BLADDER DISORDERS / UNARINY INCONTINENCE Flashcards
Does the hematuria represent glomerular or nonglomerular bleeding?
RBC casts = glomerular bleeding
glomerular bleeding
⦁ RBC casts
⦁ dysmorphic RBCs
⦁ proteinuria with the hematuria, with a large percentage being albumin
urine centrifuge
if sediment red = hematuria
if supernatant red = dipstick heme
⦁ dipstick heme negative = beets, phenazopyridine, porphyria, other
⦁ dipstick heme positive = myoglobin or hemoglobin
- if plasma color is clear = myoglobinuria
- if plasma color is red = hemoglobinuria
risk factors for malignancy
Age > 35
Smoking history (extent of exposure correlates w/ risk)
Occupational exposure to chemicals/dyes—painter, printers
History of gross hematuria
History of chronic cystitis or irritative voiding symptoms
History of pelvic irradiation
Exposure to cyclophosphamide
H/O urologic disorder BPH, nephrolithiasis, etc.
History of chronic indwelling foreign body
History of non-narcotic analgesic abuse (also associated increased risk of kidney cancer)
HEMATURIA WORKUP
Urine culture & UA in all pts with hematuria
Uriny cytology no longer needed
IMAGING = CT urography = preferred (contrast)
⦁ pregnant = US
⦁ can do US, CT without contrast, or MRI if dye from CT not tolerated
Cystoscopy
what imaging is preferred for hematuria
CT UROGRAPHY*** (same as CT IVP)
if pregnant = US
if can’t have dye = US, CT w/o contrast, or MRI
DO NOT SCREEN FOR HEMATURIA IN
ASYMPTOMATIC PATIENTS
In young & middle age-patients; usually hematuria is
mild glomerular disease
monitor GFR, creatinine, and BP***
are predisposed to stones
most common pathogen of UTI
E.coli
others
proteus & klebsiella
UTI PRESENTATION
⦁ dysuria ⦁ frequency ⦁ urgency ⦁ suprapubic pain ⦁ hematuria
pyelonephritis presentation
- symptoms of cystitis may or may not be present with pyelonephritis
- chills
- flank pain with costovertebral angle tenderness
- Nausea & Vomiting
diagnostic tests for cystitis & pyelonephritis
CYSTITIS
- UA is a MUST! - look for positive leukocytes and/or positive nitrites
- if uncertain about diagnosis or resistance is possible = do urine culture
- ALL MALES with cystitis = need a culture
FOR PYELONEPHRITIS
- UA
- urine culture & sensitivity
treatment for women with cystitis
⦁ Nitrofurantoin = 1st
⦁ Bactrim = 2nd
⦁ can give phenozopyridine (pyridium) - analgesic agent for dysuria- turns urine dark orange
-reserve fluoroquinolones for other uses in case resistance is built
treatment for men with cystitis
⦁ Bactrim
⦁ Fluoroquinolone
- want to cover possible prostatitis (also treat with either bactrim or cipro for acute or chronic)
- men = usually have longer lengths of abx
outpatient treatment of pyelonephritis
fluoroquinolones (cipro or levo) if resistance is low
others = Bactrim or augmentin
inpatient treatment of pyelonephritis
oral fluoroqinolone + aminoglycoside
non-infectious cystitis
- similar symptoms to cystitis + nocturia & pressure in pelvis
- in women of childbearing years
IRRITANTS = bubble baths, feminine hygiene sprays, tampons, spermicidal jellies, radiation, chemo, foods (tomatoes, artifical sweeteners, caffeine, chocolate)
WORK UP
- UA
- urine culture
- sometimes cystoscopy
TREATMENT
- avoid irritants
- voiding routine**
- kegel’s
Most common cause of nongonococcal urethritis
chlamydia
tx = azithro
overactive bladder
detrusor muscle contracts before bladder is filled
presentation =
Urgency
Frequency
Nocturia
tx of overactive bladder
ANTIMUSCARINICS (anticholinergics)
MOA = Block basal release of acetyl choline during bladder filling & increases bladder capacity
Oxybutynin (Ditropan)
Tolterodine (Detrol)
Solifenacin (Vesicare)—once a day
(others = 2-3x/day)
SE = dry eyes, constipation, dry mouth
pathophys of overactive bladder without incontinence
Detruser muscle contracts irregularly at smaller volumes of urine
Usually idiopathic
Can be secondary to DM, stroke, spinal disease
new agent for overactive bladder
Mirabegron (Myrbetriq)
Beta 3-adrenoceptor agonist - relaxes detrusor muscle
SE
HTN**
Incomplete bladder emptying
Dry mouth
do not give mirabegron to a pt with
uncontrolled HTN
RISK FACTORS FOR INCONTINENCE
⦁ Obesity ⦁ Functional impairment ⦁ Parity ⦁ Family history ⦁ Smoking ⦁ Age ⦁ Others: diabetes, stroke, depression, estrogen depletion, genitourinary surgery, radiation ⦁ Non-Hispanic white women higher rates than non-Hispanic Black and Hispanic women
CAUSES OF INCONTINENCE = DIAPPERS
⦁ Delirium ⦁ Infection ⦁ Atrophic vaginitis ⦁ Pharm: sedatives, diuretics, anticholinergics ⦁ Psychological: depression ⦁ Excessive urine production ⦁ Restricted mobility ⦁ Stool impaction
