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Clin med A 2 > Bladder and Urethral Disorders > Flashcards

Bladder and Urethral Disorders Flashcards

1
Q

What is the 2nd MC urologic cancer? What demographic does it affect most?

A

Bladder cancer
MC in men (~3:1) and older pts (avg age at dx - 73)

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2
Q

what are risk factors for bladder cancer?

A
  • Cigarettes - 60% of new cases
  • Industrial solvents - 15% of new cases
  • Chronic inflammation - UTIs, catheters, bladder stones
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3
Q

what are the types of bladder cancer and how common are they?

A
  • 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
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4
Q

what are the signs and symptoms of bladder cancer

A
  • 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
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5
Q

what diagnostic study results could be seen in evaluation for bladder cancer?

A
  • 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
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6
Q

what is the gold standard for diagnosing bladder cancer?

A

cystoscopy w biopsy

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7
Q

How do you stage bladder cancer?

A

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

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8
Q

What is the treatment for superficial bladder cancer (TIS, Ta, T1)

A
  • transurethral tumor resection
  • +/- intravesical chemotherapy
  • Weekly x 6-12 wks - BCG is often most effective form
  • May require anti-TB treatment
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9
Q

what is the treatment for invasive bladder cancer (T2+)

A
  • radical cystectomy, urinary diversion
  • +/- chemotherapy, immunotherapy, radiation
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10
Q

what is the prognosis for bladder cancer

A
  • Superficial ,5-year survival - 81% (50-80% at presentation are superficial )
  • Invasive, 5-year survival - 50-75%
  • Metastatic (T4) - long-term survival is rare
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11
Q

what is nocturnal enuresis

A
  • 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
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12
Q

what is primary vs secondary nocturnal enuresis

A
  • 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)
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13
Q

what is the MC demographic for nocturnal enuresis and how common is spontaneous remission?

A
  • Twice as common among males
  • about 15% of pts/yr have spontaneous remission
  • plz look at the pic for remission percentages
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14
Q

when is treatment not reccomended for nocturnal enuresis

A

before age 5!

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15
Q

what is the presentation of a patient with nocturnal enuresis

A
  • 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)

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16
Q

what are the diagnostic studies done in evaluation of nocturnal enuresis

A
  • 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
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17
Q

what lifestyle changes may help nocturnal enuresis

A
  • 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)
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18
Q

what are behavioral and medication based treatments for nocturnal enuresis

A
  • 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!)
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19
Q

what is interstitial cystitis and what is its etiology?

A
  • 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.
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20
Q

what is the epidemiology of interstitial cystitis

A
  • More common in women (5:1)
  • 18-40 per 100,000 patients
  • Most commonly diagnosed in 40s or later
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21
Q

what are risk factors for interstitial cystitis

A
  • associated with chronic pain syndromes (IBS, fibromyalgia)
  • certain foods/drinks may trigger (alcohol, caffeine, citrus, spicy)
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22
Q

what are s/s of interstitial cystitis

A
  • 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
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23
Q

what are the diagnostic studies that can be done in evaluation of interstitial cystitis

A
  • 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
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24
Q

what is the diagnosis criteria for interstitial cystitis?

A
  • 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
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25
Q

what cystoscopy findings can be associated with interstitial cystitis

A
  • 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
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26
Q

what aids s/s in 20-30% of interstitial cystitis patients?

A

hydrodistension

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27
Q

what is the treatment for interstitial cystitis

A
  • no cure, symptomatic relief is goal!
  • first line is lifestyle modification and self care
  • 2nd line - oral meds
  • 3rd line is invasive therapies
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28
Q

what medications are used as tx for interstitial cystitis

A
  • TCAs - amitriptyline (Elavil) - often 1st line rx
  • Antihistamines - hydroxyzine (Vistaril)
  • CCBs - nifedipine (Procardia)
  • Pentosan polysulfate sodium (Elmiron)
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29
Q

what is the MOA of elmiron?

A

MOA - May improve glycosaminoglycan layer over urothelium

this is the ONLY drug FDA approved for tx of interstitial cystitis

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30
Q

what are the SE, CI and DDI for elmiron

A
  • 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)
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31
Q

what are the invasive therapies used to treat interstitial cystitis (3rd line)

A
  • Hydrodistension
  • Electrocauterization of Hunner lesions (if present)
  • Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)
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32
Q

what are treatments for refractory interstitial cystitis

A
  • Botulinum injections to detrusor muscle
  • Sacral neuromodulation
  • Cystectomy with urinary diversion (last resort)

These may have more SE and/or questionable efficacy

33
Q

what are medications that could be used as adjunct tx for interstitial cystitis and what are they CI in?

A
  • Phenazopyridine (Azo) - short-term tx only!
  • Methenamine (Hiprex) - urine antimicrobial (metabolizes to formaldehyde)
  • CI in renal insufficiency
34
Q

What are urethral strictures and what is the etiology? who is this MC in?

A
  • narrowing of the urethra
  • etiology is iatrogenic (45%), can be idiopathic in developed countries
  • MC in men! can be diagnosed at any age.
35
Q

what are the risk factors for urethral stricture

A
  • Hx of GU surgery or instrumentation
  • Hx of pelvic trauma or irradiation
  • Hx of GU infection or cancer
36
Q

what are the s/s of urethral stricture

A
  • 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!
37
Q

what diagnostic studies can be done to evaluate urinary stricture? what will each of these show?

