The old aphorism urological reproduced highlight of this chapter, by its second proposal, summarized the definition of dysuria: difficulty issue of urine during urination.
This symptom is in a range of varied pathologies, dominated by obstructive etiologies cervicoprostatiques and benign tumor and urethra, where we also find neurological diseases with vésicosphinctérien impact, but the stones and malformations of the urinary tract without forgetting the “bad neighborhoods” digestive and gynecological.
DIAGNOSTIC:
Examination:
It is essential. The diversity of events dysuric is certainly linked to changes in urinary stream, but also the severity of the impact of upstream, especially bladder, drain default may be minimal or maximum with acute or chronic urinary retention.
Thus, the examination should cover the urinary stream and bladder sensation.
Urinary stream:
The urinary stream concerns:
– Difficulty in starting urination, ie awaiting the first drops, jogging to get a urinary stream;
– Strong, weak or slow urine stream once the economy urination;
– The end of urination, net or jerks, jogging to finish emptying the bladder, the presence of drops laggards once the urination.
Repercussion bladder:
Excessive urination, or urinary frequency, is defined by diurnal voiding intervals of less than 2 hours, and by night need to get up related to urination during sleep time (to be assessed).
This symptom may be due to poor bladder emptying the bladder is filling more quickly that it is not empty after urination, hence shortening intervals between urination. It can also be witnessed bladder irritation as in cystitis, for example, or polyuria as in poorly controlled diabetes or sleep disorders explaining a nocturia without slowing the evacuation urinary.
The sensation of incomplete emptying of the bladder after urination can be solved, according to the intensity, by urinating in two (need to urinate in the back minutes after urination), and a maximum by the full acute retention of urine , resulting in the painful inability to urinate in full bladder (different anuria which is defined by the absence of urine in the bladder).
Chronic urinary retention, painless, is often marked in case of bladder distension or urétérorénale by insensible loss of urine to overflow incontinence and Associated procession linked to a possible secondary renal failure, sometimes major or terminal .
Objective criteria:
In addition to data from examination by both the subjective nature “declared” the patient (and his spouse) that the “heard” by the doctor, should ensure the data as objectively as possible in the prospect of optimal treatment.
IPSS validated questionnaire:
It is not always easy to use in daily practice, its usefulness is mainly in the comparative assessment of treatment efficacy (mostly used in new treatments assessment protocols).
Urinary flow measurement:
The patient urinates in a toilet equipped with a camera that sets the curve of the volume issued over time, allowing to place the patient compared to the charts. Overall, the maximum flow must be less than 10 mL / sec for an emitted volume greater than 150 ml in order to declare effective dysuria.
Ultrasound post-micturition:
Its purpose is to assess the residual urine and bladder so the impact of dysuria. This review should be conducted under physiological conditions, ie with a need “normal” to urinate, not ultra-filled bladder in a patient who has been asked to drink more than reason, we will have done wait painfully distended bladder and unable physiologically to empty normally again. Under physiological conditions, the residue should not exceed 50 mL to be considered normal.In addition, the presence of supra-physiological residue witness bladder impact of dysuria. Signs associated thickening of the bladder wall due to detrusor muscle hypertrophy induced contractile work of expulsion against the obstacle, the presence of bladder diverticula, reflecting the age and severity of impact bladder (outside congenital diverticula), or more rarely the presence of stasis bladder stones or bilateral renal dilatation when the obstacle is major and chronic.
Urodynamics (cystometry):
It can also be offered in certain circumstances for the Exploration of urination and thus dysuria, particularly in neurological diseases Parkinson type for which you have to share things between cervicoprostatique obstructive and dysuria dysuria by hypertension of the bladder neck with urinary frequency by overactive bladder.
Etiologic:
Given the variety of etiologies of dysuria, we must rely on the interview and clinical examination that guide the complementary examinations.
Examination:
The questioning aims to clarify:
– Occurrence of circumstances;
– Seniority and scalability of voiding dysfunction;
– way of life ;
– Medical and surgical history;
– Medication; urinary or urethral same old infections;
– Term catheterization;
– Traumatic context, viral, etc.
Physical examination:
The physical examination includes:
– Palpation kidney areas (lumbar tanks);
– Palpation of the hypogastrium looking for a distended bladder;
– Examination of the external genitalia (urethral meatus, purses, vulva, urethral diverticulum under);
– Pelvic examination (rectal and vaginal touch, coupled with bimanual palpation), to assess the prostate (volume and consistency), search for a pelvic mass, gynecological or gastrointestinal (fecal impaction ++);
– Motor and sensory neurological examination;
– General physical examination.
Additional tests:
Fibroscopy urethrovesical:
She has the great advantage to explore the urine of the urethral meatus to the bladder, to have an endoscopic view of the voiding and bladder tank parade, reviewing virtually all obstructive causes intrinsically linked to the urinary tract: stenosis urethral, bladder and urethral stones, prostatic hypertrophy, hypertension bladder neck, bladder tumor.
Review of consultation, uncomfortable but not painful, endoscopy does not require anesthesia and must be done with sterile urine.
