Bladder disorders

Question 1

Interstitial Cystitis

S/Sx

Answer 1

Interstitial Cystitis (painful bladder syndrome)
Pain with bladder filling
Pain relieved with emptying bladder

Urgency
Frequency
Dramatic exaggeration of normal sensations
Chronic bladder pain or discomfort
Can have a profound detrimental impact on quality of life

Pain, pressure, or bladder discomfort with bladder filling that is relieved with urination.
Suprapubic or perineal pain
Urgency
Frequency
Nocturia

Question 2

Interstitial Cystitis

general

Answer 2

(Bladder Pain Syndrome)

Bladder disorder vs chronic pain disorder.

Also called bladder pain syndrome (BPS).
Prevalence of 18-40 per 100,000 people.
Effects both sexes, mainly women and mean age of onset is 40.

Possibly had bladder problems as child.
Likely is not a single disease but rather several diseases with similar symptoms.

Associated diseases are severe allergies, irritable bowel syndrome, or inflammatory bowel disease.

Question 3

Interstitial Cystitis

Length of sx
Labs required for dx

Answer 3

American Urological Association states the symptoms must last over 6 weeks in duration.
Diagnosis of exclusion!

Require a negative urine culture and cytology

No other obvious cause of symptoms
Rule out radiation cystitis, chemical cystitis, vaginitis, urethral diverticulum, genital herpes.

Question 4

Interstitial Cystitis

Patho

Answer 4

Little is known about the etiology and pathogenesis of interstitial cystitis/bladder pain syndrome.

Possibilities that may cause these symptoms:

Potential genetic susceptibility.

The layer of the bladder (the GAG layer) that coats the urothelial surface may be defective which allows urinary irritants to penetrate and activate the underlying nerve and muscle tissue.

Mast cells may also play in a role in propagating ongoing bladder damage after an initial insult.

Increased sensitivity may be present in the bladder itself or in the pathways within the central nervous system.

Question 5

Interstitial Cystitis

ROS and PE

Answer 5

In HPI: Ensure to ask about pelvic radiation in the past
Inquire about treatment with cyclophosphamide (CP/Cytoxan)
Chemotherapy agent

In ROS: Screen patients for signs of depression, anxiety, and stress

Pelvic exam to exclude genital herpes, vaginitis, or a urethral diverticulum

Question 6

Interstitial cystitis

Labs

Answer 6

Urinalysis
Urine culture and susceptibility
Urinary cytology
ALL WILL BE NORMAL

Urodynamic testing needs to be performed to assess bladder sensation and compliance
Need to exclude detrusor instability
Post-void residual urine volume

Question 7

Interstitial Cystitis

Cystoscopy with Hydrodistension

Answer 7

May reveal glomerulations (submucosal hemorrhage) with hydrodistension of the bladder
Total bladder capacity should be determined
Biopsy of any suspicious lesions should be performed
Presence of submucosal mast cells not needed for the diagnosis

Question 8

Interstitial Cystitis

Hydrodistension

Answer 8

Hydrodistension
Performed in the OR and patient’s bladder is stretched by filling up the bladder with fluid.

https://www.ic-network.com/bladderphotos/diannam-300.jpg

Done as part of diagnostic evaluation but also patients get symptomatic relief from this maneuver.
20-30% of patients notice some relief afterwards.

Patients with small bladder capacities, less than 200 ml, are unlikely to respond to medications.

Question 9

Interstitial Cystitis

Med Tx

Answer 9

Amitriptyline (Elavil) is often first line therapy.

Nifedipine (Procardia) and other calcium channel blockers have been noted to help with IC symptoms.
Pentosan polysulfate sodium (Elmiron) helps restore integrity to the epithelium of the bladder in certain patients.

Bladder instillations include intravesical instillation of dimethyl sulfoxide (DMSO) + heparin.

Treatment goal is not to cure since there is no curative treatment but to provide symptom relief in order to achieve a high quality of life.

Question 10

Interstitial Cystitis

alternative/nonpharm tx

Answer 10

Transcutaneous electric nerve stimulation (TENS)
Acupuncture
Exercise
Biofeedback
Massage
Pelvic floor relaxation
Surgical therapy as last resort and may require cystourethrectomy with urinary diversion for severe cases.

Evaluate patient for psychosocial needs as this is chronic pain and psychosocial support may be needed.
Some patients benefit in stress reduction, relaxation techniques, or cognitive behavioral therapy as greater levels of stress have shown to increase symptoms.

Application of local cold or heat over bladder may be beneficial.
Encourage patients to keep a symptom diary.

Question 11

Interstitial Cystitis

When to Refer?

Answer 11

When a patient has persistent and bothersome symptoms in the absence of an identifiable cause, time to refer to urologist.

Question 12

Interstitial Cystitis

Essentials of Diagnosis

Answer 12

Pain with bladder filling; urinary urgency and frequency.

Submucosal petechiae or ulcers on cystoscopic examination.

