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GU > Bladder and Urethral Disorders - Exam 2 > Flashcards

Bladder and Urethral Disorders - Exam 2 Flashcards

1
Q

_______ is the 2nd MC urologic cancer. What is the MC pt?

A

bladder cancer

MC in men and older pts

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2
Q

What are the 3 risk factors for bladder cancer?

A

cigarettes- major one
industrial solvents
chronic inflammation- think UTIs, catheters, bladder stones

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3
Q

98% _____ cell malignancies in bladder cancer. What layer specifically accounts for 90% of bladder cancer?

A

epithelial

90% - urothelial cell carcinoma

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4
Q

What type of bladder cancer is due to chronic inflammation?

A

squamous cell carcinoma

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5
Q

What is the major presenting s/s in bladder cancer?

A

hematuria: can be micro or gross and often painless!!

can also have irritative voiding but not common in early stages

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6
Q

After UA, what additional lab would you want to order? What will a negative value tell you?

A

Urine cytology looking for abnormal shed epithelial cells

a negative urine cytology does NOT rule out cancer

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7
Q

What will a CT/MRI/US of the bladder show if the pt does have bladder cancer? **What is the gold standard for dx bladder cancer?

A

“filling defect”

**Cystoscopy with biopsy

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8
Q

What are the different stages of bladder cancer? What stages are considered superficial? Invasive?

A

CIS, Ta, T1, T2, T3, T4

Superficial (TIS, Ta, T1)

Invasive (T2 +)

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9
Q

What is the tx for superficial bladder cancer? What medication is used?

A

tumor resection +/- intravesical chemo

BCG is often most effective form (type of TB tx)

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10
Q

What is the tx for invasive bladder cancer?

A

partial or radical cystectomy + urinary diversion

+/- chemotherapy, immunotherapy, radiation
Often have a urostomy after cystectomy

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11
Q

The standard urostomy is considered (incontinent/continent)?

A

incontinent: urine can out into a bad whenever it wants

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12
Q

define enuresis

Define monosymptomatic enuresis

A

Enuresis - repeated urination into clothing or bedding, must be 5+ years old

Monosymptomatic enuresis - no other lower urinary tract symptoms and no history of bladder disorders

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13
Q

What is the difference between primary and secondary nocturnal enuresis?

A

Primary - usually in young children < 5-6 years old; have never achieved urinary continence

Secondary - patients who previously were fully continent for 6+ months and often associated with stressful event in a kid’s life

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14
Q

Nocturnal enuresis is twice as common in _____. What is the common trend? When should you NOT treat?

A

twice as common in males

￪ duration = ￬ likelihood of
spontaneous resolution

tx before 5 is NOT recommended

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15
Q

What is the classic presentation of nocturnal enuresis?

A

Involuntary urination during sleep in a person who normally has voluntary urinary control that usually occurs 3-4 hours after bedtime

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16
Q

What diagnostic tests need to be ordered for nocturnal enuresis?

A

UA: to rule out UTI, DM, hematuria etc etc

US: to check for anatomical abnormalities

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17
Q

What are 2 lifestyle changes that can help with noctural enuresis? What is the behavioral intervention?

A

Voiding - frequently in day (4-7x) and just before bed

Fluids - avoid excess fluids in the evening
Especially sugary/caffeinated

Behavioral - enuresis alarm

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18
Q

What is the first line medication tx for nocturnal enuresis? 2nd line? Add-on?

A

1st line: desmopressin

2nd line: imipramine

Add-on: oxybutinin

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19
Q

What is the etiology behind interstitial cystitis? What is another name for it?

A

eitology: unknown but possible allergic response, inflammatory/autoimmune, abnormal epithelium, abnormal sensorineural response

painful bladder syndrome

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20
Q

What is the MC pt in interstitial cystitis? What are the risk factors?