Ultrasound:
More than the imaging studies such as urethrocystography upward and urinary, intravenous urography, CT urography or the MRI, which are rather second-examinations or third row, imagery is dominated by ultrasound the urinary tract, which, besides the signs of dysuria (see above), allows to direct the diagnosis positively or exclusive ways. It can also detect other diseases of the urinary system and it is not uncommon to meet fortuitously tumor, malformation, or kidney stones then totally asymptomatic.
Urodynamics:
The review second line provides functional assessment vésicosphinctérien device, measuring compliance, sensitivity, activity, responsiveness and tone of the bladder (cystometry) and the effectiveness of urethral sphincter (profilometry functional length).
ETIOLOGY TREATMENT:
Mechanical causes:
The main mechanical causes of dysuria are presented in Box 1.
Box 1. Mechanical causes
Cervicoprostatiques (benign hypertrophy, hypertension neck)
bladder stones
Urethral strictures (postinfectious, traumatic, radiation-induced)
Fecal impaction, constipation
prostate cancer, bladder, urethra, uterus, pelvis
Malformations (valves of the posterior urethra, seminal vesicles)
Adénomite
Benign prostatic hypertrophy:
This is an increase of glandular volume under the influence of testosterone, which starts at puberty and becomes symptomatic from the fifth or sixth decade.
The treatment is first medical referred to reducing prostate volume by inhibitors of 5-alpha-reductase or the plant extracts which may be associated with alpha.
In case of failure or major dysuria situation, surgery may be proposed either by endoscopy (resection) if the volume to be removed does not exceed 60 grams, or suprapubic (prostatectomy) otherwise.
Hypertension bladder neck:
This is a defect of relaxation of smooth muscle fibers of the bladder neck (periurethral) that normally relaxes reflexively when urinating, but in a context of stress or anxiety (professional, family, etc. .) may be very incomplete and induce severe dysuria.
Treatment with alpha-up the symptoms but do not address the substance anxious to be addressed with the patient. It may be necessary to achieve cervicoprostatique incision endoscopic, if treatment is inadequate or poorly tolerated in younger patients often (fourth decade).
Bladder calculation:
This is often the stigma of chronic cervicoprostatique obstacle (calculation stasis) that requires surgical treatment of the obstacle and calculating at the same time.
The calculation can sometimes enclave into the urethra and then imposes a endoscopy urgently or at least a bladder drainage through an acute urinary retention.
Urethral strictures:
Urethral any aggression whatever nature
– Catheterization during hospitalization for any reason, infectious urethritis (gonorrhea), trauma (fall on the perineum pelvic fracture.), Radiation (brachytherapy or pelvic floor radiotherapy in prostate cancer), surgery (resection endoscopic radical prostatectomy)
– May lead to a narrowing of the urethra, which is in fact a progressive scar sometimes over long periods (decades) and can therefore clinically manifest long after the initiating event.
Treatment is endoscopic urethrotomy which may be repeated as desired. In case of failure urethrotomy iterative, can be proposed urethral prostheses or surgical urethroplasties in one or two stages.
Fecal impaction, constipation:
The impaction is the most common cause of urinary retention in women, by simple mechanical compression of the urethra (ball effect).
It is only the culmination of extreme constipation, which in itself can induce the occurrence of dysuria by double-urinary neighborhood both in men than in women.
The treatment of constipation (let alone the evacuation of fecal impaction) can recover a normal urinary function as long as other factors do not intervene (psychotropic anticholinergic effect on bladder contraction and intestinal transit, obstacle cervicoprostatique, for example).
Locoregional cancer:
These cancers (prostate, bladder, uterus, rectum, urethra) will not dysuriant that in advanced stages of the disease.
Dysuria is so often associated with other local stigmas (hematuria, pyuria, infection pain) and may require an act of endoscopic unblocking or cutaneous urinary diversion that must weigh the advantages and disadvantages with respect to survival and comfort one can decently expect.
Genitourinary malformations:
Today the causes malformations are rare, the valves of the posterior urethra being treated as a child and leaving no sequelae dysuria, except in cases of scar stenosis.
Similarly, large ureteroceles given birth by the urethral meatus no longer see in adults, small ureteroceles being typically not symptomatic in the form dysuriante. Are pathological dilatation of the ejaculatory duct in connection with an ectopic anastomosis of the ureter into the seminal vesicle or ejaculatory duct directly, which can cause, among other, by dysuria.
The treatment in this case is resection laparoscopic anomaly, or in case of simple cyst, drainage by endourethral way can be considered.
Adénomite:
It relates to the inflammatory thrust prostate caused by a bacterial infection.
Generally, dysuria is then accompanied by a procession of irritative symptoms or general inflammatory (urinary frequency, burning on urination, fever, etc.).
Treatment with antibiotics adapted to the germ detected in cytobacteriological urinalysis (urine culture) is probabilistically started soon realized the urine sample. It can be beneficial to the patient to add non-steroidal anti-inflammatory drugs, and specifically for dysuria, an alpha.
