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08. Piso pelvico y Funcional (1403) > Functional Urology > Flashcards

Functional Urology Flashcards

1
Q

Pollakisuria?

A

Increased daytime frequency

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2
Q

What should an interview of a patient with LUTS contain?

A
  1. General health status
  2. Identify main complaint
  3. Get a full picture of all of the patients micturial complaints
  4. Explore pelvic function (sexual, digestive, pain)
  5. Explore domains that can interfere with micturation (neurological, diabetes, heart disease etc)
  6. Symptoms quantification
  7. Impact on QOL and patients expectations
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3
Q

Give examples of storage symptoms:

A

Urinary incontinence
Urgency
Frequency
Nocturia

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4
Q

Give examples of Voiding symptoms:

A 
Poor urinary stream
Hesitancy
Straining
Intermittent flow
Urinary retention
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5
Q

What should a physical examination of a patient with LUTS include?

A

General physical
Abdominal and lumbar examination
Pelvic examination
Sacral neurological

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6
Q

Prolapse stage classification

A 
Stage 0: 
Stage 1: upper half of vagina
Stage 2: lower half of vagina
Stage 3: outside of vagina
Stage 4: inversion of vagina
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7
Q

What tools can be used to evaluate a patient with LUTS?

A

Bladder diary
Pad test
Uroflow
PVR (post voidal residuary)

Urine analysis/blood analysis
Abdo-pelvis US or CT

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8
Q

Give examples of neurological diseases that can be suspected with LUTS as a signal symptom:

A

MS
Normal pressure hydrocephaly
Multiple system atrophy (MSA)
Occult dysraphisms

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9
Q

For what period of time should a voiding/bladder diary be completed?

A

3 days

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10
Q

What is the limitation of Uroflowmetry?

A

It is unfit for diagnosing obstruction

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11
Q

How long does a normal mictation take?

A

20-25 s

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12
Q

What is a normal Qmax as measured in Uroflowmetry for a young patient?

A

> 22-25

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13
Q

What is the percentage of women with symptoms suggesting stress incontinence that actually have detrusor overactivity?

A

11-16%

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14
Q

What is the percentage of women with storage LUTS that actually have stress incontinence?

A

up to 22%

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15
Q

When should invasive Urodynamic studies (UDS) be performed?

A 
Stress incontinence vs urge incontinence
To understand persisting symptoms
Voiding LUTS when alpha-blockers failed
Refractory OAB
Neuropathic LUT functioning
ISD (intrinsic sphincter deficiency) vs urethral hypermobility
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16
Q

Definition of Overactive Bladder syndrome:

A

Urgency
With or withour urgency incontinence
Usually with frequency
and nocturia

IF no proven infection or other obvious pathology

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17
Q

What factors increas the prevalence of OAB?

A

Age
Diabetes
Rising BMI

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18
Q

Common comorbidities in patients with OAB symptoms:

A 
Anxiety/Depression 38%
Hypertension 33%
Dyslipidemia 29%
Constipation 28%
Cystitis 26%
Sleep apnea 14%
Diabetes 13%
Asthma 11%
Chronic pulmonary disease 10%
Enuresia 9%
IBS 8%
Vertebral problems 5%
Neurological disease 2%

NONE 12%

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19
Q

What is the effect of weight loss on UI (urinary incontinence) symptoms?

A

weight loss >5% gave 50% reduction in UI

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20
Q

What is the effect of OAB diagnosis and medical treatment on elderly?

A

improves mental scores
quality of life
activity

with UI there is a greater risk for falls and fractures

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21
Q

When should a pad test NOT be used?

A

when quantification of UI is required

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22
Q

What is the first line medical treatment for OAB?

A

Antimuscarinic drugs (Solifenacin, Tolterodin)

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23
Q

What is the second line medical treatment for OAB?

A

Mirabegron (Betmiga)

OBS check blood pressure

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24
Q

When should antimuscarin treatment for OAB be used with caution?

A

Elderly patients

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25
Q

What lifestyle advice/behavioural approaches can be tried for OAB?

A

Regular voiding schedule
Pelvic floor muscle exercises

voiding by abdominal straining
triggered reflex voiding
intermittent self-catheterisation

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26
Q

What are some more invasive treatments for OAB when drugs have failed?

A

Neurostimulation
(peripheral tibial or sacral)

Augmentation cystoplasty

Urinary deviation

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27
Q

What are common side effects from Beta 3 agonists (Mirabegron)?

A

Hypertension
UTI
nasopharyngitis
Headache

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28
Q

What are common side effects from antimuscarins (Tolterodine, Solifenacin)?

A

Dry mouth
Hypertension
UTI

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29
Q

What symptoms will most likely lessen with antimuscarinic drugs?

A

Urgency
Nocturia

Will not affect
Incontinence and Frequency as much

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30
Q

What nerves affect the bladder?

