Bladder and Urethral Disorders Flashcards
What is the 2nd MC urologic cancer? What demographic does it affect most?
Bladder cancer
MC in men (~3:1) and older pts (avg age at dx - 73)
what are risk factors for bladder cancer?
- Cigarettes - 60% of new cases
- Industrial solvents - 15% of new cases
- Chronic inflammation - UTIs, catheters, bladder stones
what are the types of bladder cancer and how common are they?
- 98% - epithelial cell malignancies, this includes the following categories:
- 90% - urothelial cell carcinoma
- 7% - squamous cell carcinoma - chronic inflammation (Bladder stones, Prolonged catheter use, Chronic UTIs, Schistosomiasis, ect)
- 2% - adenocarcinomas
what are the signs and symptoms of bladder cancer
- Hematuria - presenting s/s in 85-90% (Micro or gross, intermittent or chronic, Often painless!)
- +/- irritative voiding (depending on size, location, Many pts - no major s/s in early stages!)
- Weight loss possible
- Large - may see abdominal mass
- Metastatic - hepatomegaly, lymphadenopathy +/- lymphedema
what diagnostic study results could be seen in evaluation for bladder cancer?
- hematuria (gross or micro) in most cases +/- pyuria and anemia
- of obstructed can see AKI s/s
- urine cytology will show abnormal shed epithelial cells. (80-90% sensitive in higher staged cancers, 50% sensitive in non-invasive/well-differentiated cacners)
- urine biomarkers (new study thats not preferred over cystoscopy)
- CT, MRI, or US may show mass in bladder or “filling defect”
- cystoscopy with biopsy (used to ID mass within bladder, can also be used for local resection) GOLD STANDARD Dx
what is the gold standard for diagnosing bladder cancer?
cystoscopy w biopsy
How do you stage bladder cancer?
by how far it extends into the bladder wall.
TIS - small and attached to superficial bladder lining
Ta - extends into bladder lining
T1 - extending into connective tissue
T2 - Extending into muscle
T3 - extending into fat
T4 - extending past fat
What is the treatment for superficial bladder cancer (TIS, Ta, T1)
- transurethral tumor resection
- +/- intravesical chemotherapy
- Weekly x 6-12 wks - BCG is often most effective form
- May require anti-TB treatment
what is the treatment for invasive bladder cancer (T2+)
- radical cystectomy, urinary diversion
- +/- chemotherapy, immunotherapy, radiation
what is the prognosis for bladder cancer
- Superficial ,5-year survival - 81% (50-80% at presentation are superficial )
- Invasive, 5-year survival - 50-75%
- Metastatic (T4) - long-term survival is rare
what is nocturnal enuresis
- repeated urination into clothing or bedding specifically during bedtime/sleeping hours
- considered “monosymptomatic enuresis” if there are no other lower urinary tract symptoms and no hx of bladder disorders
what is primary vs secondary nocturnal enuresis
- primary - usually in young children <5-6 y/o who have never_achieved urinary continence
- secondary - patients who previously_were_fully_continent for 6+ months (often associated with stressful events in a childs life)
what is the MC demographic for nocturnal enuresis and how common is spontaneous remission?
- Twice as common among males
- about 15% of pts/yr have spontaneous remission
- plz look at the pic for remission percentages
when is treatment not reccomended for nocturnal enuresis
before age 5!
what is the presentation of a patient with nocturnal enuresis
- Classic - Involuntary urination during sleep in a person who normally has voluntary urinary control
- Usually occurs 3-4 hours after bedtime
- Confusion and amnesia possible
- Voiding diaries can delineate timing, frequency and severity
Be sure to investigate and r/o other diagnosis! (DI, DM, polydipsia, UTI, pinworms, CKD, seizures, bladder disease, constipation)
what are the diagnostic studies done in evaluation of nocturnal enuresis
- used to r/o other causes such as infections, emotional distress, DM, epilepsy, ect.
- UA - generally indicated for most pts
- US - can help look for anatomic abnormalities
what lifestyle changes may help nocturnal enuresis
- Voiding - frequently in day (4-7x) and just before bed
- Fluids - avoid excess fluids in the evening (Especially sugary/caffeinated)
- Pull-Ups - discourage use in older children
- Education - bedwetting is unintentional (Primary usually resolves by puberty)
what are behavioral and medication based treatments for nocturnal enuresis
- behavioral - enuresis alarm (3-4 mo, lower relapse rates but requires highly motivated fam)
- medication - desmopressin (FIRST LINE!) good for short term improvement.
