Bladder & Urethral Disorders Flashcards
2nd MC urologic cancer
MC in who?
Bladder Cancer
men (~3:1) and older pts (avg age at dx - 73)
risk factors for bladder cancer
- Cigarettes - 60% of new cases
- Industrial solvents - 15% of new cases
- Chronic inflammation - UTIs, catheters, bladder stones
Epidemiology of bladder cancer
98% - epithelial cell malignancies
- 90% - urothelial cell carcinoma
- 7% - squamous cell carcinoma - chronic inflammation
- Bladder stones
- Prolonged catheter use
- Chronic UTIs
- Schistosomiasis - 2% - adenocarcinomas
s/s of bladder cancer
-
Hematuria (85-90%)
- Micro or gross, intermittent or chronic
- Often painless - +/- irritative voiding (depending on size, location)
- Many pts - no major s/s in early stages! - Weight loss possible
- Large - may see abdominal mass
- Metastatic - hepatomegaly, LAN +/- lymphedema
lab findings of bladder cancer
- Hematuria (gross/micro)
- +/- pyuria, anemia - If obstruction - signs of AKI
- Urine cytology - abnormal shed epithelial cells
- 80-90% sensitive in higher grade/stage
- 50% sensitive in noninvasive or well-differentiated - Urine biomarkers - new; not preferred over cystoscopy
imaging and diagnostic for bladder cancer
- Imaging
- CT, MRI or US may show mass within bladder
- “Filling defect” -
Cystoscopy w/ bx - gold standard
- Local anesthesia - can ID mass within the bladder
- Can perform local resection (regional or total anesthesia)
tx for bladder cancer
- Superficial (TIS, Ta, T1) - transurethral tumor resection
- +/- intravesical chemotherapy
- Weekly x 6-12 wks - BCG is often most effective form
— May require anti-TB treatment
— Alternative agents available - Invasive (T2 +) - radical cystectomy, urinary diversion
- +/- chemotherapy, immunotherapy, radiation
prognosis for bladder cancer
- Superficial ,5-year survival - 81%
- 50-80% are superficial - Invasive, 5-year survival - 50-75%
- Metastatic (T4) - long-term survival is rare
repeated urination into clothing or bedding
what is this term?
enuresis
Some sources - only applies if child is 5+ years old
May be associated with neurodevelopmental problems
no other LUTS and no history of bladder disorders
what is this term? (for Nocturnal Enuresis)
Monosymptomatic enuresis
urination occurring specifically during bedtime/sleeping hours
what term is this
nocturnal enuresis
2 types of nocturnal enuresis
- Primary - usually in young children < 5-6 years old; have never achieved urinary continence
- Secondary - patients who previously were fully continent for 6+ months
- Often associated with a stressful
who MC has nocturnal enuresis
males
About 15% of pts/yr have spontaneous resolution
5 years: 16%
6 years: 13%
7 years: 10%
8 years: 7%
10 years: 5%
12-14 years: 2-3%
≥15 years: 1-2%
￪ duration = ￬ likelihood of
spontaneous resolution
Tx for nocturnal enuresis before age ___ is usually not recommended!
5
Involuntary urination during sleep in a person who normally has voluntary urinary control
Usually occurs 3-4 hours after bedtime
Confusion and amnesia possible
this presentation is for what dx?
nocturnal enuresis
- Investigate for other conditions
- Polydipsia - DM, DI, primary polydipsia
- Infections - UTI, pinworms
- Other causes - CKD, bladder disease, constipation, seizures
what can delineate timing, frequency and severity for nocturnal enuresis
voiding diaries
diagnostics for nocturnal enuresis
as needed to rule out other causes
- Infections, emotional distress, diabetes, epilepsy, etc.