A
  • 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
38
Q

what are indications for tx in urethral strictures?

A
  • recurrent UTIs
  • problematic symptoms
  • urinary retention
  • high PVR
  • bladder stones
  • may not need tx if asymptomatic!
39
Q

what are treatment options for urethral stricture

A
  • 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.
40
Q

what is urethral prolapse? who is it MC in?

A
  • 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)
41
Q

what are the risk factors for urethral prolapse

A
  • Chronically increased intra-abdominal pressure
  • Post-menopausal status
  • Traumatic vaginal delivery
42
Q

what are the s/s of urethral prolapse in a prepubertal patient

A
  • 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.
43
Q

what are the s/s of urethral prolapse in a postmenopausal patient

A
  • 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
44
Q

what are the diagnostic studies that can be done to evaluate urethral prolapse

A
  • 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
45
Q

what is the medical therapy used in prepubertal vs postmenopausal women with urethral prolapse

A
  • 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)
46
Q

what is surgical treatment options for urethral prolapse

A
  • 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
47
Q

what is the physiology of urine storage in the bladder

A
48
Q

what is the physiology of bladder micturition

A
49
Q

What is the etiology of transient vs established urinary incontinence?

A
  • transient/reversible urinary incont - usually originates outside urinary tract
  • established/nonreversible - often d/t disorder of bladder or surrounding structures
50
Q

what are risk factors for urinary incontinence

A
  • Female gender
  • Advanced age
  • Obesity
  • Parity/Pregnancy
  • Prostate disease
  • Neurologic disease
  • Immobility
51
Q

what are the transient causes of urinary incontinence

A

DIAPPERS!
D - Delirium
I - Infection
A - Atrophic urethritis/vaginitis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction

52
Q

what medications can cause urinary incontinence

A
53
Q

what are established causes of urinary incontinence

A
  • urge incontinence - detrusor overactivity
  • stress incontinence - urethral sphincter incompetence
  • Overflow Incontinence - Detrusor underactivity
  • Mixed Incontinence - Multiple causes
  • Functional Incontinence - Problems thinking/speaking/moving
54
Q

What is the etiologies of urge incontinence? what is this associated with?

A
  • overactivity of detrusor muscle
  • “Overactive bladder”
  • Often idiopathic
  • Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI
55
Q

what is the presentation of urinary urge incontinence

A
  • 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
56
Q

What is the etiology of urinary stress incontinence

A
  • urethral incompetence
  • hypermobility of urethra d/t weak pelvic support (childbirth, estrogen, trauma, prosate surgery, hysterectomy)
  • intrinsic sphincter deficiency
57
Q

what is the presentation of urinary stress incontinence

A
  • involuntary leakage with increase in pressure (coughing, laughing, sneezing, lifting heavy objects)
  • generally seen in younger women than urge incontinence
58
Q

what is the etiology of overflow incontinence

A
  • detrusor underactivity
  • non-contractile bladder leads to distension
  • may be idiopathic or d/t neural disease (DM, spinal cord disease, neuropathy, ect)
59
Q

what is the presentation of urinary overflow incontinence

A
  • frequent involuntary leakage of small amounts of urine
  • nocturia, weak urinary stream, sensation of bladder fullness
60
Q

what is mixed urinary incontinence

A

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)

61
Q

What is the etiology of functional urinary incontinence

A
  • 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
62
Q

what is the presentation in functional urinary incontinence

A
  • varies w underlying cause
  • very common esp in women
63
Q

what are the three P’s for evaluating hx of urinary incontinence in a patient

A

Position - (setting) - supine, sitting, standing
Protection - pads/pantiliners per day, wetness of pads
Problem - impact on quality of life

64
Q

what is the physical exam for urinary incontinence

A
  • evaluate for causes or exacerbating factors (abdominal, rectal, pelvic, mobility, mental status, fluid status)
65
Q

what studies can be done to evaluate urinary incontinence

A
  • 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
66
Q

what are post void residual positive tests

A

Measure via US or catheter
< 50 cc - normal;
>200 cc - refer to urology
>400 cc - overflow incontinence highly probable

67
Q

what is the treatment for urinary stress incontinence

A
  • 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)
68
Q

what are the treatments are used in urge incontinence

A
  • 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)
69
Q

what is the MOA of anticholinergics used for urinary incontinence

A
  • 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

70
Q

what are the SE and CI of antimuscarinics

A
  • 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
71
Q

what are DDI for anticholinergics

A
  • other anticholinergics
  • potassium chloride
72
Q

what are the anticholingergics

A
  • 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!

73
Q

what are the beta 3 agonists and what is their MOA

A
  • 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

74
Q

what are the SE and CI for beta 3 agonists

A
  • 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
75
Q

what are DDI for beta 3 agonists

A
  • anticholinergics
  • QT - prolonging drugs
76
Q

what are the treatments for urinary overflow incontinence

A
  • 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)
77
Q

How do you treat mixed urinary incontinence

A
  • lifestyle mod
  • pelvic floor muscle exercises
  • meds
  • refractory is botox or surgical placement of sling
78
Q

What are the treatments for functional urinary incontinence

A
  • lifestyle mod
  • treatment of underlying disease

Clin med A 2 (30 decks)

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