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GU: Clin Med IIA > Bladder & Urethral Disorders > Flashcards

Bladder & Urethral Disorders Flashcards

1
Q

2nd MC urologic cancer
MC in who?

A

Bladder Cancer
men (~3:1) and older pts (avg age at dx - 73)

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2
Q

risk factors for bladder cancer

A
  • Cigarettes - 60% of new cases
  • Industrial solvents - 15% of new cases
  • Chronic inflammation - UTIs, catheters, bladder stones
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3
Q

Epidemiology of bladder cancer

A

98% - epithelial cell malignancies

  1. 90% - urothelial cell carcinoma
  2. 7% - squamous cell carcinoma - chronic inflammation
    - Bladder stones
    - Prolonged catheter use
    - Chronic UTIs
    - Schistosomiasis
  3. 2% - adenocarcinomas
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4
Q

s/s of bladder cancer

A
  1. Hematuria (85-90%)
    - Micro or gross, intermittent or chronic
    - Often painless
  2. +/- irritative voiding (depending on size, location)
    - Many pts - no major s/s in early stages!
  3. Weight loss possible
  4. Large - may see abdominal mass
  5. Metastatic - hepatomegaly, LAN +/- lymphedema
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5
Q

lab findings of bladder cancer

A
  1. Hematuria (gross/micro)
    - +/- pyuria, anemia
  2. If obstruction - signs of AKI
  3. Urine cytology - abnormal shed epithelial cells
    - 80-90% sensitive in higher grade/stage
    - 50% sensitive in noninvasive or well-differentiated
  4. Urine biomarkers - new; not preferred over cystoscopy
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6
Q

imaging and diagnostic for bladder cancer

A
  1. Imaging
    - CT, MRI or US may show mass within bladder
    - “Filling defect”
  2. Cystoscopy w/ bx - gold standard
    - Local anesthesia - can ID mass within the bladder
    - Can perform local resection (regional or total anesthesia)
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7
Q

tx for bladder cancer

A
  1. 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
  2. Invasive (T2 +) - radical cystectomy, urinary diversion
    - +/- chemotherapy, immunotherapy, radiation
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8
Q

prognosis for bladder cancer

A
  1. Superficial ,5-year survival - 81%
    - 50-80% are superficial
  2. Invasive, 5-year survival - 50-75%
  3. Metastatic (T4) - long-term survival is rare
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9
Q

repeated urination into clothing or bedding
what is this term?

A

enuresis

Some sources - only applies if child is 5+ years old
May be associated with neurodevelopmental problems

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10
Q

no other LUTS and no history of bladder disorders
what is this term? (for Nocturnal Enuresis)

A

Monosymptomatic enuresis

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11
Q

urination occurring specifically during bedtime/sleeping hours
what term is this

A

nocturnal enuresis

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12
Q

2 types of nocturnal enuresis

A
  1. Primary - usually in young children < 5-6 years old; have never achieved urinary continence
  2. Secondary - patients who previously were fully continent for 6+ months
    - Often associated with a stressful
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13
Q

who MC has nocturnal enuresis

A

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

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14
Q

Tx for nocturnal enuresis before age ___ is usually not recommended!

A

5

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15
Q

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?

A

nocturnal enuresis

  1. Investigate for other conditions
    - Polydipsia - DM, DI, primary polydipsia
    - Infections - UTI, pinworms
    - Other causes - CKD, bladder disease, constipation, seizures
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16
Q

what can delineate timing, frequency and severity for nocturnal enuresis

A

voiding diaries

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17
Q

diagnostics for nocturnal enuresis

A

as needed to rule out other causes

  1. Infections, emotional distress, diabetes, epilepsy, etc.
  2. UA - generally indicated for most pts
  3. US - can help look for anatomic abnormalities
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18
Q

tx for nocturnal enuresis

A
  1. 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
  2. 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)
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19
Q

etiology of interstitial cystitis

A

Unknown

  • Possible allergic response, inflammatory/autoimmune, abnormal epithelium, abnormal sensorineural response
  • possibly several diseases with similar sx
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20
Q

Epidemiology of Interstitial Cystitis

A
  • MC women (5:1)
  • 18-40 per 100,000 patients
  • MC diagnosed in 40s or later
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21
Q

risk factors for interstitial cystitis

A
  1. Associated w/ chronic pain syndromes (IBS, fibromyalgia)
  2. Certain foods/drinks may trigger
    - alc, caffeine, citrus, spicy
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22
Q

presentation + labs for interstitial cystitis

A
  1. 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
  2. labs - normal
    - UA
    - Urine C&S
    - Urine cytology
    - Urodynamics
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23
Q

imaging for Interstitial Cystitis

A
  1. US - Postvoid residual (PVR) to rule out urinary retention
  2. Cystoscopy - helps rule out bladder CA
    - May have findings associated with IC
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24
Q

how does the AUA diagnose interstitial cystitis

A
  • 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
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25
Q

what interventions can be used for interstitial cystitis

A
  1. Cystoscopy - Not required to make dx
    - Can help r/o other etiologies
  2. Hydrodistension - improves s/s in 20-30%
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26
Q

