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Urology > Bladder Disorders > Flashcards

Bladder Disorders Flashcards

1
Q

43YO smoker presents for annual exam - found to have microscopic hematuria - most likely dx?

A
  • bladder cancer
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2
Q

Signs of glomerular bleeding?

A
  • red cell casts (pathognomonic for glomerulonephritis)
  • dysmorphic RBCs
  • proteinuria w/ hematuria w/ large percentage bing albumin
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3
Q

Nonmalignant etiologies of hematuria?

A
  • UTI: pyelo, acute cystitis - present w/ suprapubic pain, dysuria, and frequency
  • trauma to kidneys
  • stones
  • menstruation or endometriosis
  • BPH
  • vigorous exercise
  • PSGN or IgA nephropathy
  • warfarin
  • over 40: at high risk for cancer
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4
Q

RFs for malignancy?

A
  • age: over 35
  • smoking hx (extent of exposure correlates with risk)
  • occupational exposure to chemicals/dyes - painter, printers
  • hx of gross hematuria
  • hx of chronic cystitis or irritative voiding sxs
  • hx of pelvic irradiation
  • exposure to cyclophophamide
  • hx of chronic indwelling fb
  • hx of analgesic abuse (also assoc increased risk of kidney cancer) - NSAIDs
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5
Q

Work up of hematuria?

A
  • urine culture - if positive tx and repeat UA (all pts)
  • urine cytology: all w/ gross hematuria and those w/ risk factors
  • imaging: CT urography preferred - US in pregnant women
    US CT w/o contrast or MRI may be used
  • cystoscopy: obtaining urine for cytology just b/f in high risk pts

(CT and cystoscopy done together)

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6
Q

What should be done if you get a negative work-up for hematuria?

A
  • in young and middle aged pts usually is:
    mild glomerular disease (monitor PP, GFR, CrCl), have predisposition to stone disease
  • pts at high risk for malignancy:
    need annual UA
    may need another work-up q 3-5 yrs (esp if wt loss, night sweats)
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7
Q

Should you screen for hematuria in asx pts?

A
  • NO!
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8
Q

Pathogenesis of cystitis?

A
  • colonization of vaginal introitus from fecal flora
  • acension to bladder via the urethra
  • can ascend to kidneys causing pyelonephritis
  • route much more difficult in males b/c longer and urethra not sitting right above anus - Much less common in men
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9
Q

MC pathogens of cystitis?

A
  • 75-90% E. coli
  • others:
    proteus
    kelbsiella
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10
Q

Clinical presentation of UTI?

A
  • dysuria
  • frequency
  • urgency
  • suprapubic pain
  • hematuria
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11
Q

Clinical presentation of Pyelonephritis?

A
  • sxs of cystitis may or may not be present
  • chills
  • flank pain w/ CV angle tenderness
  • N/V
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12
Q

Dx tests for cystitis and pyelonephritis?

A
  • UA is a must: looking for positive leukocyte esterase and/or positive nitrites
  • in women who dx is uncertain or resistance is consideration a urine cuture w/ sensitivities should be done
  • ALL males with cystitis should have a culture
  • for pyelo:
    UA
    urine culture and sensitivities
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13
Q

Women with cystitis - what should be ruled out? Tx?

A
  • common, r/o vaginal source though
  • tx:
    Nitrofurantoin (100 mg BIDx5days)
    bactrim (1 DS BID x 3 days)
    fosfomycin 3 gmsx 1 dose
    reserve fluoroquinolones for other uses
    phenozyopyridine (pyridium)
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14
Q

Diff for man presenting with cystitis sxs?

A
  • prostatitis
  • urethritis secondary to STI
  • urinary tract abnormalitiy
  • nephrolithiasis
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15
Q

Tx for men w/ cystitis?

A
  • Bactrim
  • fluoroquinolone
  • want to cover possible prostatitis
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16
Q

Tx for outpt and inpt pyelonephritis?

A

outpt:

  • mild to moderate illness: can keep meds down
  • where fluoroquinolone resistance is low: cipro or levuoquin
  • other: trimethoprim-sulphamethoxazole or augmentin

inpt:
oral fluroquinolone
plus aminoglycoside
or extended spectrum cephalosporin

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17
Q

Sxs of noninfectious cystitis? Epidemiology? Irritants?

A
  • sxs similar to cystitis w/ nocturia, pressure in pelvis
  • epidemiology: women of childbearing yrs
  • irritants:
    bubble baths, feminine hygiene sprays, tampons, spermicidial jellies
    radiation, chemo
    foods: tomato, artificial sweetners, caffeine and chocolate
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18
Q

W/u and tx of noninfectious cystitis?

A
  • w/u:
    UA
    urine culture
    sometimes cystoscopy

-tx:
avoiding irritants
voiding routine
kegels

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19
Q

Chlamydia manifestations in a male? Dx? Tx?

A
  • MC cause of nongonococcal urethritis
  • manifestations:
    urethritis: sx/asx
    epididymitis
    prostatitis
  • dx:
    NAAT - some tests are expensive and don’t produce results quickly
  • xpert CT/NG assay is a NAAT provides testing in 90 minutes
  • Tx: rocephin and Azithro
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20
Q

Presentation of gonorrhea in males? Dx, Tx?