- UA - generally indicated for most pts
- US - can help look for anatomic abnormalities
tx for nocturnal enuresis
- Lifestyle Changes
- Voiding - frequently in day (4-7x) and just before bed
- Fluids - avoid excess fluids in the evening
— Especially sugary/caffeinated
- Pull-Ups - discourage use in older children
- Education - bedwetting is unintentional
— Primary usually resolves by puberty - Interventions
- tx of coexisting conditions
- Similar outcomes for behavioral vs meds
- Behavioral - enuresis alarm
— 3-4 months
— Lower relapse rates, but require a
highly motivated family
- meds - desmopressin (1st line)
— Good for short-term improvement
— 2nd line - imipramine, oxybutinin (add-on)
etiology of interstitial cystitis
Unknown
- Possible allergic response, inflammatory/autoimmune, abnormal epithelium, abnormal sensorineural response
- possibly several diseases with similar sx
Epidemiology of Interstitial Cystitis
- MC women (5:1)
- 18-40 per 100,000 patients
- MC diagnosed in 40s or later
risk factors for interstitial cystitis
- Associated w/ chronic pain syndromes (IBS, fibromyalgia)
- Certain foods/drinks may trigger
- alc, caffeine, citrus, spicy
presentation + labs for interstitial cystitis
- pain/discomfort with bladder filling, classically is relieved w/ urination
- pain range from mild-debilitating
- +/- irritative voiding sx
— nocturia, frequency, urgency
- Suprapubic tenderness often seen on exam - labs - normal
- UA
- Urine C&S
- Urine cytology
- Urodynamics
imaging for Interstitial Cystitis
- US - Postvoid residual (PVR) to rule out urinary retention
- Cystoscopy - helps rule out bladder CA
- May have findings associated with IC
how does the AUA diagnose interstitial cystitis
- Unpleasant sensation (pain, pressure, discomfort) perceived as relating to urinary bladder, with other LUTS, for >6 wks duration, in absence of infection or other identifiable causes
- No solid confirmatory PE finding, lab test or imaging!
— Used to r/o other dx
what interventions can be used for interstitial cystitis
- Cystoscopy - Not required to make dx
- Can help r/o other etiologies - Hydrodistension - improves s/s in 20-30%
Cystoscopy findings associated with IC:
- Hunner’s ulcers/lesions (only in
5-10% of pts) - Glomerulations (nonspecific - also seen
in 45% of healthy pts) - Increased mast cells on bx
Interstitial Cystitis - Treatment
Goal - No cure - symptomatic relief
- sx may spontaneously improve
- Pt education and psychosocial support significantly help
- First Line - Lifestyle modifications/Self care
- Second Line - Oral meds
- TCAs - amitriptyline - 1st line rx
- Antihistamines - hydroxyzine
- CCBs - nifedipine
- Pentosan polysulfate sodium (PPS) - Invasive therapies
- Hydrodistension
- Electrocauterization of Hunner lesions (if present)
- Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)
Only drug FDA-approved for tx of IC
pentosan polysulfate sodium (PPS); Elmiron
MOA of pentosan polysulfate sodium (PPS); Elmiron
May improve glycosaminoglycan layer over urothelium
SE of pentosan polysulfate sodium (PPS); Elmiron
- GI upset, elevated LFTs, hair loss
- Less sedation than TCAs, antihistamines
- Longer to see results than other meds for IC
- Case reports of retinal toxicity/macular disease - dose-related
CI with pentosan polysulfate sodium (PPS); Elmiron
allergy to drug or to heparin or LMWH
DDI with pentosan polysulfate sodium (PPS); Elmiron
anticoagulants/antiplatelets (￪ bleeding)
what tx for Interstitial Cystitis is for refractory cases (more SE and/or ? efficacy)
Botulinum injections to detrusor muscle
Sacral neuromodulation
Cystectomy with urinary diversion (last resort)
adjunct tx for interstitial cystitis
often not used alone; CI in renal insuff
- Phenazopyridine (Azo) - short-term tx only!
