Bladder Disorders & Urinary Incontinence Flashcards
Signs of Glomerular Bleeding
Red cell casts: glomerulonephritis
Dysmorphic RBCs
Proteinuria with hematuria with a large percentage being albumin
Etiologies for Non-glomerular Hematuria
UTI: acute cystitis, pyelonephritis Kidney trauma Stones: calyx, ureter Contamination at menstruation or postpartum Fistula Endometriosis BPH Vigorous exercise Post strep glomerular nephritis IG nephropathy Cancer: over 40
Risk Factors for Malignancy
Age: 35+ Smoking history Occupational exposure to chemicals/dyes Hx of gross hematuria Hx of chronic cystitis or irritative voiding symptoms Hx of pelvic irradiation Exposure to cyclophosphamide Hx of chronic indwelling FB Hx of analgesic abuse
Hematuria Work-Up
Urine culture
Urine cytology
Imaging: CT IVP, US (pregnant women)
Cystoscopy
Negative Work-up of Hematuria in Young & Middle-age Patients
Mild glomerular disease
Predisposition to stone disease
Negative Work-up of Hematuria in Patients at High Risk for Malignancy
Need annual UA
May need another work-up in 1-3 years
Monitoring for Mild Glomerular Disease
BP: every 6 months
GFR/CrCl: yearly
Proteinuria: yearly
Reasons for Cystitis
UTI
Pyelonephritis
Non-infectious
STI-Male
Pathogenesis of Cystitis
Colonization of the vaginal introits from fecal flora
Ascension to the bladder via the urethra
Can ascend to the kidneys (pyelonephritis)
Most Common Pathogens in Microbiology
E. coli (75-90%)
Proteus
Klebsiella
Clinical Presentation of UTI
Dysuria Frequency Urgency Suprapubic pain Hematuria
Clinical Presentation of Pyelonephritis
Symptoms of cystitis may or may not be present Chills Flank pain with CVA tenderness N/V Appears ill
Diagnostic Tests for Cystitis
UA
Positive leukocyte esterase +/- nitrites
Consider urine culture with sensitivities
Diagnostic Tests for Pyelonephritis
UA
Urine culture & sensitivities
Treatment of Cystitis in Women
Nitrofurantoin
Bactrim
Fosfomycin
Phenozopyridine (Pyridium)
Differential for Men with Cystitis
Prostatitis
Urethritis secondary to STI
Urinary tract abnormality
Nephrolithiasis
Treatment of Cystitis in Men
Trimethoprim-sulfamethoxazole (Bactrim)
Fluoroquinolone
Outpatient Treatment for Pyelonephritis
Mild to moderate illness
Fluoroquinolone resistance low: Cipro or levoquin
Other: Bactrim or Augmentin
Inpatient Treatment for Pyelonephritis
Oral fluoroquinolone + aminoglycoside
Extended spectrum cephalosporin
Symptoms of Non-infectious Cystitis
Similar to cystitis with nocturne
Pressure in pelvis
Irritants of Non-infectious Cystitis
Bubble baths Feminine hygiene sprays Tampons Spermicidal jellies Chemoradiation Foods: tomatoes, artificial sweeteners, caffeine & chocolate
Work-up of Non-infectoius Cystitis
UA
Urine culture
Sometimes cystoscopy
Treatment of Non-infectious Cystitis
Avoiding irritants
Voiding routine
Kegel’s
Manifestations of Chlamydia in Males
Urethritis: symptomatic or asymptomatic
Epididymitis
Prostatitis
Diagnosing Chlamydia in Males
NAAT testing
Treatment of Chlamydia
Azithromycin
Rocephin
Presentation of Gonorrhea in Males
Symptomatic urethritis
Epididymitis: age
Diagnosing Gonorrhea in Males
NAAT testing
Treatment of Gonorrhea
Azithromycin
Rocephin
Presentation of Overactive Bladder Without Incontinence
Urgency
Frequency
Nocturia
Pathophysiology of Overactie Bladder Without Incontinence
Detruser muscle contracts irregularly at small volumes
Usually idiopathic
Can be secondary to DM, stroke, spinal disease
Treatment of Overactive Bladder
Anti-muscarinics
SE of Anti-muscarinics
No spit
No shit
No pee
No see
MOA of Anti-muscarinics
Increase bladder capacity
Block basal release of acetyl choline during bladder filling
Anti-muscarinic Agents for Overactive Bladder
Oxybutynin (ditropan)
Tolterodine (Detrol)
Solifenacin (Vesicare)
New Agent for the Treatment of Overactive Bladder
Mirabegron (Myrbetriq)
Beta 3-adrenoceptor agonist
SE of Mirabegron (Myrbetriq)
HTN
Incomplete bladder emptying
Dry mouth
Medical Morbidity of Urinary Incontinence
Perineal candida infection
Cellulitis & pressure ulcers
UTIs & urosepsis
Falls & fractures from slipping on urine
Sleep interruption & deprivation
Psychologically: poor self esteem, social withdrawal, depression & sexual dysfunction
Reasons for Sexual Dysfunction with Urinary Incontinence
Afraid of leaking urine during sex
Pathophysiology of Incontinence
Non-intact micturition physiology
Lack of functional ability to toilet oneself
Risk Factors for Incontinence
Obesity Functional impairment Parity (# of pregnancies) Family history Smoking Age DM Stroke Depression Estrogen depletion Genitourinary surgery Radiation
Transient Causes of Incontinence
D: delirium I: infection A: atrophic vaginitis P: pharmacologic P: psychological E: excessive urine production R: restricted mobility S: stool impaction
Pharmacologic Causes of Incontinence
Sedatives
Diuretics
Anti-cholinergics
Excessive Urine Production Causes of Incontinence
Diuretics ADH problems Psychogenic polydipsia DM Hypercalcemia
Incontinence Questions for Screening
In the past 3 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?