Diagnosis of exclusion.

Question 13

Urinary Incontinence

etiologies

Answer 13

“DIAPPERS”
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmaceuticals
Psychological Factors
Excess Urinary Output
Restricted Mobility
Stool Impaction

Detrusor Overactivity/Urge Incontinence
Urethral Incompetence/Stress Incontinence
Overflow Incompetence

Delirium: A clouded sensorium impedes recognition of both the need to void and location of nearest toilet. Most common cause in hospitalized patients.
Infection: Symptomatic urinary tract infection can cause urgency and incontinence.
Atrophic urethritis/vaginitis: Diagnosed on physical exam with the presence of vaginal erosions, erythema, petechiae, or friability.
Pharmaceuticals:Potent diuretics, anticholinergics, psychotropics, opioid analgesics, alpha-blockers, alpha-agonists, calcium channel blockers
Psychological factors: Severe depression with psychomotor retardation may impeded the ability or motivation to reach a toilet.
Excess urinary output: Excessive urination may overwhelm an elderly patient to reach a toilet in time.
Causes include excess fluid intake, hyperglycemia, hypercalcemia, diabetes insipidus.
Restricted mobility: If mobility cannot be improved, access to a urinal or commode may improve continence.
Stool impaction: Common cause of urinary incontinence in hospitalized or immobile patients.

Question 14

Detrusor Overactivity/Urge Incontinence

Answer 14

Detrusor overactivity refers to uncontrolled bladder contractions that cause leakage.

It’s the most common cause of incontinence in older adults, accounting for two-thirds of the cases.

In women, they will have urinary leakage after an intense urge to urinate that cannot wait.

Men have similar symptoms but usually their detrusor overactivity coincides with urethral obstruction from benign prostate hyperplasia.

Overactive bladder is characterized by frequency, urgency, and nocturia.

Can present with or without urge incontinence.

Question 15

Pathophysiology of Urge Incontinence

Answer 15

The underlying mechanism of urge incontinence is bladder overactivity, so uninhibited bladder contractions occur during the filling and storage phase.

Most women will not find any type of identifiable pathology.
Some patients as they get older, also have impaired bladder contractility.

This increases the risk of urinary retention by reducing the intravesical bladder pressure in overcoming bladder outlet pressure during bladder contractions, which is now thought to be a function of bladder underactivity.

Question 16

Detrusor Overactivity/Urge Incontinence

Physical Exam

Answer 16

Pelvic examination:
To test for urge incontinence, have the patient relax her perineum and cough vigorously while standing with a full bladder. The patient may also lay on the table and perform Valsalva test (bearing down as if trying to have a bowel movement).
Delayed leakage of several seconds or persistent leakage suggests that the problem is caused by uninhibited bladder contraction induced by coughing.

Question 17

Labs for all Urinary Incontinence

Answer 17

Urinalysis
Rule out infection or diabetes-related glycosuria
Fasting blood glucose
Serum Creatinine
Blood Urea Nitrogen (BUN)
Electrolytes (BMP)
Post-void residual urine volume
Consider urodynamic studies, ultrasound, cystoscopy to determine anatomic abnormalities.

Question 18

Detrusor Overactivity/Urge Incontinence

Non pharm Tx

Answer 18

Start with behavioral approaches:
Cornerstone of treatment for urge incontinence is bladder training.
Patient starts on a voiding schedule based on the shortest interval recorded on a bladder log, then gradually lengthen the interval by 30 minutes each week.

Lifestyle modifications
Weight loss and caffeine reduction can help improve symptoms.
Cognitively impaired and nursing home patients need timed and prompted voiding by caregivers.
Pelvic floor muscle “Kegel” exercises can reduce the frequency of incontinence when performed correctly.

Question 19

Detrusor Overactivity/Urge Incontinence

Pharm Tx

Answer 19

Medical therapy is second line:
Antimuscarinic/anticholinergic agents like Tolterodine (Detrol) and Oxybutynin (Ditropan) have the most experience.
Both of these medications come in short acting and long acting regimens, while Oxybutynin has an option for a patch.
Helpful for overactive bladder symptoms.

Side effects are delirium, dry mouth, or urinary retention.

Long-acting agents may be better tolerated.
Other antimuscarinic agents Fesoterodine (Toviaz), trospium chloride (Sanctura), and solifenacin (Vesicare) are available.

More medical therapy options:
Beta-3-agonists Mirabegron (Myrbetriq) and Vibegron (Gemtesa) is approved for overactive bladder symptoms which includes urge urinary incontinence.
Less dry mouth and better adherence to it than antimuscarinic medications in the over age 70 group

Question 20

Detrusor Overactivity/Urge Incontinence

procedural Tx

Answer 20

An injection of Onabotulonum toxin A (Botox) into the detrusor muscle can be effective.

However, can cause urinary retention and then the need for the patient to perform self-catheterization.