A
  • urethritis: sx
  • epididymitis: younger than 35
  • dx: NAAT
  • tx: Azithro and rocephin
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21
Q

Presentation and PP of overactive bladder w/o incontinence?

A
  • urgency, frequency, nocturia
  • PP:
    detrusor muscle contracts irregularly at smaller volumes of urine, usually idiopathic, can be secondary to DM, stroke, spinal disease
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22
Q

Tx of OAB? Mechanism, agents used?

A
  • antimuscarinics
  • MOA: increase bladder capacity, block basal release of acetyl choline during bladder filling
  • agents:
    oxybutynin (Ditropan)
    tolterodine (Detrol)
    solifenacin (vesicare) - once a day
    SE: anticholinergic - constipation, dry mouth, blurred vision
  • new agent:
    Mirabegron (Myrbetriq) - beta 3-adrenoceptor agonist, can use alone or w/ other agents
    SE:
    HTN, incomplete bladder emptying (relaxes detrusor so much), dry mouth
23
Q

Epidemiology of urinary incontinence?

A
  • prevalence in women: 25-45%
  • prevalence increases with age (both men and women)
  • 6-10% nursing home admissions in US due to urinary incontinence
24
Q

Medical morbidity - from incontinence?

A
  • perineal candida infection
  • cellulitis and pressure ulcers
  • UTIs and urosepsis
  • falls and fractures from slipping on urine
  • sleep interruption and deprivation
  • psychologically: poor self esteem, social withdrawl, depression and sexual dysfxn
25
Q

Continence depends on?

A
  • intact micturition physiology

- intact fxnl ability to toilet onself

26
Q

RFs for incontinence?

A
  • obesity
  • fxnl impairment
  • parity
  • family hx
  • smoking
  • age
  • others: diabetes, stroke, depression, estrogen depletion, genitourinary surgery, radiation
  • non-hispanic white women higher rates than non-hispanic black and hispanic women
27
Q

Transient causes of incontinence? DIAPERS?

A 
D: delirium
I: infection
A: atrophic vaginitis
P: pharm - sedatives, diuretics, anticholinergics
P: psychological: depression
E: excessive urine production (DI, hypercalcemia, psychogenic polydipsia)
R: restricted mobility
S: stool impaction
28
Q

Incontinence questions for screening?

A
  • in past 3 months: have you leaked urine?
  • which precipitants led to leakage?
  • which precipitant caused leakage most often?
  • do you ever wears pads, tissues or cloth in your underwear to catch urine?
29
Q

Hx questions to ask pt about incontience?

A
  • questions about incontinence
  • precipitants
  • bowel and sexual fxn
  • status of other medical conditions, parity, meds
  • any prior continence therapy, particularly surgical tx
30
Q

Etiology and presentation of urge incontinence?

A

etiology:

  • uninhibited bladder contractions
  • detrusor over activity
  • may be due to bladder abnormalities or idiopathic

presentation:

  • sudden urge to void
  • preceded or accompanied by leakage of urine
  • more common in older women
  • also seen in men
31
Q

What is stress incontinence? Who does this occur in? What is this due to?

A
  • leakage of urine w/ increased intra-abdominal presure in absence of bladder contraction:
    it is impt to determine if leakage occurs coincident or several seconds after a cough
  • occurs in young women
  • due to:
    urethral hypermobility
    intrinsic sphincter deficiency
  • prostate surgery MC cause in men
32
Q

Mixed incontinence MC in what pop?

A
  • MC type in women

- pts vary in predominance and/or bother of urge or stress leakage

33
Q

What is incomplete emptying? Due to?

A
  • incomplete bladder empyting preferred term
  • continuous leakage or dribbling of urine

due to:

  • detrusor underactivity: low estrogen, aging, peripheral neuropathy, damage to spinal detrusor efferents (MS)
  • bladder outlet obstruction (BPH)
34
Q

Possible etiologies of nocturia?

A
  • CHF: fluid redistribution from pedal edema
  • late evening beverages
  • sleep apnea
  • sleep disturbances: chronic pain, depression
  • detrusor overactivity
35
Q

Dx tool to use for incontinence - for pt?

A
  • bladder diary:
    record time and volume of every continent and incontinent void over 42-78 hrs
  • other pertinents include: activity, caffeine intake, hours of sleep, episodes of nocturia
36
Q

PE for incontinence?

A
  • don’t forget above waistline: respiratory, CV, neuro
  • in women thorough genital exam:
    check for cystocele/rectocele, atrophy, have pt cough looking for leakage of urine while standing
  • in males: exam of prostate
  • older persons: cognitive and fxnl status - including mobility, manual dexterity, depression screening looking for fxnl incontinence (ambulatory?)
37
Q

What is a post-void residual?

A
  • have pt void until they feel they have emptied their bladder completely
  • then do bladder US or clean cath
  • PVR less than 1/3 the total voided volume is considered adequate emptying
38
Q

Labs for incontinence?