A

women that is older than 40

risk:
other chronic pain syndromes: IBS, fibromyalgia)
certain food/drinks: alcohol, caffeine, citrus, spicy foods

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21
Q

pain/discomfort with bladder filling
classically is relieved with urination
+/- suprapubic tenderness
+/- irritative voiding symptoms

What am I?
What will urine labs show?

A

interstitial cystitis

urine labs will be normal!

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22
Q

What imaging should be ordered in interstitial cystitis?

A

US - Postvoid residual (PVR) to rule out urinary retention

Cystoscopy - helps rule out bladder CA

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23
Q

What is the AUA criteria for diagnosing interstitial cystitis? What is the diagnostic test to confirm interstitial cystitis?

A

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!- order tests to rule out other potential diagnosis

aka dx of exclusion

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24
Q

Is a cystoscopy required to dx interstitial cystitis? What is common to find? What is a common finding on bx?

A

cystoscopy is NOT required

common findings include:
Hunner’s ulcers/lesions
Glomerulations- also found in healthy pts

Bx: increased mast cells

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25
Q

What are glomerulations?

A

pinpoint bleeding (in this context will be pinpoint bleeding on the bladder wall)

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26
Q

What is the first line tx for interstitial cystitis?

A

heating/cool pads
fluid consumption management
avoid trigger foods
frequent pee breaks

medication- amitriptyline (Elavil) - often 1st line rx

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27
Q

What are 2nd line txs for interstitial cystitis? Which one is the only FDA approved medication for IC?

A

Antihistamines - hydroxyzine (Vistaril)

CCBs - nifedipine (Procardia)

**Pentosan polysulfate sodium (Elmiron)- FDA approved for IC

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28
Q

______ MOA may improve glycosaminoglycan layer over urothelium. What are the SE?

A

pentosan polysulfate sodium (PPS) Elmiron

SE: GI upset, elevated LFTs, hair loss

Case reports of retinal toxicity/macular disease - dose-related

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29
Q

What are the CI to pentosan polysulfate sodium (PPS)? DDI?

A

CI - allergy to drug or to heparin or LMWH

DDI - anticoagulants/antiplatelets (￪ bleeding) because it is structurally similiar to heparin

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30
Q

What are 3rd line treatments for intersititial cystitis?

A

Hydrodistension

Electrocauterization of Hunner lesions (if present)

Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)

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31
Q

What are adjunct treatments for interstitial cystitis? When are the CI?

A

often not used alone; CI in renal insuff.

OTC analgesics (NSAIDs, or acetaminophen)

Phenazopyridine (Azo) - short-term tx only!

Methenamine (Hiprex) - urine antimicrobial (metabolizes to formaldehyde)

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32
Q

What is the MC cause of urethral strictures?

A

Iatrogenic (surgery, catheters) - 45% of all cases

33
Q

What is the MC population of urethral strictures? What are the risk factors?

A

males of any age including children

risk:
Hx of GU surgery or instrumentation
Hx of pelvic trauma or irradiation
Hx of GU infection or cancer

34
Q

May see irritative voiding s/s
Spraying of the urinary stream
Recurrent UTIs/prostatitis
obstructive voiding s/s

What am I?
What will urine labs look like?

A

urethral stricture

often normal!

35
Q

What will the following imaging studies show if a pt has an urethral stricture?

A
36
Q

Under what conditions would you want to treat an urethral stricuture? Do you always have to tx them?

A

recurrent UTIs
problematic symptoms
urinary retention
high PVR
bladder stones

do not have to tx if asymptomatic

37
Q

What are the minimally invasive treatment options for urethral stricture? What are more invasive treatment options?

A

minimal: urethral dilation

minimal: urethrotomy (cut the scar tissue to allow better urine flow)

both have a fairly high rates of recurrence

invasive: urethroplasty +/- replacement graft

invasive: urinary diversion: suprapubic catheter, perineal urethrostomy, permanent urinary diversion

38
Q

in urethral prolapse, it is a protrusion of the _____ through the ______. Who is the MC pt population?

