Bladder Disorders & Urinary Incontinence Flashcards
Hematuria: Are there any clues in the H & P to suggest etiology?
- Gross vs. microscopic
- Glomerular [???] vs. nonglomerular
- Microscopic: transient vs. persistent
Hematuria—nonglomerular
- Etiologies? 6
- Etiology if older than 40?
- Fever,
- vigorous exercise,
- trauma,
- nephrolithiasis,
- infection,
- prostatitis,
- IgA nephropathy
- Strep glomerulonephritis
- Bladder cancer
Risk Factors for Malignancy
9
- 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 cyclophophamide
- History of chronic indwelling foreign body
- History of analgesic abuse (also associated increased risk of kidney cancer)
Hematuria—Work-up
6
- Urine culture—if positive treat and repeat UA
- Urine cytology: all w/ gross hematuria & those w/ risk factors
- Imaging—CT urography preferred**:
- US in pregnant women
- US, CT without contrast or MRI may be used
- Cystoscopy: obtaining urine for cytology just before in high risk patients
Hematuria—Negative Work-up
1. In young and middle-age patients usually is? 2
- Patients at high risk for malignancy may need what? 2
- Signs of glomerular bleeding? 3
- Mild glomerular disease (Monitor–???)
- Predisposition to stone disease
- Need annual UA
- May need another work-up in 1-3 years
- Red cell casts
- Dysmorphic RBCs
- Proteinuria with the hematuria with a large percentage being albumin
Pathogenesis of cystitis?
3
- Colonization of the vaginal introitus from fecal flora
- Ascension to the bladder via the urethra
- Can ascend to the kidneys causing pyelonephritis
This route much more difficult in males—why?
Because of the length of the urethra
- What is the most common pathogen in cystitis?
2. Others? 2
- E. coli
- Others:
- Proteus
- Klebsiella
Clinical Presentation—UTI
5
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
- Hematuria
- Diagnostic tests for cystitis? 1
- What are we looking for?
- In women who the diagnosis is uncertain or resistance is a consideration what should be done?
- ALL males with cystitis should have what?
- UA is a must!
- Looking for positive leukocyte esterase and/or positive nitrites
- urine culture with sensitivities should be done
- ALL males with cystitis should have a culture
Dx tests for pyleonephritis? 2
- UA
2. Urine culture and sensitivities
Women with Cystitis: This is Common!
1. What do we have to Rule out?
- Treatment? 5
- R/O vaginal source
- Treatment:
- Nitrofurantoin (100 mg BID x 5 days)
- Bactrim [Trimethoprim-Sulphamethoxazole] (1 DS BID x 3 days)
- Fosfomycin 3 gms. X 1 dose
- Reserve fluoroquinolones for other uses
- Phenozopyridine (pyridium)**
Men with Cystitis
1. Differential? 4
- Treatment? 3
- Differential:
- Prostatitis
- Urethritis secondary to STI
- Urinary tract abnormality
- Nephrolithiasis - Treatment:
- Trimethoprim-sulphamethoxazole (Bactrim)
- Fluoroquinolone
- Want to cover possible prostatitis
Treatment for Pyelonephritis
1. OUtpatient? 3
- Inpatient? 3
- Outpatient:
- Where fluoroquinolone resistance low use Cipro or levuoquin
- Other: trimethoprim-sulphamethoxazole or
- Augmentin - Inpatient:
- Oral fluoroquinolone
- Plus aminoglycoside
- Or extended spectrum cephalasporin
Noninfectious Cystitis
- How does it present?
- Most common in what population?
- Irritants? 6
- Symptoms similar to cystitis along with nocturia, Pressure in pelvis
- Epidemiology: women of childbearing years
- Irritants:
- Bubble baths,
- feminine hygiene sprays,
- tampons,
- spermicidal jellies
- Radiation, chemo
- Foods—tomatoes, artificial sweeteners, caffeine and chocolate
Noninfectious Cystitis
1. Work up? 3
- Treatment? 3
- Work-up:
- UA
- Urine culture
- Sometimes cystoscopy - Treatment:
- Avoiding irritants
- Voiding routine**
- Kegel’s
Chlamydia—Male
1. It is the most common cause of what?
- Manifestations? 3
- Main symptoms? 2
- Most common cause of nongonococcal urethritis
- Manifestations:
- Urethritis: symptomatic*/asymptomatic
- Epididymitis
- Prostatitis - Symptoms—
- dysuria,
- thin watery sometimes scant discharge
Chlamydia in Males
1. Dx?
- Tx?
- NAAT testing:
-Some tests are expensive and don’t produce results quickly
Xpert CT/NG assay is a NAAT provides testing in 90 minutes - Treatment–1000mg of Azithromycin in one pill
Gonorrhea in males:
- Presents how? 2
- Dx? 2
- Tx?