Cystoscopy findings associated with IC:

A
  1. Hunner’s ulcers/lesions (only in
    5-10% of pts)
  2. Glomerulations (nonspecific - also seen
    in 45% of healthy pts)
  3. Increased mast cells on bx
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27
Q

Interstitial Cystitis - Treatment

A

Goal - No cure - symptomatic relief
- sx may spontaneously improve
- Pt education and psychosocial support significantly help

  1. First Line - Lifestyle modifications/Self care
  2. Second Line - Oral meds
    - TCAs - amitriptyline - 1st line rx
    - Antihistamines - hydroxyzine
    - CCBs - nifedipine
    - Pentosan polysulfate sodium (PPS)
  3. Invasive therapies
    - Hydrodistension
    - Electrocauterization of Hunner lesions (if present)
    - Intravesical lidocaine, heparin, or dimethyl sulfoxide (DMSO)
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28
Q

Only drug FDA-approved for tx of IC

A

pentosan polysulfate sodium (PPS); Elmiron

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29
Q

MOA of pentosan polysulfate sodium (PPS); Elmiron

A

May improve glycosaminoglycan layer over urothelium

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30
Q

SE of pentosan polysulfate sodium (PPS); Elmiron

A
  1. 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
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31
Q

CI with pentosan polysulfate sodium (PPS); Elmiron

A

allergy to drug or to heparin or LMWH

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32
Q

DDI with pentosan polysulfate sodium (PPS); Elmiron

A

anticoagulants/antiplatelets (￪ bleeding)

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33
Q

what tx for Interstitial Cystitis is for refractory cases (more SE and/or ? efficacy)

A

Botulinum injections to detrusor muscle
Sacral neuromodulation
Cystectomy with urinary diversion (last resort)

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34
Q

adjunct tx for interstitial cystitis

A

often not used alone; CI in renal insuff

  1. Phenazopyridine (Azo) - short-term tx only!
  2. Methenamine (Hiprex) - urine antimicrobial (metabolizes to formaldehyde)
35
Q

MCC of urethral stricture

A

(Numerous)

  1. Iatrogenic (surgery, catheters) - 45% of all cases
  2. Idiopathic (developed countries)
36
Q

urethral stricture is MC in who?

A

men
Can be diagnosed in any age, including children

37
Q

risk factors for urethral stricture

A

Hx of GU surgery or instrumentation
Hx of pelvic trauma or irradiation
Hx of GU infection or cancer

38
Q

s/s of urethral stricture

A
  1. 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
39
Q

labs and imaging for urethral stricture

A
  1. Labs - often normal UA/UC (unless infection present)
  2. 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
40
Q

tx for urethral stricture

A
  1. Indications for Tx - recurrent UTIs, problematic sx, urinary retention, high PVR, bladder stones
    - May not need tx if asx
  2. Minimally Invasive - urethral dilation, urethrotomy
    - MC initial therapy
    - high rates of recurrence after tx
  3. Reconstruction - urethroplasty +/- replacement graft
    - Consider effects on erectile function
  4. Urinary Diversion - suprapubic catheter, perineal urethrostomy, permanent urinary diversion
41
Q

cause of urethral prolapse

A

protrusion of the distal urethra through the external urethral meatus

  • Malformation of the urethra
  • Weak pelvic floor structures
42
Q

urethral prolapse is MC in who and when?

A

women
Ages - prepubertal (avg age - 4 y/o), postmenopausal

43
Q

risk factors for urethral prolapse

A

Chronically increased intra-abdominal pressure
Post-menopausal status
Traumatic vaginal delivery

44
Q

s/s of urethral prolapse

A

vary depending on age of patient!