- Methenamine (Hiprex) - urine antimicrobial (metabolizes to formaldehyde)
MCC of urethral stricture
(Numerous)
- Iatrogenic (surgery, catheters) - 45% of all cases
- Idiopathic (developed countries)
urethral stricture is MC in who?
men
Can be diagnosed in any age, including children
risk factors for urethral stricture
Hx of GU surgery or instrumentation
Hx of pelvic trauma or irradiation
Hx of GU infection or cancer
s/s of urethral stricture
- obstructive voiding s/s
- May see irritative voiding s/s
- Spraying of the urinary stream
- Recurrent UTIs/prostatitis
- Some (about 10%) of pts may be asx
labs and imaging for urethral stricture
- Labs - often normal UA/UC (unless infection present)
- Imaging
- Uroflometry - can show poor bladder emptying
- US - Postvoid residual (PVR) to help rule out urinary retention
- Cystourethrogram - can help visualize stricture
- Cystourethroscopy - helps directly visualize stricture via scope
tx for urethral stricture
- Indications for Tx - recurrent UTIs, problematic sx, urinary retention, high PVR, bladder stones
- May not need tx if asx - Minimally Invasive - urethral dilation, urethrotomy
- MC initial therapy
- high rates of recurrence after tx - Reconstruction - urethroplasty +/- replacement graft
- Consider effects on erectile function - Urinary Diversion - suprapubic catheter, perineal urethrostomy, permanent urinary diversion
cause of urethral prolapse
protrusion of the distal urethra through the external urethral meatus
- Malformation of the urethra
- Weak pelvic floor structures
urethral prolapse is MC in who and when?
women
Ages - prepubertal (avg age - 4 y/o), postmenopausal
risk factors for urethral prolapse
Chronically increased intra-abdominal pressure
Post-menopausal status
Traumatic vaginal delivery
s/s of urethral prolapse
vary depending on age of patient!
-
Prepubertal - asx (found incidentally)
- May see vaginal bleeding along with periurethral mass
- Bloody spotting on underwear/diapers
- May complain of irritative voiding
- round, “donut-shaped” protrusion of tissue obscuring the external urethral meatus -
Postmenopausal - symptomatic
- Vaginal bleeding
- Dysuria, urinary urgency, urinary frequency, nocturia
- Hematuria
- If large - venous obstruction, thrombosis, necrosis
- round, “donut-shaped” protrusion of tissue obscuring the external urethral meatus
labs and imaging for urethral prolapse
- Labs - may see hematuria, signs of UTI
- Imaging - typically only done if concern over complications
- Cystourethroscopy - can help confirm diagnosis and the presence of the urethral meatus; primarily used in adults
— May also use urinary catheterization
tx for urethral prolapse
Medical Therapy
- Prepubertal - sitz baths, topical antibiotics, topical estrogen
- Management of comorbid/predisposing disease - Postmenopausal - sitz baths, topical estrogen cream, antibiotics
- Not recommended if significant necrosis, thrombosis or bleeding
Surgical Therapy - better outcomes if done early
- Manual reduction and urethral cath for 1-2 days
- High recurrence rates - Ablative therapy - not commonly used
-
Excision of mucosa with short-term catheterization - MC method
- May need long-term estrogen cream tx if postmenopausal
bladder can store up to ___ cc of urine
no stretch to detrusor muscle
200-300
what part of the brain stimulates the sympathetics and somatic nerves?
how does that affect the bladder?
Pons
- sympathetics - Inhibit (relax) detrusor muscle, Closes internal urethral sphincter
- somatic - Contraction of external urethral sphincter
bladder physiology of Micturition
- More urine fills bladder
- Detrusor/Trigone stretch → signal to Pons
- Inhibits SYMPATHETICS and SOMATICS
- Activates PARASYMPATHETICS
- Stimulates (contracts) detrusor
- Relaxes (opens) internal urethral sphincter
What if it’s not the time or place to urinate?
- Voluntary control overrides involuntary pathway!
