Bladder and Urethral disorders Flashcards
Age is the single largest risk factor for _____
Urinary Incontinence
Urinary Incontinence
Involuntary leakage of urine – Stress – Urge – Mixed – Overflow
Urinary Incontinencen epidemiology
● 10-13 million people in the US
● Female incontinence is reported at 38%
○ 20–30% during young adult life
○ 50% in the elderly (peaks in the 5th decade)
● Stress incont more likely in caucasian women
● Age is the single largest risk factor
● Pregnancy/Childbirth
● Obesity
Patients often live with this condition for 6-9 years before seeking medical therapy
Urinary Incontinence
Transient/Reversible Causes of Incontinence – DIAPPERS
● D: Delirium or acute confusion
● I: Infection (symptomatic UTI)
● A: Atrophic vaginitis or urethritis
● P: Pharmaceutical agents
● P: Psychological disorders (depression, behavioral disturbances)
● E: Excess urine output (due to excess fluid intake, alcoholic or caffeinated
beverages, diuretics or hyperglycemia)
● R: Restricted mobility (limits ability to reach a bathroom in time)
● S: Stool impaction
Pathophysiology/Etiology of urinary incontinence
● Multifactorial – not completely understood
○ Can be transient or chronic
● Two-part system – the urinary bladder as a reservoir and the bladder outlet as a
sphincteric mechanism
Functional cause of urinary incontinence
Problem with the bladder’s ability to contract (neves or muscle)
Problem with sphincter, bladder (or other pelvic structure) positioning would be _____ causes of Urinary Incontinence
Anatomical
Stress Incontinence Etiology
○ Urethra hypermobility
■ Due to loss of structural support from the pelvic floor
○ Intrinsic sphincter deficiency
■ Sphincter unable produce enough closing pressure
■ Typically secondary to surgery
Stress Incontinence clinical presentation
● Urine leaks when pressure is exerted on the
bladder by coughing, sneezing, laughing,
exercising or lifting something heavy
○ Worse with high impact sports
● Typically small amounts of urine lost
● Absence of urinary frequency and urgency
Urge Incontinence
Involuntary loss of urine associated with LUTS
● LUTS – lower urinary tract symptoms (urgency, frequency, nocturia)
Etiology of Urge Incontinence
● Detrusor overactivity
● Low bladder compliance while attempting to inhibit micturition
● Bladder irritants, psychological
Urge Incontinence clinical presentation
● Uncontrolled urine loss associated with a strong desire to void
● Occurs without warning
● Cannot be prevented
● Not associated with physical activity
Syndrome of urinary urgency that Presents with frequency and nocturia and Occurs with or without urgency urinary incontinence
Overactive Bladder
Mixed Incontinence
Combination of stress and urge incontinence
Epidemiology of Mixed Incontinence
● 40-60% of females have this combination
● More common in older patients
Etiology of Mixed Incontinence
Detrusor overactivity and impaired urethral function
Clinical Presentation of Mixed Incontinence
● Mild-to-moderate urine loss with physical exertion (stress incontinence)
● Acute urine loss without warning (urge incontinence)
● LUTS
Overflow Incontinence
Involuntary loss of urine associated with bladder overdistension
Etiology
● Bladder outlet obstruction
● Inadequate bladder contractions
○ Neurogenic bladder
● Intravesical pressure exceeds the resting
urethral closure pressure and urine overflows
despite the absence of detrusor contraction
● With overdistension, the detrusor becomes
acontractile
Overflow Incontinence Clinical Presentation
● Frequent small voids
● Sensation of incomplete emptying
● Urine hesitancy and slow flow
● Dribble
● High PVR (>200 mL)
Diagnosis of Incontinence
● Voiding Log: “How often, how much, how many pads…”
● UA: Urine culture
● Blood work: BUN and Creatinine, A1c
● PVR/ultrasound: High PVR (>200 mL)
● Pelvic Exam
● Neurologic Exam
● Stress Incontinence Testing
● Cystoscopy
● Urodynamic Testing
Pelvic exam for urinary incontinence
○ Inspection of the external genitalia and
urethral meatus
○ The vaginal mucosa should be inspected
for pallor, thinning, loss of rugae, fistula
○ Evaluate for cystocele, rectocele, uterine
or vaginal prolapse, and enterocele
○ Evaluate for pelvic organ prolapse
○ Inspect the perineal floor of tone
○ Anal sphincter tone
Male Exam
○ Prostate exam
■ Enlargement, tenderness, nodules
○ Rectal tone
Whats included in a neurologic exam for urinary incontinence?
○ Sensation of the perineum and perianal areas
○ Anal Wink reflex
○ Bulbocavernosus Reflex
What is included in a Stress Incontinence Testing for urinary incontinence?
○ Q-Tip Test
○ Stress Test
When to perform a Cystoscopy for diagnosing incontinence?