- medication - imipramine, oxybutynin (add-on, second line!)
what is interstitial cystitis and what is its etiology?
- painful bladder syndrome
- etiology is unknown but could be possible allergic response, inflam/immune, abnormal epithelium, abnormal sensorineural response.
- though to be several diseases with similar problems.
what is the epidemiology of interstitial cystitis
- More common in women (5:1)
- 18-40 per 100,000 patients
- Most commonly diagnosed in 40s or later
what are risk factors for interstitial cystitis
- associated with chronic pain syndromes (IBS, fibromyalgia)
- certain foods/drinks may trigger (alcohol, caffeine, citrus, spicy)
what are s/s of interstitial cystitis
- pain/discomfot with bladder filling, classically is relieved with urination
- range of pain varies from mild to debilitating
- +/- irritative voiding symptoms (nocturia, frequency, urgency)
- suprapubic tenderness on exam
what are the diagnostic studies that can be done in evaluation of interstitial cystitis
- all of the following have normal findings! used to r/o other conditions!
- UA
- urine C&S
- Urine cytology
- urodynamics
- US - postvoid residual to r/o urinary retention
- cystoscopy to r/o bladder cancer
what is the diagnosis criteria for interstitial cystitis?
- AUA - Unpleasant sensation (pain, pressure, discomfort) perceived as relating to the urinary bladder, with other LUTS, for more than 6 weeks’ duration, in the absence of infection or other identifiable causes
- No solid confirmatory PE finding, lab test or imaging! all testing is done to r/o other potential dx
what cystoscopy findings can be associated with interstitial cystitis
- Hunner’s ulcers/lesions (only seen in
5-10% of IC pts) - Glomerulations (nonspecific - also seen
in 45% of healthy pts) - Increased mast cells on biopsy
what aids s/s in 20-30% of interstitial cystitis patients?
hydrodistension
what is the treatment for interstitial cystitis
- no cure, symptomatic relief is goal!
- first line is lifestyle modification and self care
- 2nd line - oral meds
- 3rd line is invasive therapies
what medications are used as tx for interstitial cystitis
- TCAs - amitriptyline (Elavil) - often 1st line rx
- Antihistamines - hydroxyzine (Vistaril)
- CCBs - nifedipine (Procardia)
- Pentosan polysulfate sodium (Elmiron)
what is the MOA of elmiron?
MOA - May improve glycosaminoglycan layer over urothelium
this is the ONLY drug FDA approved for tx of interstitial cystitis
what are the SE, CI and DDI for elmiron
- SE - GI upset, elevated LFTs, hair loss (Less sedation than TCAs, antihistamines) (Longer to see results than other meds for IC)
- Case reports of retinal toxicity/macular disease - dose-related
- CI - allergy to drug or to heparin or LMWH
- DDI - anticoagulants/antiplatelets (￪ bleeding)
what are the invasive therapies used to treat interstitial cystitis (3rd line)
- Hydrodistension
- Electrocauterization of Hunner lesions (if present)
- Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)
what are treatments for refractory interstitial cystitis
- Botulinum injections to detrusor muscle
- Sacral neuromodulation
- Cystectomy with urinary diversion (last resort)
These may have more SE and/or questionable efficacy
what are medications that could be used as adjunct tx for interstitial cystitis and what are they CI in?
- Phenazopyridine (Azo) - short-term tx only!
- Methenamine (Hiprex) - urine antimicrobial (metabolizes to formaldehyde)
- CI in renal insufficiency
What are urethral strictures and what is the etiology? who is this MC in?
- narrowing of the urethra
- etiology is iatrogenic (45%), can be idiopathic in developed countries
- MC in men! can be diagnosed at any age.
what are the risk factors for urethral stricture
- Hx of GU surgery or instrumentation
- Hx of pelvic trauma or irradiation
- Hx of GU infection or cancer
what are the s/s of urethral stricture
- obstructive voiding s/s
- May see irritative voiding s/s
- Spraying of the urinary stream
- Recurrent UTIs/prostatitis
- Some (about 10%) of pts may be asymptomatic!
what diagnostic studies can be done to evaluate urinary stricture? what will each of these show?
- UA/UC that is normal unless infection is present
- uroflowmetry - poor bladder emptying
- US - post void residual (PVR) to help rule out urinary retention
- Cystourethrogram - can help visualize stricture
- cystourethroscopy - helps directly visualize stricture via scope
what are indications for tx in urethral strictures?