- Cerebral cortex → pudendal nerve → contraction of the external urethral sphincter
causes of transient urinary incontinence
- Transient/Reversible - Potentially correctable cause
- Often originates outside the urinary tract
DIAPPERS
- Delirium
- Infection
- Atrophic urethritis/vaginitis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
risk factors of urinary incontinence
Female gender
Advanced age
Obesity
Parity/Pregnancy
Prostate disease
Neurologic disease
Immobility
causes of established incontinence
Established - Harder to treat; often not reversible/curable
- d/t disorder of bladder or surrounding structures
- Urge Incontinence
- Detrusor overactivity - Stress Incontinence
- Urethral sphincter incompetence - Overflow Incontinence
- Detrusor underactivity - Mixed Incontinence
- Multiple causes - Functional Incontinence
- Problems thinking/speaking/moving
meds that cause incontinence
- Alcohol
- Sedatives/Hypnotics
- BZDs
- Insomnia meds - Alpha-adrenergic drugs
- Blockers - women
- Agonists - men - Diuretics
- Anticholinergics
- Antihistamines
- Antipsychotics
- Antidepressants - Narcotics
- CCB
overactivity of detrusor muscle
- “Overactive bladder”
- Often idiopathic
- Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI
what type of incontinence
urge
very strong urge to urinate immediately preceding or accompanying involuntary passage of urine
Few drops to totally soaked clothing
this presentation if what type of incontinence?
urge
More common in elderly pts
cause of stress incontinence
Urethral incompetence
- Hypermobility of urethra - weak pelvic support
- Childbirth, ￬ estrogen, trauma, prostate surgery, hysterectomy
- Men - radical prostatectomy - Intrinsic sphincter deficiency
- involuntary leakage with increase in “pressure”
- coughing, laughing, sneezing, lifting heavy objects
what type of incontinence
stress
MC younger women than urge incontinence
cause of overflow incontinence
- Detrusor underactivity
- Less common than other intrinsic causes
- Non-contractile bladder leads to distension
- May be idiopathic or due to neural disease (spinal cord disease, DM neuropathy, etc.)
frequent involuntary leakage of small amounts of urine,
Nocturia, weak urinary stream, sensation of bladder fullness
this presentation is for what type dx?
overflow incontinence
Should rule out bladder outlet obstruction
cause and presentation of mixed incontinence
- cause - combo of causes
- Often stress + urge incontinence - Presentation - combo of sx from other forms of incontinence
- Very common - especially in women
inability to recognize need to urinate or to get to restroom in a timely fashion when the need to urinate arises
what type of incontinence?
causes?
functional
- Psych/Neuro - dementia, delirium, psych disorder
- Mobility - inability to ambulate or to request help to get to restroom
Presentation - varies with underlying cause
Very common - especially in women
Why is urinary incontinence important?
Social stigma - restricted activities, depression
Medical complications - skin breakdown, UTIs
Institutionalization - significantly increases likelihood of pt being placed in a nursing home
hx for when asking about incontinence
- “Do you have a problem with urine leakage or bladder accidents?”
- Triggering Factors
- Duration, frequency, severity
- hx of GU tract symptoms, disease, surgery
- Bladder/voiding diary
- Medication review
- 3 Ps
- Position - (setting) - supine, sitting, standing
- Protection - pads/pantiliners per day, wetness of pads
- Problem - impact on quality of life
PE for urinary incontinence
- General Exam - evaluate for causes or exacerbating factors
- Abdominal, rectal, pelvic
- Mobility, mental status, fluid status (CV) - Bladder Stress Test - have pt with full bladder stand and cough
- Instant leakage - stress incontinence
- Delayed leakage - urinary bladder contraction stimulated by coughing
diagnostic studies/findings for incontinence
-
UA - screen for UTI, hematuria
- Cx and/or urine cytology if indicated -
Postvoid Residual - if overflow incontinence, urologic disease, neuropathy suspected
Measure via US or catheter
- < 50 cc - normal;
- >200 cc - refer to urology
