction and
commonly results from benign prostatic hyperplasia (BPH) or a urethral stricture.
• Most patients are unaware of a change in the force and caliber of their urinary
stream. These changes usually occur gradually.
• The other obstructive symptoms noted later are more commonly recognized and
are usually secondary to bladder outlet obstruction in men due to either BPH or a
urethral stricture.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

• Urinary hesitancy
• a delay in the start of micturition. Normally, urination begins within a second
after relaxing the urinary sphincter, but it may be delayed in men with
bladder outlet obstruction.
• Intermittency
• involuntary start-stopping of the urinary stream. It most commonly results
from prostatic obstruction with intermittent occlusion of the urinary stream
by the lateral prostatic lobes.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

• Postvoid dribbling
• The terminal release of drops of urine at the end of micturition.
• This is secondary to a small amount of residual urine in either the bulbar or
the prostatic urethra that is normally “milked back” into the bladder at the
end of micturition (Stephenson and Farrar, 1977).
• In men with bladder outlet obstruction, this urine escapes into the bulbar
urethra and leaks out at the end of micturition.
• Postvoid dribbling is often an early symptom of urethral obstruction related to
BPH, but, in itself, seldom necessitates any further treatment.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

• Straining
• The use of abdominal musculature to urinate.
• Normally, it is unnecessary for a man to perform a Valsalva maneuver except
at the end of urination.
• Increased straining during micturition is a symptom of bladder outlet
obstruction.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

• The International Prostate Symptom Score (I-PSS)

• Seven questions, as well as a global quality-of-life question (Table 1-1).
• The total symptom score ranges from 0 to 35 with scores of 0 to 7, 8 to 19,
and 20 to 35 indicating mild, moderate, and severe lower urinary tract
symptoms, respectively.
• The IPSS is a helpful tool both in the clinical management of men with lower
urinary tract symptoms and in research studies regarding the medical and
surgical treatment of men with voiding dysfunction

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

• Incontinence
Urinary incontinence is the involuntary loss of urine. A careful history of
the incontinent patient will often determine the etiology.
Urinary incontinence can be subdivided into four categories;
1. Continuous Incontinence
2. Stress Incontinence
3. Urgency Incontinence
4. Overflow Urinary Incontinence

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Continuous incontinence is most commonly due to a urinary tract

fistula that bypasses the urethral sphincter.
• The most common type of fistula that results in urinary incontinence
is a vesicovaginal fistula usually secondary to gynecologic surgery,
radiation, or obstetric trauma. Less commonly, ureterovaginal fistulae.
• A second major cause of continuous incontinence is an ectopic
ureter that enters either the urethra or the female genital tract.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Stress incontinence; the sudden leakage of urine with coughing, sneezing,

exercise, or other ctivities that increase intra-abdominal pressure.
• During these activities, intra-abdominal pressure rises transiently above
urethral resistance, resulting small amount of urinary leakage.
• Stress incontinence most common in women after childbearing or
menopause, related to a loss of anterior vaginal support and weakening of
pelvic tissues. In men after prostatic surgery, most commonly radical
prostatectomy, related to injury the external urethral sphincter.
• Stress urinary incontinence is difficult to manage pharmacologically, and
patients with significant stress incontinence are best treated surgically.
Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Urgency incontinence: the precipitous loss of urine preceded by a strong urge to

void.
• This symptom is commonly observed in patients with cystitis, neurogenic bladder,
and advanced bladder outlet obstruction with secondary loss of bladder
compliance.
• Urgency incontinence may result from a secondary underlying pathologic
process, which should be identified; treatment of this primary problem such as
infection or bladder outlet obstruction may result in resolution of urgency
incontinence.
• Urgency incontinence are usually not amenable to surgical correction but, rather,
are more appropriately treated with pharmacologic agents.
Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Overflow urinary incontinence, often called paradoxical incontinence, is secondary

to advanced urinary retention and high residual urine volumes.
• In these patients, the bladder is chronically distended and never empties
completely. Urine may dribble out in small amounts as the bladder overflows.
• This is particularly likely to occur at night when the patient is less likely to inhibit
urinary leakage. Overflow incontinence has been termed paradoxical
incontinence because it can often be cured by relief of bladder outlet
obstruction.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Enuresis; urinary incontinence that occurs during sleep.

• It occurs normally in children up to 3 years of age but persists in about 15% of
children at age 5 and about 1% of children at age 15 (Forsythe and Redmond,
1974).
• Enuresis must be distinguished from continuous incontinence, which occurs in
the day and night and which, in a young girl, usually indicates the presence of an
ectopic ureter.
• All children older than age 6 years with enuresis should undergo a urologic
evaluation, although the vast majority will be found to have no significant
urologic abnormality.

Refference : G. S. Gerber, C B. Brendler. “Evaluation of the Urologic Patient: History, Physical Examination,
and Urinalysis.” Campbell-Walsh Urology Eleventh Edition, Philladelphia, 2016, p 3-6
 Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Thanks for your attention