- recurrent UTIs
- problematic symptoms
- urinary retention
- high PVR
- bladder stones
- may not need tx if asymptomatic!
what are treatment options for urethral stricture
- urethral dilation or urethrotomy (minimally invasive, common initial therapy, high recurrence rate)
- urethroplasty +/- replacement graft (consider effects on erectile funciton)
- suprapubic catheter, perineal urethrostomy, permanent urinary diversion.
what is urethral prolapse? who is it MC in?
- protrusion of the distal urethra through the external urethral meatus d/t malformation of urethra or weakness of pelvic floor structures.
- MC in prepubertal or postmenopausal women (av age is 4 yo)
what are the risk factors for urethral prolapse
- Chronically increased intra-abdominal pressure
- Post-menopausal status
- Traumatic vaginal delivery
what are the s/s of urethral prolapse in a prepubertal patient
- often asymptomatic and found incidentally
- may see vaginal bleeding and periurethral mass
- bloody spotting on underwear/diapers
- may complain of irritative voiding
- exam shows round “donut shaped” protrusion of tissue obscuring the external urethral meatus.
what are the s/s of urethral prolapse in a postmenopausal patient
- often symptomatic
- vaginal bleeding
- dysuria, urinary urgency, urinary frequency, nocturia
- hematuria
- if large - venous obstruction, thrombosis, necrosis
- exam shows round, “donut-shaped” protrusion of tissue obscuring the external urethral meatus
what are the diagnostic studies that can be done to evaluate urethral prolapse
- UA - hematuria and signs of UTI
- imaging done only if concern over complications
- cystourethroscopy can help confirm diagnosis and presence of mass in urethral meatus, primarily used in adults.
- may also use urinary catheterization
what is the medical therapy used in prepubertal vs postmenopausal women with urethral prolapse
- Prepubertal - sitz baths, topical antibiotics, topical estrogen and management of comorbid/predisposing disease
- postmenopausal - sitz baths, topical estrogen cream, antibiotics (Not recommended if significant necrosis, thrombosis or bleeding)
what is surgical treatment options for urethral prolapse
- better outcomes if doe early
- manual reduction and urethral catch for 1-2 days (high recurrence rates with this)
- ablative therapy - not commonly used
- excision_of_mucosa_with_short_term_cath- MC method! may need long term estrogen cream if post menopausal
what is the physiology of urine storage in the bladder
what is the physiology of bladder micturition
What is the etiology of transient vs established urinary incontinence?
- transient/reversible urinary incont - usually originates outside urinary tract
- established/nonreversible - often d/t disorder of bladder or surrounding structures
what are risk factors for urinary incontinence
- Female gender
- Advanced age
- Obesity
- Parity/Pregnancy
- Prostate disease
- Neurologic disease
- Immobility
what are the transient causes of urinary incontinence
DIAPPERS!
D - Delirium
I - Infection
A - Atrophic urethritis/vaginitis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction
what medications can cause urinary incontinence
what are established causes of urinary incontinence
- urge incontinence - detrusor overactivity
- stress incontinence - urethral sphincter incompetence
- Overflow Incontinence - Detrusor underactivity
- Mixed Incontinence - Multiple causes
- Functional Incontinence - Problems thinking/speaking/moving
What is the etiologies of urge incontinence? what is this associated with?
