Bladder and urinary disorders

Question 1

What are the four types of urinary incontinence?

Answer 1

Stress, urgency, mixed, and overflow incontinence

Question 2

What is stress incontinence?

Answer 2

Involuntary leakage…

On effort or exertion, or on sneezing or coughing.

Making an effort is stressful!

Question 3

What is urgency incontinence?

Answer 3

Involuntary leakage…

Accompanied or immediately preceded by a sudden compelling desire to pass urine.

I’ve URGENTLY got to pee-pee.

Question 4

What is overactive bladder syndrome?

Answer 4

Urinary urgency, not necessarily incontinence, but associated with increased frequency and nocturia.

You pee a-lot at night at night (noct).

Question 5

What is mixed incontinence?

Answer 5

Involuntary leakage associated with stress and urgency (where one is pre-dominant).

Question 6

What is overflow incontinence?

Answer 6

Inability to empty bladder completely.

It’s not overflowing out the toilet, it’s over-flowing in you, baby.

Question 7

What drugs are risk factors for stress incontinence?

Answer 7

ACE inhibitors; alpha-adrenergic blockers; cholinesterase inhibitors (muscarinics); drugs that cause constipation

ACE inhibitors make you cough. Alpha blockers relax the bladder. Muscarinics contract the detrusor muscle.

Question 8

First line treatment for urgency and stress incontinence (non-pharmacological)?

Answer 8

Urgency: bladder training for at-least 6 weeks

Stress: Supervised pelvic floor muscle training for at least 3 months (12 weeks, work it twice as hard girl)

Mixed: Both!

Question 9

What should you test in women presenting with incontinence?

Answer 9

Haematuria (haem for blood, uria for pee - that’s bloody piss) and active infection using a urine dipstick test.

Just dip a stick in the urine and hope it doesn’t come out red.

Question 10

When do you refer somone with incontinence to a specialist?

Answer 10

Persistent bladder or urethral pain, pelvic mass, faecal incontinence, suspected neurological disease, urogenital fistulae, recurrent or persistent UTI if aged over 60, symptoms of voiding difficulty, any pelvic operations

If it hurts, refer.
If you think it's their brain, refer.
if they're old and infected often, refer.
Surgeries in that region, refer. 
The VOID? Refer.

Question 11

Pharmacological treatment for urgency incontinence.

Answer 11

Anticholinergics (muscarinic antagonist): oxybutynin, tolterodine, and darifenacin. That’s first line.

Mirabegron as second line. It’s a beta-3 agonist! It constricts the blood vessels. Don’t give this to hypertensive people, please… Also, half the dose if their kidneys suck (15-29 ml/min).

Also, don’t give propanetheline bromide (which inhibits acetylcholine), imipramine (a TCA), or flavoxate

Damsel On My Toilet. Darifenacin, Oxybutynin, Mirabegron, Tolterodine.

Question 12

Why do we use antimuscarinics to treat incontinence?

Answer 12

There are muscarinic receptors on the detrusor muscle (that’s the muscle around your bladder, bro).

They are stimulated by acetylcholine by cholinergic (parasympathetic) nerves which causes them to contract and that’s how you urinate.

You want to stop this, right? So, stop the neurotransmitter (muscarinic agonist) from going to the site (muscarinic receptor) using an antagonist (antimuscarinic) - simple. This allows the bladder to relax while it gets filled and stops involuntary leakage.

Question 13

In what conditions should antimuscarinics (muscarinic antagonists) not be used?

Answer 13

Narrow-angle glaucoma, gastro-intestinal obstruction, myasthenia gravis (generally), urinary retention, toxic megacolon, severe ulcerative colitis, pyloric stenosis, paralytic ileus, intestinal atony.

Why?
Mydriasis (dilation) exacerbates glaucoma as excess aqueous humour is not absorbed.
GI motility is decreased by antimuscarinics.

Question 14

What are side effects of antimuscarinics (muscarinic antagonists)?

Answer 14

Constipation and dyspepsia (decreased secretions in the GI)
Nausea and vomiting
Dry mouth (under-active salivary glands)
Vision disorders (mydriasis, inhibition of iris sphincter muscle contraction)
Palpitations (muscarinic receptors [M2] coupled to Gi-protein on the AV and SA node, muscarinics decreases heart rate)
Dizziness, drowsiness
Skin reactions

Question 15

Dose adjustments of solifenacin in renal impairment.

Answer 15

The normal adult dose is 5mg increased to 10mg if necessary.

If the kidney is impaired (with eGFR less than or equal to 30 ml/min) then do not increase to 10mg. Stay at 5mg.

Question 16

What drugs can increase the risk of urinary retention?

Answer 16

Antimuscarinics (your bladder muscles are way too chill, bro).
Sympathomimetics (sympathetic nerve fibres or adrenergic agonists contract the urethra restricting urinary outflow)
Tricyclic antidepressants (they have antimuscarinic properties!)

Question 17

Acute urinary retention is classified as an emergency. What do you do to treat?

Answer 17

Alpha-adrenoceptor blockers at-least two days before catheterization.

Alpha-adrenoceptor blockers: doxazosin, tamsulosin, prazosin, indomarin, terazosin

Question 18

How do you treat chronic urinary retention?

Answer 18

Alpha-adrenoceptor blockers: alfuzosin, doxazosin, tamsulosin or terazosin

Question 19

How do you treat urinary retention due to benign prostatic hyperplasia?

Answer 19

Finasteride or dutasteride, which are 5a-reductase inhibitors

Question 20

What is important patient and/or carer advice to give when supplying finasteride or dutasteride?

Answer 20

They are excreted in semen. So, use a condom, dude.

Risk of breast cancer (male). Patient or carer should report any changes in breast tissue (e.g. lumps, pain or nipple discharge).

Question 21

How do you treat primary or recurrent bladder carcinoma and prevent the recurrence following transurethral resection?

Answer 21

Bacillus Calmette-Guerin or BCG.

Question 22

How do you treat recurrent superficial bladder tumours?

Answer 22

Doxorubicin and mitomycin

Question 23

What can you use to treat common infections of the bladder? [IRRIGATION]

Answer 23

Aqueous chlorhexidine (not effective against Pseudomonas spp.)

Chlorhexidine 0.02% solution can cause burning and haematuria. Sodium chloride 0.9% is a preferred mechanical irrigant.

Question 24

How do you dissolve blood clots in the bladder?

Answer 24

Sodium chloride 0.9% or bladder irrigation 3%

Question 25

What advise can you give patients with recurring renal or uteric stones?

Answer 25

2.5-3 litres of water a day with the addition of fresh lemon juice.
Avoid carbonated drinks.
Calcium intake of 700-1200mg a day and salt under 6g a day.

Avoid excessive intake of oxolate-rich products such as rhubarb, spinach, cocoa, tea, nuts, soy products, strawberries and wheat bran - Patients with calcium stones.

Avoid urate rich products such liver, kidney, calf thymus, poultry skin and certain fish (herring with skin, sardines and anchovies) - Patients with uric acid stones.