A

Th10-L2 Hypogastric nerve (bladder)
S2-S4 Pelvic nerve (bladder)
Pudendal nerve (sfinkter)

Tibial nerve inhibits pudendal nerve at S2-S4 level

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31
Q

What did the Rosetta trial study?

A

Sacral neuromodulation vs Botulinum toxin

higher risk for UTI and intermittent self catherisation with Botox

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32
Q

How effective can Percutaneous Tibial Nerve Stimulation be compared to placebo?

A

PTNS ~55%

placebo ~20%

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33
Q

What is obligatory exams for a Stress Urinary Incontinence diagnosis?

A

Cough test
Urinalysis
Bladder diary

Optional:
cystoscopy
urodynamics

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34
Q

How do you perform a cough test?

A

Full bladder (200-400 cc)

in a gynecologial chair
speculum
visualize meatus
cough forcefully 4 times

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35
Q

What is ureteral vaginal dystopy?

A

Congenital where vagina and urether is one

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36
Q

How do you classify Stress urinary incontinence?

A

Classification by McGuire

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37
Q

McGuire Type 0:

A

neg cough test

typical symptoms

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38
Q

McGuire Type 1:

A

pos cough test

no significant urethral hypermobility

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39
Q

McGuire Type 2:

A

pos cough test
significant urethral hypermobility
cystocele

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40
Q

McGuire Type 3:

A

fixed urethra
intrinsic sphincter insuficiency
low leak point pressure

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41
Q

Treatment options for better sphincter function in patients with Stress urinary incontincence:

A

Kegels exercise
Duloxetine (SNRI) 80-120 mg
Bulking agents

Artificial urinary sphincters

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42
Q

Treatment options for better pressure transmission in patients with Stress urinary incontincence:

A

Burch colposuspention:

At surgery the bladder outlet is resupported by 6 permanent sutures suspending the vagina from the pelvic side wall

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43
Q

Treatment options for better bladder neck function in patients with Stress urinary incontincence:

A

Pubovaginal Fascial slings

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44
Q

Treatment options for better mid-urethral support in patients with Stress urinary incontincence:

A

mid-urethral slings:
retropubic
transobturator
minislings

45
Q

What kind of TVT has the best cure rate?

A

Retropubic tapes

highest risk of bleeding and bladder perforations

46
Q

What kind of TVT has the least UTI:s and bladder perforations?

A

Transobturator tapes

BUT gives more voiding LUTS and pain

47
Q

How well does bulking agents work in stress urinary incontinence?

A

provides short-time improvement (3 months)
repeat injections often required
less effective than slings

higher risk or urinary retention with transperitoneal route vs transurethral route

48
Q

Complications of TVT-surgery:

A

urethral trauma
bladder perforation
bleeding
perforation of lateral fornix of vagina

obstruction
urgency

infection
erotions to bladder/vagina/urethra

pain
dyspareunia

49
Q

What can you do if the sling causes obstruction?

A 
Loosen it (ideal timing 10-14 days postop)
Cut it
50
Q

What is gold standard for surgical treatment of Stress urinary incontinence?

A

Synthetic mid-urethral slings

51
Q

How many men require pads 2 years after a radical prostatectomy?

A

28%

52
Q

How many men undergo surgical treatment for urinary incontinence caused by a prostatectomy?

A

6-9%

53
Q

Risk factors for urinary incontinence after prostatectomy:

A

Age >75 years
BMI > 35
prior bladder neck procedures
larger prostate weight

54
Q

Factors predicting surgery for incontinence after prostatectomy:

A

patients age
radiotherapy after surgery
surgeon volume

55
Q

What should you do with an elderly patient that has asymptomatic bacteriuria and urinary incontinence?

A

Do NOT treat UTI

56
Q

What is the role of Pelvic floor muscle training (PFMT) in patients that undergo a radical prostatectomy?

A

It appears to speed recovery of continence after surgery. No evidence to support pre-operative PFMT

57
Q

If a patient has moderate/severe urinary incontinence. What different containment regiments can be considered?

A

Pads
Clamps
Catheters

58
Q

What is the role of bulking agents for patients who has incontinence after a prostatectomy?

A

There is weak or no evidence for its use

59
Q

What is the elevation test?

A

TRUS can show an elevation of the sphincteric level (positive test)

60
Q

Who is the ideal male sling patient?

A

Not irradiated
No previous surgery for urethral stricture/incontinence
Mild/moderate incontinence
Cystoscopy without strictures/bladder neck contracture
Positive elevation test

61
Q

What is gold standard for surgical treatment of moderate-to-severe incontinence after prostatectomy?