- overactivity of detrusor muscle
- “Overactive bladder”
- Often idiopathic
- Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI
what is the presentation of urinary urge incontinence
- very strong urge to urinate immediately preceding or accompanying involuntary passage of urine
- could range from a few drops to totally soaked clothing
- more common in elderly patients
What is the etiology of urinary stress incontinence
- urethral incompetence
- hypermobility of urethra d/t weak pelvic support (childbirth, estrogen, trauma, prosate surgery, hysterectomy)
- intrinsic sphincter deficiency
what is the presentation of urinary stress incontinence
- involuntary leakage with increase in pressure (coughing, laughing, sneezing, lifting heavy objects)
- generally seen in younger women than urge incontinence
what is the etiology of overflow incontinence
- detrusor underactivity
- non-contractile bladder leads to distension
- may be idiopathic or d/t neural disease (DM, spinal cord disease, neuropathy, ect)
what is the presentation of urinary overflow incontinence
- frequent involuntary leakage of small amounts of urine
- nocturia, weak urinary stream, sensation of bladder fullness
what is mixed urinary incontinence
a urinary incontinence d/t a combination of causes (often stress + urge) presenting with a combo of s/s from other forms of incontinence (very common esp in women)
What is the etiology of functional urinary incontinence
- inability to recognize need to urinate or to get to restroom in a timely fashion when the need to urinate arises
- can be d/t psych/neuro - dementia, delirium, psych disorder
- mobility - inability to ambulate or to request help to get to the restroom
what is the presentation in functional urinary incontinence
- varies w underlying cause
- very common esp in women
what are the three P’s for evaluating hx of urinary incontinence in a patient
Position - (setting) - supine, sitting, standing
Protection - pads/pantiliners per day, wetness of pads
Problem - impact on quality of life
what is the physical exam for urinary incontinence
- evaluate for causes or exacerbating factors (abdominal, rectal, pelvic, mobility, mental status, fluid status)
what studies can be done to evaluate urinary incontinence
- bladder stress test (full bladder, stand and cough. instant leakage = incontinence. delayed leakage = urinary bladder contraction stimulated by coughing)
- UA - screen for UTI, hematuria (culture and/or urine cytology if indicated
- post void residual - for overflow, urologic disease or neuropathy
- second line studies include - cystoscopy, urodynamics, other imaging - as indicated for suspected etiology
what are post void residual positive tests
Measure via US or catheter
< 50 cc - normal;
>200 cc - refer to urology
>400 cc - overflow incontinence highly probable
what is the treatment for urinary stress incontinence
- lifestyle mod (limit caffiene and alcohol, control amount/timing of fluid, bladder training, adult urinary pads/protective garments)
- pelvic floor muscle exercises (kegels, takes up to 6 weeks to see benefit)
- Pessaries - if due/to bladder prolapse in women
- injections - urethal bulking agents
- meds - duloxetine (off label)
- surgery - often last resort but most effective
- emerging/specialty treatments (intravesical balloon, electrical stim of pelvic floor/electroacupuncture, pulsed magnetic stimulation)
what are the treatments are used in urge incontinence
- lifestyle mods (limit caffiene, alcohol, control amount of timing and fluid intake, bladder training, adult urinary pads)
- pelvic floor exercises (may take 6 weeks)
- meds - anticholinergics/antimuscarinics are mainstay
- can also use beta-3 adrenergic agonists, TCAs, alpha blockers (men)
- injection (botox in detrusor muscles, may cause UR)
- Neuromodulation (tibial nerve stim, sacral neuromodulation)
- surgery - last resort (cystoplasty, urinary diversion, suprapubic catheter)
what is the MOA of anticholinergics used for urinary incontinence
- Inhibit acetylcholine at muscarinic receptors, Blocks parasympathetic pathway leading to bladder contraction, May take up to 4 wks to improvement, 12 wks to full efficacy
these are aka antimuscarinics and antispasmodics
what are the SE and CI of antimuscarinics
- SE - dry mouth, constipation, urinary retention, dizziness or drowsiness, blurred vision, impaired cognition, Special caution in elderly due to SE, May have less SE with extended-release formulations.
- CI - gastric retention, glaucoma
what are DDI for anticholinergics
- other anticholinergics
- potassium chloride
what are the anticholingergics
- Oxybutynin (Ditropan) - often MC prescribed d/t cost
- Darifenacin (Enablex) - slightly less cog impairment
- Solifenacin (Vesicare) - slightly less cog impairment
- Tolterodine (Detrol)
- Fesoterodine (Toviaz)
- Trospium (Sanctura)
All have equal efficacy on paper - individual patient responses vary!
what are the beta 3 agonists and what is their MOA
- mirabegron and vibegron
- beta-3 agonist
these are For pts who cannot tolerate anticholinergic therapy for OAB
May also be used as add-on to anticholinergics in severe/refractory OAB
what are the SE and CI for beta 3 agonists
- SE - HTN, tachycardia, dry mouth, constipation, UTI (May be a little less problematic for SE than anticholinergics, Often not prescribed first due to cost)
- CI - allergy
what are DDI for beta 3 agonists
- anticholinergics
- QT - prolonging drugs
what are the treatments for urinary overflow incontinence
- lifestyle modifications (Limit caffeine and alcohol, Control amount and timing of fluid intake, Bladder training (timed voiding), Adult urinary pads/protective garments)
- treatment of underlying cause
- neuromodulation - sacral nerve stimulation, high rate of device failure
- indwelling catheter - last resort (risk of increased UTIs, urethral scarring, consider suprapubic catheter, intermittent cath)
How do you treat mixed urinary incontinence
- lifestyle mod
- pelvic floor muscle exercises
- meds
- refractory is botox or surgical placement of sling
What are the treatments for functional urinary incontinence
- lifestyle mod
- treatment of underlying disease