detrusor over-activity = __________ incontinence
urge
URGE INCONTINENCE
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
Leakage of urine with increased intra-abdominal pressure in the absence of a bladder contraction:
STRESS INCONTINENCE
It is important to determine if leakage occurs coincident or several seconds after a cough++
Occurs in younger women
Due to:
Urethral hypermobility
Intrinsic sphincter deficiency
due to Intrinsic sphincter deficiency
stress incontinence
= MOST COMMON CAUSE OF STRESS INCONTINENCE IN MEN
PROSTATE SURGERY
Most common type of incontinence in women
MIXED INCONTINENCE
INCOMPLETE BLADDER EMPTYING = OVERFLOW INCONTINENCE
- continuous leakage/dribbling of urine
due to detrusor underactivity (occurs with low estrogen, aging, peripheral neuropathy - DM, MS) or bladder outlet obstruction (BPH / stones)
detrusor underactivity
incomplete bladder emptying = overflow incontinence
possible etiologies of nocturia
- possible etiologies
⦁ CHF—fluid redistribution form pedal edema
⦁ Late evening beverages
⦁ Sleep apnea****
⦁ Sleep disturbances—chronic pain, depression
⦁ Detrusor overactivity
PVR for incontinence
Have patient void until they feel they have emptied their bladder completely
Then do bladder ultrasound or clean cath
PVR < 1/3 the total voided volume is considered adequate emptying
labs for incontinence
Renal function
Serum calcium, and glucose
UA
Those with increased post-void residual—B12, etc.
PSA for men if indicated
Urine cytology if there is hematuria or pelvic pain
lifestyle & behavioral treatment
Lifestyle:
Weight loss
Adequate, but not excessive fluid intake (2 L)
Avoid caffeinated beverages and alcohol
Minimize evening fluid intake for nocturia
Smoking cessation
Behavioral therapy: for urge, stress and mixed:
Bladder training:
- Frequent voluntary voiding
- Relaxation techniques for urge incontinence
Pelvic muscle exercises: Kegels
Biofeedback
Pessaries for organ prolapse or stress incontinence
rx therapy for incontinence = for urge & mixed
Anticholinergics w/ antimuscarinic activity
Increase bladder capacity
Tolterodine (Detrol LA), Solifenacin (Vesicare)
SE: dry mouth, blurred vision, constipation, drowsiness, decreased cognitive function
CI: Narrow angle glaucoma
CI to anticholinergics with antimuscarinic activity = increase bladder capacity and relaxes the bladder
narrow angle glaucoma
which anticholinergic med for incontinence has Less SE although dry mouth still prominent
oxybutynin (Ditropan) = ER & Patch
Direct antispasmodic effect on detrusor muscle
newer agent for incontinence
Miragebron (Myratriq)
Causes bladder relaxation…..? works on alpha receptors, which are in the internal sphincter -
Help urge and mixed incontinence
SE: HTN, tachycardia, urinary retention (infection), inflammation of the nasal passages, dry mouth, constipation, abdominal pain, and memory problems
NOT recommended for patients with uncontrolled HTN
Mirabegron = NOT recommended for patients with uncontrolled
HTN
surgery = used for ________ incontinence
stress
The selected procedure for SUI (stress urinary incontinence)
mesh midurethral sling
when to refer immediately for incontinence
Incontinence w/ abdominal and/or pelvic pain Hematuria in the absence of UTI Suspected fistula Complex neurological conditions Abnormal findings
INTERSTITIAL CYSTITIS
also known as BPS = Bladder Pain Syndrome
- usually presents in 4th decade or later
- much more common in women
Persistent feature: pain or “unpleasant” sensation with filling of the bladder—relieved with bladder voiding
interstitial cystitis
Gradual onset w/ worsening symptoms
May have other urinary symptoms:
Urinary frequency
Urgency
Nocturia
DIAGNOSIS OF INTERSTITIAL CYSTITIS
- thorough PE - pt usually has a tender suprapubic area
- may have other pain conditions, such as dyspareunia, irritable bowel, vulvodynia
- do UA & culture to r/o cancer and infection
TREATMENT OF INTERSTITIAL CYSTITIS
1st line = Management; patient education about pain relief & chronicity of condition; psychosocial support. self-care & behavioral modification
- very difficult to manage; basically a chronic pain condition
2nd line = PT - for those pts with pelvic muscle pain
- Meds
⦁ Amitryptiline
⦁ PPS (Elmiron) = Pentosan polysulfate sodium = concentrates in the bladder and has a protective layer over urothelium
⦁ Hydroxyzine = antihistamine - makes you sleepy
MEDS THERAPY FOR INTERSTITIAL CYSTITIS
amitryptiline
PPS
hydroxyzine