A

distal urethra through the external urethral meatus

women either prepubertal (around 4) or postmenopausal

39
Q

What are the risk factors for urethral prolapse?

A

Chronically increased intra-abdominal pressure (think chronic constipation)

Post-menopausal status

Traumatic vaginal delivery

40
Q

in the prepubertal presentation of urethral prolapse, what is the presentation? What is the associated PE finding?

A

often asymptomatic (found incidentally)

May see vaginal bleeding along with periurethral mass

Bloody spotting on underwear/diapers

May complain of irritative voiding

“donut-shaped” protrusion of tissue obscuring the external urethral meatus

41
Q

_____ can help confirm diagnosis of urethral prolapse and the presence. Especially in _____ population

A

Cystourethroscopy

used primarily in the adult population

42
Q

What is the tx for urethral prolapse in prepubertal patients? postmenopausal? When are these treatments NOT recommended?

A

Prepubertal - sitz baths, topical antibiotics, topical estrogen

Postmenopausal - sitz baths, topical estrogen cream, antibiotics

significant necrosis, thrombosis or bleeding

43
Q

What are the surgical therapies commonly used for urethral prolapse? Which one is MC?

A

Manual reduction and urethral cath for 1-2 days- but tend to have a high recurrence rate

MC **Excision of mucosa with short-term catheterization- may need long-term estrogen cream if postmenopausal

44
Q

Up to _____ of urine and there will be no stretch to detrusor muscle

A

200-300 cc

45
Q

When the Pons stimulates SYMPATHETICS nerves what happens?

A

Inhibit (relax) detrusor muscle
Closes internal urethral sphincter

46
Q

When the Pons stimulates SOMATIC nerves, what happens?

A

Contraction of external urethral sphincter

47
Q

What is the physiology behind urination?

A

More urine fills bladder

Detrusor/Trigone stretch → signal to Pons

Inhibits SYMPATHETICS and SOMATICS

Activates PARASYMPATHETICS which
Stimulates (contracts) detrusor
Relaxes (opens) internal urethral sphincter

48
Q

When the Pons activates the parasympathetics, what happens?

A

Stimulates (contracts) detrusor
Relaxes (opens) internal urethral sphincter

49
Q

How does the body tell the bladder to NOT pee?

A

the voluntary control overrides the involuntary pathway

Cerebral cortex → pudendal nerve → contraction of the external urethral sphincter

50
Q

What are the 2 types of urinary incontinence? What are the underlying causes of each? Which one is easier to treat?

A

Transient/Reversible: often originates outside the urinary tract -> easier to tx

Established: Often due to disorder of bladder or surrounding structures -> harder to tx

51
Q

What are the risk factors for urinary incontinence?

A

Female gender
Advanced age
Obesity
Parity/Pregnancy
Prostate disease
Neurologic disease
Immobility

52
Q

What are the transient causes of urinary incontinence?

A

aka things we can hopefully fix

53
Q

What are the established causes of urinary incontinence?

A
54
Q

What is urge urinary incontinence caused by? What are 5 things it is associated with?

A

overactivity of detrusor muscle

Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI

55
Q

_____ is a very strong urge to urinate, then immediately precedes to pee

A

urge UI

the bladder does NOT always have to be full before the urge to pee comes on

56
Q

What is stress UI caused by?

A

Hypermobility of urethra - weak pelvic support

or intrinsic sphincter deficiency

57
Q

What are some causes of hypermobility of urethra?

A

Childbirth, ￬ estrogen, trauma, prostate surgery, hysterectomy

58
Q

_____ presents with involuntary leakage that occurs with increased pressure. Name some sources of pressure

A

stress UI

coughing, laughing, sneezing, lifting heavy objects

59
Q

What is the cause behind overflow UI?

