Functional Urology and Female Urology
Functional urology tests your ability to turn a symptom pattern into a diagnosis and then into a stepped treatment plan. It covers male lower urinary tract symptoms, overactive bladder, stress incontinence, pelvic organ prolapse and neurogenic bladder, with urodynamics used selectively rather than reflexively.
Male LUTS and benign prostatic enlargement
- Assessment: IPSS, uroflowmetry, post-void residual, PSA, prostate volume, urinalysis.
- Absolute indications for surgery: refractory retention, recurrent urinary infection, bladder stones, hydronephrosis or renal impairment, recurrent haematuria, failure of medical therapy.
- Alpha-blockers act within days; warn about retrograde ejaculation and orthostatic hypotension. 5-alpha reductase inhibitors shrink the prostate by about 25 percent over 6 months and halve PSA, so double the value when interpreting it. Combination therapy suits large prostates; antimuscarinics and beta-3 agonists require caution when residual volume is high.
- Surgery: bipolar TURP remains the reference; holmium laser enucleation is size-independent; laser vaporisation and prostatic urethral lift have specific niches.
Female stress incontinence and prolapse
- Diagnosis: history, cough stress test, voiding diary, pad test; urodynamics before surgery in complex or mixed cases.
- Mid-urethral sling is first-line surgery for urodynamic stress incontinence; colposuspension and autologous fascia are alternatives; bulking agents suit intrinsic sphincter deficiency or frailty.
- Prolapse is staged with POP-Q. Conservative treatment (pelvic floor muscle training, pessary) comes first; anterior colporrhaphy, posterior repair and sacrocolpopexy for apical prolapse; transvaginal mesh is restricted after safety concerns.
Overactive bladder and neurogenic bladder
- Bladder diary for three days; exclude infection, stone, malignancy and outflow obstruction.
- First line: bladder training plus antimuscarinic or beta-3 agonist. Second line: intradetrusor onabotulinumtoxinA 100 units idiopathic, 200-300 units neurogenic, counselling about retention and intermittent catheterisation. Third line: sacral neuromodulation or posterior tibial nerve stimulation.
- Neurogenic bladder: clean intermittent catheterisation, antimuscarinics, botulinum toxin, augmentation cystoplasty, ileal conduit; monitor compliance and upper tracts.
Worked example
A 55-year-old woman leaks on coughing three times weekly, has no urgency, a negative urinalysis and a body mass index of 26. Cough stress test is positive and urodynamics confirm urodynamic stress incontinence without detrusor overactivity. Offer pelvic floor muscle training first, then a mid-urethral sling; counsel about tape erosion of around 2 percent, de novo urgency and retention.
Traps that cost marks
Operating without urinalysis; offering surgery for overactivity mistaken for stress incontinence; forgetting that a 5-alpha reductase inhibitor halves PSA; giving antimuscarinics in high residual volume; treating neurogenic bladder without protecting the upper tracts.