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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
What are glomerulations?
pinpoint bleeding (in this context will be pinpoint bleeding on the bladder wall)
26
What is the first line tx for interstitial cystitis?
heating/cool pads fluid consumption management avoid trigger foods frequent pee breaks medication- amitriptyline (Elavil) - often 1st line rx
27
What are 2nd line txs for interstitial cystitis? Which one is the only FDA approved medication for IC?
Antihistamines - hydroxyzine (Vistaril) CCBs - nifedipine (Procardia) **Pentosan polysulfate sodium (Elmiron)- FDA approved for IC
28
______ MOA may improve glycosaminoglycan layer over urothelium. What are the SE?
pentosan polysulfate sodium (PPS) Elmiron SE: GI upset, elevated LFTs, hair loss Case reports of retinal toxicity/macular disease - dose-related
29
What are the CI to pentosan polysulfate sodium (PPS)? DDI?
CI - allergy to drug or to heparin or LMWH DDI - anticoagulants/antiplatelets (￪ bleeding) because it is structurally similiar to heparin
30
What are 3rd line treatments for intersititial cystitis?
Hydrodistension Electrocauterization of Hunner lesions (if present) Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)
31
What are adjunct treatments for interstitial cystitis? When are the CI?
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)
32
What is the MC cause of urethral strictures?
Iatrogenic (surgery, catheters) - 45% of all cases
33
What is the MC population of urethral strictures? What are the risk factors?
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
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?
urethral stricture often normal!
35
What will the following imaging studies show if a pt has an urethral stricture?
36
Under what conditions would you want to treat an urethral stricuture? Do you always have to tx them?
recurrent UTIs problematic symptoms urinary retention high PVR bladder stones do not have to tx if asymptomatic
37
What are the minimally invasive treatment options for urethral stricture? What are more invasive treatment options?
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
in urethral prolapse, it is a protrusion of the _____ through the ______. Who is the MC pt population?
distal urethra through the external urethral meatus women either prepubertal (around 4) or postmenopausal
39
What are the risk factors for urethral prolapse?
Chronically increased intra-abdominal pressure (think chronic constipation) Post-menopausal status Traumatic vaginal delivery
40
in the prepubertal presentation of urethral prolapse, what is the presentation? What is the associated PE finding?
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
_____ can help confirm diagnosis of urethral prolapse and the presence. Especially in _____ population
Cystourethroscopy used primarily in the adult population
42
What is the tx for urethral prolapse in prepubertal patients? postmenopausal? When are these treatments NOT recommended?
Prepubertal - sitz baths, topical antibiotics, topical estrogen Postmenopausal - sitz baths, topical estrogen cream, antibiotics significant necrosis, thrombosis or bleeding
43
What are the surgical therapies commonly used for urethral prolapse? Which one is MC?
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
Up to _____ of urine and there will be no stretch to detrusor muscle
200-300 cc
45
When the Pons stimulates SYMPATHETICS nerves what happens?
Inhibit (relax) detrusor muscle Closes internal urethral sphincter
46
When the Pons stimulates SOMATIC nerves, what happens?
Contraction of external urethral sphincter
47
What is the physiology behind urination?
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
When the Pons activates the parasympathetics, what happens?
Stimulates (contracts) detrusor Relaxes (opens) internal urethral sphincter
49
How does the body tell the bladder to NOT pee?
the voluntary control overrides the involuntary pathway Cerebral cortex → pudendal nerve → contraction of the external urethral sphincter
50
What are the 2 types of urinary incontinence? What are the underlying causes of each? Which one is easier to treat?
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
What are the risk factors for urinary incontinence?
Female gender Advanced age Obesity Parity/Pregnancy Prostate disease Neurologic disease Immobility
52
What are the transient causes of urinary incontinence?
aka things we can hopefully fix
53
What are the established causes of urinary incontinence?
54
What is urge urinary incontinence caused by? What are 5 things it is associated with?
overactivity of detrusor muscle Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI
55
_____ is a very strong urge to urinate, then immediately precedes to pee
urge UI the bladder does NOT always have to be full before the urge to pee comes on
56
What is stress UI caused by?
Hypermobility of urethra - weak pelvic support or intrinsic sphincter deficiency
57
What are some causes of hypermobility of urethra?
Childbirth, ￬ estrogen, trauma, prostate surgery, hysterectomy
58
_____ presents with involuntary leakage that occurs with increased pressure. Name some sources of pressure
stress UI coughing, laughing, sneezing, lifting heavy objects
59
What is the cause behind overflow UI?
Detrusor muscle underactivity and non-contractile bladder leads to distension
60
_______ 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?
overflow UI Should rule out bladder outlet obstruction
61
A mixed UI presents as a combination between _____ and _____ incontinence
stress and urge very common in women!!
62
What is the cause of functional UI? What are some likely culprits of the problem?
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
What is one question need to start asking pts about during routine visits? Need to ask about ____, _____ and _____ as follow up questions
“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
What is the bladder stress test? What can either of the two results tell you about the type of UI?
Bladder Stress Test - have pt with full bladder stand and cough Instant leakage - stress incontinence Delayed leakage - urinary bladder contraction stimulated by coughing
65
What are 2 tests you should order when working a pt up for UI in the primary care setting?
UA - screen for UTI, hematuria Postvoid Residual - if overflow incontinence, urologic disease, neuropathy suspected
66
In the postvoid residual test, how much urine is normal? _____ refer to urology and ______ overflow incontinence is highly probable
< 50 cc - normal; >200 cc - refer to urology >400 cc - overflow incontinence highly probable
67
What are 5 lifestyle modifications/exercises that are beneficial in ALL TYPES of UI?
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
How long does it take to see an improvement after starting kegel exercises?
May take up to 6 weeks to see benefit
69
What are some non-lifestyle tx options for stress UI?
70
What medication can be helpful in urge UI?
Beta-3 adrenergic agonists- becoming for favored as initial treatment consider anticholinergics or TCAs alpha blockers can be used in men
71
What are the drugs in the Beta-3 agonist drug class? What are the SE? What are the DDI?
mirabegron (Myrbetriq), vibegron (Gemtesa) **HTN**, tachycardia, dry mouth, constipation, UTI anticholinergics, QT-prolonging drugs
72
What is the MOA of anticholinergics? What are the SE?
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
What are the CI to anticholinergics? What are the DDI?
gastric retention, glaucoma other anticholinergics, potassium chloride
74
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?
Anticholinergics UpToDate - recommends trospium (Sanctura) or darifenacin (Enablex) due to slightly less cognitive impairment Oxybutinin (Ditropan) - often most commonly prescribed due to cost
75
What is the tx for urge UI?
botox injections into detrusor muscle neuromodulation sx as the last resort
76
What is the tx for overflow UI? Which one is considered a last resort?
tx the underlying cause neuromodulation: sacral nerve stimulation but has a high rate of device failure indwelling cath- last resort tx
77
What are 2 additional lifestyle modifications that are specific to functional UI? What is the tx?
Bedside commode for limited mobility Call bell or other signal if assistance needed to get to restroom tx the underlying cause!
78

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