- Urethritis—symptomatic
- Epididymitis—age less than 35years
- NAAT testing of urine or swab
- GS showing PMNs with gram neg diplococci
- ceftriaxone 250 mg intramuscularly in a single dose
Gonorrhea most common symptoms?
2
- Dysuria and
2. copious amounts of purulent discharge
What is the difference between a normal bladder and an overactive bladder?
- Normal- detrusor muscle contracts with a full bladder
2. Overactive- Detrusors muscle contacts before bladder is filled
Overactive bladder Without Incontinence
1. Presentation? 3
- PP? 1
- Causes? 4
- Presentation:
- Urgency
- Frequency
- Nocturia - Pathophysiology:
- Detruser muscle contracts irregularly at smaller volumes of urine - -Usually idiopathic
Can be secondary to
-DM,
-stroke,
-spinal disease
Treatment of OAB
- Antimuscarinics SE? 5
- MOA? 2
- Agents? 3
- SE:
- Dry mouth,
- constipation,
- blurry vision,
- confusion,
- drowsiness - Mechanism:
- Increase bladder capacity
- Block basal release of acetyl choline during bladder filling - Agents:
- Oxbutynin (Ditropan)
- Tolterodine (Detrol)
- Solifenacin (Vesicare)—once a day
Treatment of OA- New Agent?
Mirabegron (Myrbetriq)
Mirabegron (Myrbetriq)
- MOA?
- SE? 3
- Beta 3-adrenoceptor agonist
- Can use alone or with other agents - SE:
- HTN**
- Incomplete bladder emptying
- Dry mouth
Urinary Incontinence: types? 3
- Stress
- Urge
- Overflow
Medical Morbidity of urinary incontinece?
6
- Perineal candida infection
- Cellulitis and pressure ulcers
- UTIs and urosepsis
- Falls & fractures from slipping on urine
- Sleep interruption and deprivation
- Psychologically: poor self esteem, social withdrawal, depression and sexual dysfunction
Pathophysiology: Continence depends on what? 2
- Intact micturition physiology
2. Intact functional ability to toilet oneself
Risk factors for urinary incontinece?
12
- Obesity
- Functional impairment
- Parity
- Family history
- Smoking
- Age
- diabetes,
- stroke,
- depression,
- estrogen depletion,
- genitourinary surgery,
- radiation
Non-Hispanic white women higher rates than non-Hispanic Black and Hispanic women
Transient causes
of Urinary incontinence?
DIAPPERS
Delirium
Infection
Atrophic vaginitis
Pharmacoloic: sedatives, diuretics, anticholinergics
Psychological: depression
Excessive urine production (?)
Restricted mobility
Stool impaction
Screening Tool for urinary incontience: Questions?
4
- In the past three months: have you leaked urine?
- Which precipitants led to leakage?
- Which precipitant caused leakage most often?
- Do you ever wear pads, tissue or cloth in your underwear to catch urine?
Urge Incontinence
1. Etiologies? 3
- Presentation? 4
- 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
- Stress Incontinence is what?
- It is important to know what about the timing of the incontinence?
- Occurs in what age?
- Due to? 2
- What is the most common cause in men?
- Leakage of urine with increased intra-abdominal pressure in the absence of a bladder contraction:
- 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 - Prostate surgery most common cause in men**
Mixed Incontinence
- Most common type in who?
- What is it?
- Most common type in women
2. Patients vary in predominance and/or bother of urge or stress leakage
Incomplete Emptying (Overflow Incontinence)
- Preferred term?
- What is it?
- Due to? 2
- Preferred term is: incomplete bladder emptying
- Continuous leakage or dribbling of urine
- Due to:
- Detruser underactivity
- Bladder outlet obstruction
Detrusor underactivity is due to what?
4
- Low estrogen
- Aging
- Peripheral neuropathy (due to DM, B12 etc)
- Damage to the spinal detrusor efferents (MS)
Nocturia: Possible etiologies? 5
- CHF—fluid redistribution form pedal edema
- Late evening beverages
- Sleep apnea
- Sleep disturbances—chronic pain, depression
- Detrusor overactivity
Diagnostic Tool: Nocturia?
Bladder diary:
- Record time & volume of every continent and incontinent void over 42 to 78 hours
- Other pertinents include: activity, Caffeine intake, hours of sleep, episodes of nocturia etc.
Physical exam for incontience?
4
- Neurologic conditions
- In women thorough genital exam:
3, In males exam of the prostate - Older persons: cognitive & functional status, including mobility, manual dexterity, depression screening looking for “functional incontinence”
Physical exam for incontience: What should we check for in women in the genital exam?