In men with BPH and detrusor overactivity, along with a PVR less than 150 ml or less, an antimuscarinic agent added to an alpha blocker can be helpful.

Question 21

Urethral Incompetence/Stress Incontinence

general

Answer 21

Second most common case of established urinary incontinence in older women.

Stress incontinence is most commonly seen in men after a radical prostatectomy.

It is characterized by instantaneous leakage of urine in response to an increase in intra-abdominal pressure.
This can occur along with detrusor overactivity and have a “mixed incontinence.”

Typically has urinary loss with laughing, coughing, or lifting heavy objects.

Question 22

Pathophysiology of Stress incontinence

Answer 22

The primary issue of stress incontinence is urethral underactivity, related to either decreased tone of the internal urethral sphincter or hypermobility of the bladder neck.

Stress incontinence occurs with elevated intra-abdominal pressure, which causes a sudden increase in the bladder pressure.

Normally these changes are counteracted by contractions of the internal urethral sphincter. Stress incontinence occurs when the bladder pressure is higher than that of the urethra.

Hypermobility of the bladder refers to displacement of the bladder neck and urethra during increases of intra-abdominal pressure.

Normally this results in the urethra compressed against the muscles of the anterior vaginal wall, which provides support for both the bladder neck and urethra. If the muscles are weak, they can’t provide this support, which displaces them both so incomplete urethral closure and leakage of small amounts of urine occur.

Stress incontinence is commonly related to vaginal deliveries and hormonal changes associated with menopause in women.

Question 23

Urethral Incompetence/Stress Incontinence

Physical Exam

Answer 23

Pelvic examination:
To test for stress incontinence, have the patient relax her perineum and cough vigorously while standing with a full bladder. The patient may also lay on the table and perform Valsalva test (bearing down as if trying to have a bowel movement).
Instantaneous leakage indicates stress incontinence, or a urethral spurt occurs.

Question 24

Urethral Incompetence/Stress Incontinence

Lifestyle Modifications

Answer 24

Limit caffeine and fluid intake.
Weight loss in obese women or men.
Pelvic floor muscle exercises for mild to moderate stress incontinence.
Pull in the pelvic floor muscles and hold for 6-10 seconds and to perform three sets of 8-12 contractions daily. Benefits may not be seen for up to 6 weeks.

Pessaries or vaginal cones can be used.

Surgery is a last resort but most effective treatment, as high as 96% in women.

Question 25

Overflow Incontinence

general

Answer 25

This occurs when urinary retention leads to bladder distention and overflow of urine from the urethra.

Urethral obstruction (due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostate cancer) is a common cause of established incontinence in older men but rare in older women.

When it causes incontinence, detrusor underactivity is associated with urinary frequency, nocturia, and frequent leakage of small volumes.
On post void residual urine volumes, they are generally over 200 ml in overflow incontinence.

Can present as:
Dribbling incontinence after voiding
Urge incontinence due to detrusor overactivity
Or overflow incontinence due to urinary retention.

Can be caused by:
Medications
Sacral lower motor nerve dysfunction

Question 26

Overflow Incontinence

Pathophysiology

Answer 26

Overflow incontinence is related to bladder underactivity and/or outflow obstruction.

When the bladder is filled to capacity, the bladder cannot empty due to poor contractility or obstruction around the urethral sphincter.

Incontinence occurs when bladder pressure exceeds outlet pressure and urine leaks into the urethra.

This is more common in men due to benign prostatic hyperplasia.

Overflow incontinence can occur in women if they develop neurogenic bladder or have a prolapsed uterus.

Question 27

Overflow Incontinence

Treatment

Answer 27

Most men will first require bladder decompression with intermittent or indwelling catheter if overflow incontinence is caused by obstructive uropathy.

Untreated overflow incontinence can lead to hydronephrosis.

Next an alpha blocking agent is initiated like Tamsulosin (Flomax) and Finasteride (Proscar) can be added for men with enlarged prostates.

If medical therapy does not work, may have to proceed with surgical decompression.

Can add double voiding and suprapubic pressure to lifestyle modifications to help empty the bladder but if further emptying is needed, then intermittent or indwelling catherization is the only option.

Antibiotics should be used only for symptomatic urinary tract infection or as prophylaxis against recurrent symptomatic infections in a patient using intermittent catherization

Antibiotics should be not used as prophylaxis in a patient with an indwelling catheter

Question 28

Summary of Urinary Incontinence

Answer 28

Involuntary loss of urine.
Stress incontinence is the leakage of urine upon coughing, sneezing, or standing.

Urge incontinence is urgency and inability to delay urination.

Overflow incontinence has a variable presentation but occurs when urinary retention leads to bladder distention and overflow of urine from the urethra.

Mixed incontinence is a combination of both stress and urge incontinence.

Incontinence is common with neurologic disease (stroke or dementia), metabolic disorders (diabetic neuropathy) and pelvic disorders (uterine prolapse).