A
  • renal fxn
  • serum Ca, glucose
  • UA
  • those with increased PVR: B12
  • PSA for men if indicated
  • urine cytology if there is hematuria or pelvic pain
39
Q

Tx of incontinence other than pharm?

A

lifestyle:

  • wt loss
  • adequate but not excessive fluid intake (2 L)
  • avoid caffeinated beverages and alcohol
  • minimize evening fluid intake for nocturia
  • smoking cessation

behavioral therapy: urge, stress, mixed:

  • bladder training - frequent voluntary voiding, relaxation techniques for urge incontinence
  • pelvic muscle exercises: kegels (have to do a lot)
  • biofeedback
  • pessiaries for organ prolapse for stress incontinence
40
Q

Pharm tx for incontinence?

A

used for urge and mixed if behavioral alone isn’t successful:
- anticholinergic w/ antimuscarinic activity:
increase bladder capacity - Detrol LA, Vesicle, SE: dry mouth, blurred vision, constipation, drowsiness, decreased cog. fxn
CI: narrow angle glaucoma
- Oxybutynin (Ditropan): IR, ER, patch - direct antispasmodic effect on detrusor muscle, less SE although dry mouth still prominent

  • new agent:
    miragebron (Myratriq) -
    causes bladder relaxation, help urge and mixed incontinence
    SE: HTN, tachycardia, urinary retention (Infection), inflammation of nasal passages, dry mouth, constipation, abdominal pain, and memory problems
  • not recommended for pts with uncontrolled HTN
41
Q

Surgical therapy for incontinence?

A
  • used for stress incontinence
  • high rate of success
  • abdominal or vaginal approaches
  • vaginal includes:
    midurethral sling
    bladder neck sling
    submucosal injection of urethral bulking agents
42
Q

Mesh kit complications?

A 
- these were previously used for repair of stress incontinence and pelvic floor prolapse
complications:
- mesh exposure (erosion)
- dyspareunia
- infection
- urinary problems
- bleeding
- organ perf
- deaths assoc w/ bowel perf or hemorrhage
43
Q

Surgery for incontinence used today?

A
  • stricter guidelines
  • mesh kits no longer used
  • more stringent training is reqd to do surgeries
  • selected procedure for SUI is mesh midurethral sling
44
Q

When would you refer a pt with incontience immediately?

A
  • incontinence w/ abdominal and or pelvic pain
  • hematuria in absence of UTI
  • suspected fistula
  • complex neuro conditions
  • abnormal findings
45
Q

When would you electively refer on a pt with incontinence?

A
  • persistent sxs after adequate therapeutic trial
  • uncertainty in dx
  • significantly elevated PVR that doesn’t resolve after tx of possible precipitants
  • prior pelvic surgery or pelvic irradiation
  • desiring surgical therapy for stress incontinence
46
Q

a 56YO hispanic woman presents to clinic complaining of wetting herself - says she feels urgent need to urinate and can’t get to BR soon enough, doesn’t occur when she sneezes or coughs. This occurs 1-2x a week. BMI 36, drinks 2-3 cups of coffee in morning. Dx? Labs? Tx?

A

labs:
UA and CMP
- urge incontinence
- wt loss, stop caffeine intake, relaxation (biofeedback), meds - hold off on (only have episodes 1-2x a week)

47
Q

49 yo female presents to clinic for annual exam. G5P5, no specific complaints, what do you want to ask her?

A
  • if she ever leaks urine, does she use a pad?

- check for stress incontinence - coughing

48
Q

What is interstitial cystitis AKA? Epidemiolgy? Definition?

A
  • bladder pain syndrome (BPS)
  • epidemiolgy: usually dx in 4th decade or later, female to male ratio: 5:1
  • an unpleasant sensation (pain, pressure, discomfort) - perceived to be related to urinary blladder, assoc with lower urinary tract sxs of more than 6 wks duration, in absence of infection or other ID causes
49
Q

Presentation of IC/BPS?

A
  • persistent feature: pain or unpleasant sensatio w/ filling of bladder - relieved by voiding
  • gradual onset w/ worsening sxs
  • may have other urinary sxs:
    urinary frequency
    urgency
    nocturia
50
Q

Dx of IC/BPS?

A

throrough PE:
pt usually has tender suprapubic area, may have other pain conditions such as dyspareunia, irritable bowel, vulvodynia
- UA and culture to r/o cancer and infection

51
Q

1st line management of IC/BPS?

A
  • pt education noting reasonable expectations about pain relief and chonicity of condition
  • psychosocial support
  • self-care and behavior modification
52
Q

2nd line management of IC/BPS?

A
  • PT: for pts with pelvic muscle pain
  • Meds: amitriptyline (chronic pain)
    pentosan polysulfate sodium (PPS - Elmiron) - concentrates in the ballder, proposed mechanism is reconstitutes deficient protective glycosaminoglycan layer over urothelium
  • hydroxyzine: antihistamine inhibits histamine release
  • referral
53
Q

What should you always rule out if pt presents with painless hematuria?

A
  • CANCER

Urology (12 decks)

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