○ Irritative voiding symptoms/OAB
■ Cystitis, stones, tumors
○ Postoperative incontinence
○ Voiding dysfunction
What is Stress Incontinence Testing?
○ Stress Test
■ The bladder is filled with sterile fluid at least halfway (eg, 200-250 ml)
■ Visualizing the urethra, instruct the patient to bear-down or cough
■ Observation of leakage during valsalva or cough denotes a positive test
● Display immediate loss of a few drops to a brief squirt of urine
Urodynamic Testing in Urinary incontinence
○ Evaluate the pressure-flow relationship between the bladder and the urethra
■ Electromyography (EMG), Uroflow, voiding
cytometrography (CMG)
Stress Incontinence Management
● Absorbent products – pads
● Weight loss
● Timed voids – “Bladder Training”
● Pelvic floor muscle training – Kegels
● Acupuncture
● Radio-frequency
● Mechanical devices
Mechanical Devices for Stress Incontinence
● Pessary
○ May be useful severe pelvic organ prolapse
Kegels
● Stress and mixed incontinence
● Pelvic prolapse
● Sexual function
● Benefits men who develop urinary
incontinence following prostate surgery
● Success rate of 75-80%
Surgical management of stress incontinence
● Bladder neck suspension
○ Mid-urethral sling surgery
● Periurethral bulking therapy
● Artificial urinary sphincter placement
Urge Incontinence Management
● Absorbent products – pads
● Weight loss
● Timed voids – “Bladder Training”
● Pelvic floor muscle training – Kegels
● Medication Modification
○ Diuretics, sedatives, muscle relaxers,
antidepressants
● Dietary Modification – Avoid the irritants
● Pharmacotherapy (Antimuscarinics, Beta-3 adrenergic agonists, etc.)
Antimuscarinics for Urge incontinence
○ Oxybutynin (Ditropan), solifenacin (Vesicare), fesoterodine (Toviaz), tolterodine (Detrol)
○ MOA – binding the muscarinic receptor on the detrusor decreasing the contractility of the
detrusor muscle
○ S/E (ABCD’s) - Anorexia, Blurry vision, Constipation/confusion, Dry mouth, Stasis urine
○ Contraindications – Narrow or closed-angle glaucoma, caution in patients with history of
impaired gastric emptying or history of urinary retention
○ High discontinuation rate due to intolerable side effects
Beta-3 adrenergic agonist for Urge Incontinence
○ Mirabegron (Mybetriq)
○ MOA – binding the β-3 adrenergic receptor on the bladder signaling relaxation of the detrusor muscle
○ S/E – hypertension (7-25%) increase systolic by 4 mm/Hg and diastolic of 1.6 mm/Hg, headaches, UTI
○ Contraindications – Uncontrolled hypertension, Hx of or current low-risk papillary thyroid cancer, beta-blockers and antiarrhythmics (CYP-2D6)
Other interventions for Urge Incontinence
● Posterior Tibial Nerve Stimulation
(PTNS)
● Botox
What is Posterior Tibial Nerve Stimulation
(PTNS)?
Neuromodulation — aims to
change the abnormal pattern
of stimulation of the nerves
that supply the bladder and
pelvic floor
-Used for urge incontinence
Overflow Incontinence management
Pharmacotherapy
● Alpha-adrenergic antagonist
● 5-alpha reductase inhibitors
● Self catheterization
Alpha-adrenergic antagonist
(Overflow Incontinence)
Tamsulosin (Flomax), Doxazosin (Cardura), Prazosin (Minipress), others
■ Smooth muscle relaxer
■ S/E – Orthostatic hypotension
5-alpha reductase inhibitors
(Overflow incontinence)
Finasteride (Proscar), Dutasteride (Avodart)
■ Shrink the prostate (may take several months)
■ S/E – ED, breast enlargement/tenderness
Urethral catheter is contraindicated in the treatment of _____
urge incontinence
When can catheters be used for incontinence?