  1. 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
  2. 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
45
Q

labs and imaging for urethral prolapse

A
  1. Labs - may see hematuria, signs of UTI
  2. 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
46
Q

tx for urethral prolapse

A

Medical Therapy

  1. Prepubertal - sitz baths, topical antibiotics, topical estrogen
    - Management of comorbid/predisposing disease
  2. Postmenopausal - sitz baths, topical estrogen cream, antibiotics
  3. Not recommended if significant necrosis, thrombosis or bleeding

Surgical Therapy - better outcomes if done early

  1. Manual reduction and urethral cath for 1-2 days
    - High recurrence rates
  2. Ablative therapy - not commonly used
  3. Excision of mucosa with short-term catheterization - MC method
    - May need long-term estrogen cream tx if postmenopausal
47
Q

bladder can store up to ___ cc of urine
no stretch to detrusor muscle

A

200-300

48
Q

what part of the brain stimulates the sympathetics and somatic nerves?
how does that affect the bladder?

A

Pons
- sympathetics - Inhibit (relax) detrusor muscle, Closes internal urethral sphincter
- somatic - Contraction of external urethral sphincter

49
Q

bladder physiology of Micturition

A
  1. More urine fills bladder
  2. Detrusor/Trigone stretch → signal to Pons
  3. Inhibits SYMPATHETICS and SOMATICS
  4. Activates PARASYMPATHETICS
    - Stimulates (contracts) detrusor
    - Relaxes (opens) internal urethral sphincter
50
Q

What if it’s not the time or place to urinate?

A
  • Voluntary control overrides involuntary pathway!
  • Cerebral cortex → pudendal nerve → contraction of the external urethral sphincter
51
Q

causes of transient urinary incontinence

A
  1. 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
52
Q

risk factors of urinary incontinence

A

Female gender
Advanced age
Obesity
Parity/Pregnancy
Prostate disease
Neurologic disease
Immobility

53
Q

causes of established incontinence

A

Established - Harder to treat; often not reversible/curable
- d/t disorder of bladder or surrounding structures

  1. Urge Incontinence
    - Detrusor overactivity
  2. Stress Incontinence
    - Urethral sphincter incompetence
  3. Overflow Incontinence
    - Detrusor underactivity
  4. Mixed Incontinence
    - Multiple causes
  5. Functional Incontinence
    - Problems thinking/speaking/moving
54
Q

meds that cause incontinence

A
  1. Alcohol
  2. Sedatives/Hypnotics
    - BZDs
    - Insomnia meds
  3. Alpha-adrenergic drugs
    - Blockers - women
    - Agonists - men
  4. Diuretics
  5. Anticholinergics
    - Antihistamines
    - Antipsychotics
    - Antidepressants
  6. Narcotics
  7. CCB
55
Q

overactivity of detrusor muscle

  • “Overactive bladder”
  • Often idiopathic
  • Associated with Parkinson’s, bladder stones, tumor, prostate disease, UTI

what type of incontinence

A

urge

56
Q

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?

A

urge
More common in elderly pts

57
Q

cause of stress incontinence

A

Urethral incompetence

  1. Hypermobility of urethra - weak pelvic support
    - Childbirth, ￬ estrogen, trauma, prostate surgery, hysterectomy
    - Men - radical prostatectomy
  2. Intrinsic sphincter deficiency
58
Q
  1. involuntary leakage with increase in “pressure”
    - coughing, laughing, sneezing, lifting heavy objects

what type of incontinence

A

stress
MC younger women than urge incontinence

59
Q

cause of overflow incontinence

A
  1. 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.)
60
Q

frequent involuntary leakage of small amounts of urine,
Nocturia, weak urinary stream, sensation of bladder fullness

this presentation is for what type dx?

A

overflow incontinence
Should rule out bladder outlet obstruction

61
Q

cause and presentation of mixed incontinence

A
  1. cause - combo of causes
    - Often stress + urge incontinence
  2. Presentation - combo of sx from other forms of incontinence
    - Very common - especially in women
62
Q

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?

A

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

63
Q

Why is urinary incontinence important?

A

Social stigma - restricted activities, depression
Medical complications - skin breakdown, UTIs
Institutionalization - significantly increases likelihood of pt being placed in a nursing home

64
Q

hx for when asking about incontinence

A
  1. “Do you have a problem with urine leakage or bladder accidents?”
  2. Triggering Factors
  3. Duration, frequency, severity
  4. hx of GU tract symptoms, disease, surgery
  5. Bladder/voiding diary
  6. Medication review
  7. 3 Ps
    - Position - (setting) - supine, sitting, standing
    - Protection - pads/pantiliners per day, wetness of pads
    - Problem - impact on quality of life
65
Q