2
- Check for cystocele/rectocele, atrophy
2. Have the patient cough looking for leakage of urine (standing!)*
Post-Void Residual
- What is it?
- What is considered adequate emtying?
- Have patient void until they feel they have emptied their bladder completely
- Then do bladder ultrasound or clean cath
- PVR
Labs for incontience?
7
- Renal function
- Serum calcium, and
- Serum 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 treatment of incontinence? 5
- Weight loss
- Adequate, but not excessive fluid intake (2 L)
- Avoid caffeinated beverages and alcohol
- Minimize evening fluid intake for nocturia
- Smoking cessation
Treatment: Behavioral therapy: for urge, stress and mixed?
4
- Bladder training: (Frequent voluntary voiding and relaxation techniques for urge incontinence)
- Pelvic muscle exercises: Kegels
- Biofeedback
- Pessiaries for organ prolapse or stress incontinence
Pharmacotherapy: Used for urge & mixed if behavioral alone is not successful?
- Anticholinergics w/ antimuscarinic activity
2. Oxybutynin (Ditropan): IR, ER, Patch
Anticholinergics w/ antimuscarinic activity
- MOA?
- Which drugs? 2
- SE? 5
- CI?
Oxybutynin (Ditropan): IR, ER, Patch
- MOA?
- Advantage?
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
Oxybutynin (Ditropan): IR, ER, Patch
5. Direct antispasmodic effect on detrusor muscle
- Less SE although dry mouth still prominent
New Pharmacotherapy: Miragebron (Myratriq)
- Causes what?
- Helps which incontinence types?
- SE? 8
- Not reccommended for who?
- Causes bladder relaxation
- 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
- Surgical Therapy for what kind of incontinence?
- How successful?
- Which type of approaches?
- Vaginal includes? 3
- Used for stress incontinence
- High rate of success
- Abdominal or vaginal approaches
- Vaginal include:
- Midurethral sling
- Bladder neck sling
- Submucosal injection of urethral bulking agents
Surgery Using Mesh
- Explain this?
- Mesh related complications? 7
- Synthetic mesh kits were frequently used for repair of stress incontinence and pelvic floor prolapse
- Mesh related complications:
- Mesh exposure (erosion)
- Dyspareunia
- Infection
- Urinary problems
- Bleeding
- Organ perforation
- Deaths associated w/ bowel perforation or hemorrhage
The selected procedure for SUI is a what?
mesh midurethral sling
Incontinence: When to Refer Immediately
5
- Incontinence w/ abdominal and/or pelvic pain
- Hematuria in the absence of UTI
- Suspected fistula
- Complex neurological conditions
- Abnormal findings
Elective Referral for incontinence?
5
- Persistent symptoms after adequate therapeutic trial
- Uncertainty in diagnosis
- Significantly elevated PVR that does not resolve after treatment of possible precipitants
- Prior pelvic surgery or pelvic irradiation
- Desiring surgical therapy for stress incontinence
Interstitial Cystitis (IC)
- AKA?
- Usually dx in what demographic of people? 2
- Also known as—bladder pain syndrome (BPS)
- Epidemiology:
- Usually diagnosed in the 4th decade or later
- Female to male ratio—5:1
IC/BPS Presentation
- Presistant feature?
- Progression?
- May have other urinary symptoms? 3
- Persistent feature: pain or “unpleasant” sensation with filling of the bladder—relieved with bladder voiding
- Gradual onset w/ worsening symptoms
- May have other urinary symptoms:
- Urinary frequency
- Urgency
- Nocturia
Diagnosis for Interstitial Cystitis (IC)?
4
Thorough PE:
- Patient usually has a tender suprapubic area
- May have other pain conditions such as dyspareunia, irritable bowel, vulvodynia
- UA and
- culture to r/o cancer and infection
Definition of IC/BPS
“An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes.”
IC Management—1st Line
3
- Patient education noting reasonable expectations about pain relief and chronicity of condition
- Psychosocial support
- Self-care and behavior modification
IC Management—2nd Line
- Used for which pts?
- Meds? 3
REFERRAL
- PT—for those patients w/ pelvic muscle pain
- Meds:
- Amitriptyline–TCA
- Pentosan polysulfate sodium (PPS) [Elmiron]
- Hydroxyzine–Antihistamine
Pentosan polysulfate sodium (PPS) [Elmiron] MOA?
- It concentrates in the bladder
- Proposed mechanism is reconstitutes deficient protective glycosaminoglycan layer over the urothelium
Always rule out cancer when what is present?
Always ask appropriate patients about symptoms of incontinence
painless hematuria