● Healing of a perineal wound
● Overflow incontinence
○ Intermittent self catheterization
Nocturnal Enuresis (NE)
Involuntary voiding of urine at night – “Bed-wetting”
● Twice as common in boys as in girls
Nocturnal Enuresis etiology
● Small bladder, inability to recognize a full bladder, low ADH, UTI, diabetes, constipation, structural or neurological abnormality
● Genetics - 77% of children when both mom and dad had history of NE
Impact of Nocturnal Enuresis on children
● Children with NE are commonly punished and are at risk for emotional and physical abuse
● Children with NE report feelings of embarrassment and anxiety, loss of self-esteem, and
effects on self-perception, interpersonal relationships, quality of life, and school
performance even with only one episode a month
Nocturnal Enuresis Clinical presentation
Primary – bladder control never attained
Secondary – has had control for at least 6 months before return of NE
DDx – See the list in “Etiology”
Nocturnal Enuresis Diagnosis
● History
○ Hydration history
○ Daytime voiding history (urine and stool)
○ Number (how many/night) and timing (interval between episodes)
○ Sleep history
○ Nutrition history
○ Behavior, personality, and emotional status
● Physical
○ Inspection of external genitalia
○ Thorough neurologic exam
● UA – glucose, inflammation
● Urine culture
● Bladder ultrasound – Full and PVR
● X-ray (if indicated by exam)
Nocturnal Enuresis Management
● Reassurance – especially with family Hx
● Timed voids – just before bed
● Avoid sugary and caffeinated drinks
● Majority of fluid intake should occur in the
morning and early afternoon (nothing after 7 pm)
● Consistency with fluid, voiding, and bedtime
routine
● Alarms
● Desmopressin (DDAVP) – synthetic ADH
● Imipramine – TCA
● Referral if no improvement despite appropriate treatments
Desmopressin (DDAVP) – synthetic ADH use in nocturnal enuresis
○ Use for 5 years old or older
○ Dose tritrat from 0.2 mg up to 0.6
mg/night
■ Take 1 hour before bedtime
○ Monitor electrolytes (hyponatremia)
Imipramine – TCA use in nocturnal enuresis
○ Decreases smooth muscle
contractility
■ Using the S/E of TCA’s to
“dry” thing out
■ Take 1-2 hours before bed
○ Overdose can be fatal
Interstitial Cystitis
Chronic Bladder Pain Syndrome
Urinary frequency, urgency, and bladder pain with unknown etiology
Interstitial Cystitis Presentation
● Not uniform
● Irritative voiding symptoms
○ Dysuria, urgency, frequency, nocturia
● Bladder pain worsened with certain foods
● Dyspareunia
● “Feeling of chronic pelvic pressure”
Men
● Chronic scrotal, testicular, or prostatic pain
Interstitial Cystitis Diagnosis
● Diagnosis of exclusion
○ Physical exam – typically noncontributory
○ Labs
■ Microscopic hematuria
■ Negative (no growth on C&S)
○ Imaging
■ No stones, hydro, reflux, normal bladder capacity
● Cystoscopy - critical part of diagnosis
○ Still may be completely negative
Findings on cystoscopy for Interstitial Cystitis
Hunner’s lesions
○ Distinctive areas of scarring and cracking of the
mucosa after hydrodistention
○ 5-10% of interstitial cystitis patients
Glomerulations
○ Pinpoint-sized areas of bleeding in the bladder wall
■ Not specific to interstitial cystitis
Interstitial Cystitis Management
● Stress reduction (anxiety and depression control)
● Avoidance of triggers – 3-6 months trial
● Analgesics
● Antihistamines
○ Cimetidine (H2 receptor antagonist)
○ Hydroxyzine (1st Gen Antihistamine)
● Others
○ Amitriptyline (TCA)
○ Gabapentin
Interstitial Cystitis Surgical management
● Bladder Hydrodistention
○ Under anesthesia, the bladder is filled, and then some, with water and kept full for several minutes (this process may be repeated in the same visit)
Urethral Stricture
Scarring or narrowing of the urethra
Urethral Stricture Pathophysiology/Epidemiology
● Congenital (rare)
● Acquired
○ Trauma
○ Infection
■ Catheters
■ Post G&C
Urethral Stricture Clinical presentation
● Decreased urine stream
● Urinary frequency
● Dysuria
● Spray or double stream
● Post void dribbling
● Possible cystitis
Urethral Stricture Diagnosis
● Urinary flow rates/Peak flow
● Urine culture
● Imaging
○ Voiding cystourethrogram
● Ureteroscopy
Urethral Stricture Management
● Dilatation – temporary fix, but relieves Sx
● Urethrotomy – endoscope → several cuts (blade or laser) → catheter for days.
30-80% recurrence rates
● Ureteroplasty – surgically removing stricture → anastomosis or graft to repair
Urethral Stricture Complications
● Prostatitis
● Urinary retention
● Bladder hypertrophy
● Ureteral reflux → renal failure
● Recurrence after surgery
Urethral Stricture referral
● Decreased or spray in urine stream
● Urinary frequency and/or dysuria with negative
infection work-up
Urethral Prolapse
Outward eversion of the urethra
Urethral Prolapse epidemiology
Prepubertal girls (2-10 years old) and
in postmenopausal women
Urethral Prolapse Clinical Presentation
● Bleeding/spotting
● Uncomfortable voiding symptoms
● “Beefy red” doughnut-shaped lesion with the urethral meatus at the center
Urethral Prolapse DDx
● Urethral caruncle – postmenopausal
● Ureterocele
Urethral Prolapse Diagnosis
● Visual inspection
● Cystoscopy (after reduction to rule out
ureterocele)
Urethral Prolapse Management
● Topical estrogen cream (BID)
● Sitz baths (BID)
● Surgical cauterization/ligation or excision
Urethral Prolapse complications
● Urethral mucosa may become gangrenous if it is not reduced promptly
● Recurrence