PE for urinary incontinence

A
  1. General Exam - evaluate for causes or exacerbating factors
    - Abdominal, rectal, pelvic
    - Mobility, mental status, fluid status (CV)
  2. Bladder Stress Test - have pt with full bladder stand and cough
    - Instant leakage - stress incontinence
    - Delayed leakage - urinary bladder contraction stimulated by coughing
66
Q

diagnostic studies/findings for incontinence

A
  1. UA - screen for UTI, hematuria
    - Cx and/or urine cytology if indicated
  2. 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
  3. 2nd-line - cystoscopy, urodynamics, other imaging - as indicated for suspected etiology
67
Q

stress incontinence tx

A
  1. Lifestyle Modifications
    - Limit caffeine and alcohol
    - Control amount and timing of fluid intake
    -Bladder training (timed voiding)
    - Adult urinary pads/protective garments
  2. Pelvic floor muscle exercises (Kegels)
    - May take up to 6 wks to see benefit
  3. Pessaries - if d/t bladder prolapse in women
  4. Injections - urethral bulking agents
  5. meds - duloxetine (off label)
  6. Surgery - often last resort - most effective
  7. Emerging/Specialty Treatments
    - Intravesical balloon
    - Electrical stimulation of pelvic floor/Electroacupuncture
    - Pulsed magnetic stimulation
68
Q

urge incontinence tx

A
  1. Lifestyle Modifications
    - Limit caffeine and alcohol
    - Control amount and timing of fluid intake
    - Bladder training (timed voiding)
    - Adult urinary pads/protective garments
  2. Pelvic floor muscle exercises (Kegels)
    - May take up to 6 weeks to see benefit
    - Can help improve control when urge to urinate occurs
  3. meds - anticholinergics (antimuscarinics) are traditional mainstay
    - Others - Beta-3 adrenergic agonists, TCAs, alpha-blockers (men)
69
Q

MOA of Anticholinergics

A

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
70
Q

SE of Anticholinergics

A

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
71
Q

CI of anticholinergics

A

gastric retention, glaucoma

72
Q

DDI with anticholinergics

A

other anticholinergics, potassium chloride

73
Q

6 Anticholinergics drugs

A
  1. Oxybutynin (Ditropan)
  2. Darifenacin (Enablex)
  3. Solifenacin (Vesicare)
  4. Tolterodine (Detrol)
  5. Fesoterodine (Toviaz)
  6. Trospium (Sanctura)

All have equal efficacy on paper - individual pt responses vary!
Oxybutinin (Ditropan) - often most commonly prescribed due to cost

74
Q

mirabegron

A

Beta-3 Agonists

75
Q

vibegron

A

Beta-3 Agonists

76
Q

MOA of Beta-3 Agonists

A

For pts who cannot tolerate anticholinergic therapy for OAB
May also be used as add-on to anticholinergics in severe/refractory OAB

77
Q

SE of Beta-3 Agonists

A

HTN, tachycardia, dry mouth, constipation, UTI

  • May be a little less problematic for SE than anticholinergics
  • Often not prescribed first due to cost
78
Q

DDi with Beta-3 Agonists

A

anticholinergics, QT-prolonging drugs

79
Q

CI with Beta-3 Agonists (Canada)

A

severe uncontrolled HTN; pregnancy

80
Q

tx for urge incontinence

A
  1. Injection - Botox into detrusor muscle
    - Less anticholinergic SE, more urinary retention
  2. Neuromodulation
    - Tibial nerve stimulation
    - Sacral neuromodulation
  3. Surgery - typically last resort
    - Cystoplasty
    - Urinary diversion
    - Suprapubic catheter
81
Q

tx for overflow incontinence

A
  1. Lifestyle Modifications
    - Limit caffeine and alcohol
    - Control amount and timing of fluid intake
    - Bladder training (timed voiding)
    - Adult urinary pads/protective garments
  2. Treatment of underlying cause
    - Surgical decompression
    - Management of related conditions (DM, BPH)
    - abx if UTI
  3. Neuromodulation - sacral nerve stimulation
    - High rate of device failure
  4. Indwelling catheter - last resort
    - Risk of increased UTIs, urethral scarring
    - Consider suprapubic catheter, intermittent catheterization
82
Q

tx for mixed incontinence

A
  1. Lifestyle Modifications
    - Limit caffeine and alcohol
    - Control amount and timing of fluid intake
    - Bladder training (timed voiding)
    - Adult urinary pads/protective garments
  2. Pelvic floor muscle exercises (Kegels)
    - May take up to 6 weeks to see benefit
  3. Medication - for urge incontinence
  4. Refractory cases
    - Botox injection of detrusor muscle
    - Surgical placement of sling
83
Q

tx for functional incontinence

A
  1. 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
  2. Treatment of Underlying
    - Evaluate etiology of delirium (if present)
    - Mobility aids
    - PT to improve ambulation

GU: Clin Med IIA (13 decks)

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