- >400 cc - overflow incontinence highly probable - 2nd-line - cystoscopy, urodynamics, other imaging - as indicated for suspected etiology
stress incontinence tx
- Lifestyle Modifications
- Limit caffeine and alcohol
- Control amount and timing of fluid intake
-Bladder training (timed voiding)
- Adult urinary pads/protective garments - Pelvic floor muscle exercises (Kegels)
- May take up to 6 wks to see benefit - Pessaries - if d/t bladder prolapse in women
- Injections - urethral bulking agents
- meds - duloxetine (off label)
- Surgery - often last resort - most effective
- Emerging/Specialty Treatments
- Intravesical balloon
- Electrical stimulation of pelvic floor/Electroacupuncture
- Pulsed magnetic stimulation
urge incontinence tx
- Lifestyle Modifications
- Limit caffeine and alcohol
- Control amount and timing of fluid intake
- Bladder training (timed voiding)
- Adult urinary pads/protective garments - Pelvic floor muscle exercises (Kegels)
- May take up to 6 weeks to see benefit
- Can help improve control when urge to urinate occurs - meds - anticholinergics (antimuscarinics) are traditional mainstay
- Others - Beta-3 adrenergic agonists, TCAs, alpha-blockers (men)
MOA of Anticholinergics
Inhibit acetylcholine at muscarinic receptors
- Blocks parasympathetic pathway leading to bladder contraction
- May take up to 4 wks to improvement, 12 wks to full efficacy
SE of Anticholinergics
dry mouth, constipation, urinary retention, dizziness or drowsiness, blurred vision, impaired cognition
- Special caution in elderly due to SE
- May have less SE with extended-release formulations
CI of anticholinergics
gastric retention, glaucoma
DDI with anticholinergics
other anticholinergics, potassium chloride
6 Anticholinergics drugs
- Oxybutynin (Ditropan)
- Darifenacin (Enablex)
- Solifenacin (Vesicare)
- Tolterodine (Detrol)
- Fesoterodine (Toviaz)
- Trospium (Sanctura)
All have equal efficacy on paper - individual pt responses vary!
Oxybutinin (Ditropan) - often most commonly prescribed due to cost
mirabegron
Beta-3 Agonists
vibegron
Beta-3 Agonists
MOA of Beta-3 Agonists
For pts who cannot tolerate anticholinergic therapy for OAB
May also be used as add-on to anticholinergics in severe/refractory OAB
SE of Beta-3 Agonists
HTN, tachycardia, dry mouth, constipation, UTI
- May be a little less problematic for SE than anticholinergics
- Often not prescribed first due to cost
DDi with Beta-3 Agonists
anticholinergics, QT-prolonging drugs
CI with Beta-3 Agonists (Canada)
severe uncontrolled HTN; pregnancy
tx for urge incontinence
- Injection - Botox into detrusor muscle
- Less anticholinergic SE, more urinary retention - Neuromodulation
- Tibial nerve stimulation
- Sacral neuromodulation - Surgery - typically last resort
- Cystoplasty
- Urinary diversion
- Suprapubic catheter
tx for overflow incontinence
- Lifestyle Modifications
- Limit caffeine and alcohol
- Control amount and timing of fluid intake
- Bladder training (timed voiding)
- Adult urinary pads/protective garments - Treatment of underlying cause
- Surgical decompression
- Management of related conditions (DM, BPH)
- abx if UTI - Neuromodulation - sacral nerve stimulation
- High rate of device failure - Indwelling catheter - last resort
- Risk of increased UTIs, urethral scarring
- Consider suprapubic catheter, intermittent catheterization
tx for mixed incontinence
- Lifestyle Modifications
- Limit caffeine and alcohol
- Control amount and timing of fluid intake
- Bladder training (timed voiding)
- Adult urinary pads/protective garments - Pelvic floor muscle exercises (Kegels)
- May take up to 6 weeks to see benefit - Medication - for urge incontinence
- Refractory cases
- Botox injection of detrusor muscle
- Surgical placement of sling
tx for functional incontinence
- Lifestyle Modifications
- Limit caffeine and alcohol
- Control amount and timing of fluid intake
- Bladder training (timed voiding)
- Adult urinary pads/protective garments
- Bedside commode for limited mobility
- Call bell or other signal if assistance needed to get to restroom - Treatment of Underlying
- Evaluate etiology of delirium (if present)
- Mobility aids
- PT to improve ambulation