In extreme cases of acute retention of urine with fever, it is appropriate to drain the urine, and this exclusively suprapubic catheter to prevent septic shock when an inappropriate urethral catheterization.
Neurological causes:
Dysuria induced neurological disorder may respond to different mechanisms. Indeed urination is the result of synchronous contraction of muscle fibers of the bladder wall (parasympathetic) and the simultaneous relaxation of the sphincter fibers as the striated sphincter (voluntary) that smooth sphincter (reflex) (sympathetic alpha), all under autonomic and higher neurological control (metameric reflex arc and cortical control). An imbalance of this resultant, from one to the other, or both elements controlling micturition resulting in a mechanism different from dysuria or default sphincter relaxation (hypertonia sphincter) or default contraction the bladder wall (hypotonia or bladder weakness), and finally by combining the two phenomena combine to varying degrees.
The different pathological situations encountered in neurology and can intervene at the cortical level (stroke, Parkinson), bone marrow (multiple sclerosis, HIV, herpes, trauma) and peripheral (trauma) and obviously mixed way.
The evolution of the disease depends on the recovery possible or not normal urination and appropriate treatment.
The main neurological causes of dysuria are presented in Box 2.
Box 2. Neurological causes
Multiple sclerosis
Parkinson
Neuropathies degenerative, diabetics, enolic, etc.
dyssynergy vésicosphinctérienne
Medullary suffering viral (HIV, herpes, etc.)
Spinal cord trauma, spinal cord cysts, etc.
In the acute phase:
Therapeutic measures based dysuria according to the intensity of symptoms of bladder drainage in acute retention (suprapubic catheterization or indwelling or intermittent) or alpha blockers if dysuria not too intense and responsive to treatment (residual urine).
Chronic Phase:
We must be able ensure good bladder emptying.
Alpha-blockers can be helpful, as well as rehabilitation of urination (automatic bladders), but in cases of chronic retention, or self hétérosondages can often avoid the indwelling and sometimes severe infectious procession or the renal disease in advanced chronic forms, which may require the use of cutaneous urinary diversion.
It takes longer to distinguish between the neurological cause of dysuria and a possible associated cervicoprostatique obstacle which may require appropriate treatment, after careful neuro-urological assessment.
Iatrogenic causes:
The main neurological causes of dysuria are presented in Box 3.
Box 3. Causes Iatrogenic
Medication (anticholinergics, alpha +, muscle relaxants, narcotic, neurotropic)
Postoperatively (suburethral tape retropubic, anorectal surgery)
Urethral strictures (laying bladder catheter, prostate or pelvic irradiation with brachytherapy or conformal radiotherapy)
Drug:
Alpha +:
They strengthen the smooth sphincter tone.
Indicated in cases of viral or allergic rhinitis, + alphas can cause dysuria up acute retention of urine, especially if associated BPH.
The treatment of dysuria is stopping the drug or temporary urinary catheter during the few hours of the therapeutic effect in case of acute retention of urine.
Neuroleptic:
They have a direct anticholinergic effect on the bladder and constipating, sometimes to fecal impaction.
The treatment of dysuria is possible adaptation of neurotropic treatment for a better tolerated drug, provided symptomatic treatment by alpha-and improved intestinal transit was not satisfactory. The need long-term therapy of benign prostatic hyperplasia by volume reducer (inhibitors of 5-alpha-reductase) or surgical or endoscopic treatment is evaluated.
Anticholinergic:
They inhibit bladder contraction (motor urination). Indicated in cases of urge incontinence by overactive bladder, their goal is to provoke a smaller bladder contractility. However, they can induce in the event of unsuitable feed, or in case of prostatic hypertrophy, dysuria up retention.
The treatment of dysuria is stopped or the dose adjustment. If cervicoprostatique barrier to treatment, it is associated with either alpha or to an endoscopic or surgical treatment of the adenoma.
Muscle relaxants (morphine, benzodiazepine):
They lower bladder contractility and therefore the engine of urination. This situation is relatively common in the early management of postoperative pain in particular.
Acute urinary retention is frequent and the treatment of dysuria is the transient sample and the use of other painkillers.
Surgical:
Surgery for urinary incontinence:
The strips suburethral TVT Type (retropubic) and TOT (transobturator) aim to restore a sub-urethral pulley allowing physiological bend of the distal urethra preventing urinary leakage during stress. Sometimes the tension adjustment of the strip is too excessive, and can lead to dysuria or retention. This is especially true with the TVT to which the tension of the strip is increased in a semi-sitting position due to the verticality of its retropubic position.
The treatment of this almost immediate dysuria through the indwelling or self-catheterization in the initial phase for a few days, but can lead to simple sub-urethral section of the strip in the absence of significant improvement, with the risk in this case of recurrence of urinary incontinence.
Anorectal surgery resection:
It is in this case a dysuria by denervation sacred roots for vésicosphinctérienne, with a full bladder hypotonia (device) that can be associated with sphincter deficiency that must be wary in case of surgical or endoscopic of adenoma, due to a significant risk of postoperative incontinence.
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