Important History for Incontinence
Questions about incontinence
Precipitants
Bowel & sexual function
Status of other medical conditions, parity, & meds
Any prior continence therapy, particularly surgical treatments
Etiology of Urge Incontinence
Uninhibited bladder contractions
Detrusor over activity
May be due to bladder abnormalities or idiopathic
Presentation of Urge Incontinence
Sudden urge to void: nocturia, frequency
Preceded or accompanied by leakage of urine
More common in older women
Also seen in men
Define Stress Incontinence
Leakage of urine with increased intra-abdominal pressure in the absence of a bladder contraction
Stress Incontinence Due to
Urethral hypermobility
Intrinsic sphincter deficiency
Mixed Incontinence
Most common type in women
Vary in predominance and/or bother of urge or stress leakage
Define Incomplete Emptying
Continuous leakage or dribbling of ruine
Causes of Incomplete Emptying
Detruser underactivity
Bladder outlet obstruction
Reasons for Detrusor Underactivity
Low estrogen
Aging
Peripheral neuropathy due to DM, chemo, B12 deficiency, meds, ETOH
Damage to the spinal detrusor efferents (MS)
Possible Etiologies of Nocturia
CHF
Late evening beveragesSleep apnea
Sleep disturbances: chronic pain, depression
Detrusor overactivity
Diagnostic Tool for Bladder Issues
Bladder diary
Bladder Diary
Record time & volume of continent & incontinent voiding Activity Caffeine intake House of sleep Episodes of nocturia
Physical Exam in a Patient with Urinary Incontinence
Heart Lungs Neurologic conditions Check for cystocele/rectocele, atrophy Have patient cough: look for leakage Examination of the prostate Cognitive & functional status
Post-Void Residual
How much urine is left in the bladder after the patient empties their bladder
Labs for Urinary Incontinence
Renal function Serum calcium & glucose UA PSA for men if indicated Urine cytology if there is hematuria or pelvic pain Increased post-void residual
Treatment of Urinary Incontinence
Weight loss Adequate but not excessive fluid intake Avoid caffeinated beverages & alcohol Minimize evening fluid intake for nocturia Smoking cessation Behavioral therapy Pessiaries Pharmacotherapy
Behavioral Therapy for Urinary Incontinence
Bladder training: frequent voluntary voiding, relaxation techniques for urge incontinence
Kegel exercises
Biofeedback
Pharmacotherapy for Urge & Mixed Incontinence
Tolterodine (Detrol LA)
Solifenacin (Vesicare)
Oxybutynin (Ditropan): IR, ER, Patch
SE of Anti-muscarinics
Dry mouth Blurred vision Constipation Drowsiness Decreased cognitive function
Contraindication of Anti-muscarinics
Narrow angle glaucoma
MOA of Oxybutynin (Ditropan)
Direct antispasmodic effect on detrusor muscle
MOA of Miragebron (Myratriq)
Causes bladder relaxation
SE of Miragebron (Myratriq)
HTN Tachycardia Urinary retention Inflammation of the nasal passages Dry mouth Constipation Abdominal pain Memory problems
Surgical Therapy for Incontinence
Used for stress incontinence
Abdominal or vaginal approaches
Vaginal Surgical Therapy Includes
Midurethral sling
Bladder neck sling
Submucosal injection of urethral bulking agents
Mesh Related Complications of Surgeries Performed Prior to New Guidelines
Mesh exposure (erosion) Dyspareunia Infection urinary problems Bleeding Organ perforation Deaths associated with bowel perforation or hemorrhage
When to Immediately Refer for Urinary Incontinence
Incontinence with abdominal and/or pelvic pain Hematuria in the absence of UTI Suspected fistula Complex neurological conditions Abnormal findings
When to Electively Refer for Urinary Incontinence
Persistent symptoms after adequate therapeutic trial
Uncertainty in diagnosis
Significantly elevated PVR that doesn’t resolve after treatment of precipitants
Prior pelvic surgery or pelvic irritation
Desiring surgical therapy for stress incontinence
Presentation of Interstitial Cystitis
Persistent pain or “unpleasant” sensation with filling of the bladder, relieved with voiding
Gradual onset with worsening symptoms
Urinary frequency
Urgency Nocturia
Diagnosis of Interstitial Cystitis
Through PE Tender suprapubic area Dyspareunia Irritable bowel Vulvodynia UA & culture
Define Interstitial Cystitis
Unpleasant sensation 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
1st Line Management of Interstitial Cystitis
Patient education noting reasonable expectations about pain relief & chronicity of condition
Psychosocial support
Self-care & behavior modification
2nd Line Management of Interstitial Cystitis
PT: patients with pelvic muscle pain
Meds: amitriptyline, pentosan polysulfate sodium (PPS), hydroxyzine
MOA of Pentosan Polysulfate Sodium (PPS)
Reconstitues deficient protective glycosaminoglycan layer over the urothelium