A

Detrusor muscle underactivity and non-contractile bladder leads to distension

60
Q

_______ presents as frequent involuntary leakage of small amounts of urine, nocturia, weak urinary stream, sensation of bladder fullness. What do you need to rule out?

A

overflow UI

Should rule out bladder outlet obstruction

61
Q

A mixed UI presents as a combination between _____ and _____ incontinence

A

stress and urge

very common in women!!

62
Q

What is the cause of functional UI? What are some likely culprits of the problem?

A

inability to recognize need to urinate or to get to restroom in a timely fashion when the need to urinate arises

psych/neuro: dementia, delirium, psych disorder

mobility issues

63
Q

What is one question need to start asking pts about during routine visits? Need to ask about ____, _____ and _____ as follow up questions

A

“Do you have a problem with urine leakage or bladder accidents?”

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

64
Q

What is the bladder stress test? What can either of the two results tell you about the type of UI?

A

Bladder Stress Test - have pt with full bladder stand and cough

Instant leakage - stress incontinence

Delayed leakage - urinary bladder contraction stimulated by coughing

65
Q

What are 2 tests you should order when working a pt up for UI in the primary care setting?

A

UA - screen for UTI, hematuria

Postvoid Residual - if overflow incontinence, urologic disease, neuropathy suspected

66
Q

In the postvoid residual test, how much urine is normal? _____ refer to urology and ______ overflow incontinence is highly probable

A

< 50 cc - normal;
>200 cc - refer to urology
>400 cc - overflow incontinence highly probable

67
Q

What are 5 lifestyle modifications/exercises that are beneficial in ALL TYPES of UI?

A

Limit caffeine and alcohol
Control amount and timing of fluid intake
Bladder training (timed voiding)
Adult urinary pads/protective garments

kegels- may take up to 6 weeks to see full effect

68
Q

How long does it take to see an improvement after starting kegel exercises?

A

May take up to 6 weeks to see benefit

69
Q

What are some non-lifestyle tx options for stress UI?

A
70
Q

What medication can be helpful in urge UI?

A

Beta-3 adrenergic agonists- becoming for favored as initial treatment

consider anticholinergics or TCAs

alpha blockers can be used in men

71
Q

What are the drugs in the Beta-3 agonist drug class? What are the SE? What are the DDI?

A

mirabegron (Myrbetriq), vibegron (Gemtesa)

HTN, tachycardia, dry mouth, constipation, UTI

anticholinergics, QT-prolonging drugs

72
Q

What is the MOA of anticholinergics? What are the SE?

A

Inhibit acetylcholine at muscarinic receptors and blocks parasympathetic pathway leading to bladder contraction

dry mouth, constipation, urinary retention, dizziness or drowsiness, blurred vision, impaired cognition

73
Q

What are the CI to anticholinergics? What are the DDI?

A

gastric retention, glaucoma

other anticholinergics, potassium chloride

74
Q

Oxybutynin (Ditropan)
Darifenacin (Enablex)
Solifenacin (Vesicare)
Tolterodine (Detrol)
Fesoterodine (Toviaz)
Trospium (Sanctura)

What drug class?
Which ones do UpToDate recommend?
Which one is prescribed most often?

A

Anticholinergics

UpToDate - recommends trospium (Sanctura) or darifenacin (Enablex) due to slightly less cognitive impairment

Oxybutinin (Ditropan) - often most commonly prescribed due to cost

75
Q

What is the tx for urge UI?

A

botox injections into detrusor muscle

neuromodulation

sx as the last resort

76
Q

What is the tx for overflow UI? Which one is considered a last resort?

A

tx the underlying cause

neuromodulation: sacral nerve stimulation but has a high rate of device failure

indwelling cath- last resort tx

77
Q

What are 2 additional lifestyle modifications that are specific to functional UI? What is the tx?

A

Bedside commode for limited mobility

Call bell or other signal if assistance needed to get to restroom

tx the underlying cause!

78
Q
A

GU (13 decks)

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