A

AMS 800

Artificial urinary sphincter

62
Q

Definition of Chronic Pelvic Pain (CPP):

A
  • Chronic or persistent pain percieved in structures related to the pelvis
  • often associated with neg cognitive, behavioural, sexual and emotional consequences
  • severe enough to cause functional disability and require medical or surgical treatment
  • No evidence of infection/inflammation
  • At least 6 months duration
63
Q

Causes of Chronic Pelvic Pain (CPP):

A

Gastrointestinal 37%
Urinary 31%
Reproductive 20%
Musculosceletal/other 12%

64
Q

Definition of Bladder Pain syndrome (BPS):

A
  • Pain/pressure/discomfort percieved related to bladder and increasing with bladder content
  • Located suprapubically, sometimes radiating
  • Relieved by voiding
  • Aggravated by food or drink

NOT associated with incontinence

65
Q

What investigation is needed to diagnose Bladder Pain Syndrome (BPS)?

A 
RULE OUT OTHER DISEASE
urine culture
uroflowmetry
cystoscopy
Micturation diary
phenotyping
VAS and questionairres
66
Q

How do you treat Hunner’s lesions?

A

Hydrodistention of the bladder 80-100 cm H2O
Resection of lesions
Fulguration (burning with laser)

67
Q

Physical therapy for Bladder Pain Syndrome (BPS)?

A

Trigger points and connective tissure manipulation
Avoid pelvic floor strengthening exercises

+ stress management

68
Q

What kind of oral and intravesical treatments are recommended for Bladder Pain Syndrome (BPS)?

A

Amitriptyline (Tricyclic antidepressant)
Pentosane Polysulphate Sodium PPS
Hydrozine (against anxiety)

DMSO (coctail: lidocain, sodium bicarbonate, intravesical PPS)
Hydrodistention
Botulinum toxin A

69
Q

Definition of nocturia

A

waking up 1 or more times to void

each time preceeded and followed by sleep

70
Q

Definition of polyuria

A

> 40 ml/kg body weight

71
Q

Nocturnal polyuria:

A

> 33% during the night

> 20% age <35

72
Q

Can nocturia be treated with anticholinergics?

A

NO,

only if it is associated with urgency

73
Q

What is important in taking the history of a patient with Nocturia?

A 
LUTS
General medical
Surgical
Sleep disturbances
Medications
Fluid intake behavior
74
Q

What is the patophysiology behind nocturia in patients with diabetes?

A

hyperglycemia –>osmotic diuresis

75
Q

How high is the prevalence of nocturnal polyuria in patients with nocturia?

A

76-88%

76
Q

How do you treat nocturnal polyuria?

A 
Desmopressin
CPAP
compression stockings
reduce fluid intake
physical activity
77
Q

What are common symptoms of urethral diverticula?

A

Palpable mass in vagina
Recurrent UTI
Frequency

78
Q

How do you diagnose urethral diverticula?

A

Vaginal exam
Ultrasound

MRI in selected cases

79
Q

What is the most common cause of Urogenital fistulas?

A

Obstetric trauma 95%

Surgical
Oncological/radiotherapy
Traumatic

80
Q

How do you diagnose a urogential fistula?

A

Direct visualization

cystoscopy
MRI
CT

81
Q

What are the benefits of vaginal approach in operating a urogenital fistula?

A

90,8 success rate

avoids laparotomy, splitting of the bladder
recovery is shorter
less morbidity, blood loss and bladder irritability

82
Q

What is the successrate of abdominal approach in operating a urogenital fistula?

A

83,9%

83
Q

What determines the approach in operating a urogenital fistula?

A

The training and experience of the surgeon

84
Q

In fistula surgery, should one trim the fistula edges?

A

It does not influence the outcome

85
Q

What surgical should be used for post radiation fistulas?

A

repair with flaps

86
Q

How is Detrusor Underactivity diagnosed?

A

urodynamically based on pressure-flow

87
Q

Causes of Underactive bladder:

A

Bladder outlet obstruction
Aging

Diabetes
Neurologic disorders
Injury to the spinal cord/ cauda equina/ pelvic plexus
Infectious neurologic problems

88
Q

How do your treat Under Active Bladder (UAB)?

A 
Physiotherapy
Drugs
-α-adrenoceptor antagonists
-muscarin receptor agonists
-achetylcholinesterase
89
Q

What part of the anatomy does the Pelvic nerve (S2-S3) affect?

A

the ureter
detrusor muscle
(in the voiding phase)

90
Q

What part of the anatomy does the Hypogastric nerve (Th10-L4) affect?

A

Stretch receptors

filling phase

91
Q

What part of the anatomy does the Pudendal nerve (S2-S4) affect?

A

Sphinkter

filling and voiding phase

92
Q

Possible effect on Urinary Function if it is a “brain problem”:

A

Unaware of bladder filling and emptying

“voiding right, timing wrong”

93
Q

Possible effect on Urinary Function if it is a “brain/upper spinal cord problem”:

A

affects co-ordination/relaxation

autonomic dysreflexia

94
Q

Possible effect on Urinary Function if it is a “lower spinal cord/ peripheral nerves problem”:

A

retention, sphincter denervation

poor compliance

95
Q

What are the symptoms of a Upper motor neuron lesion?

A

Overactive bladder

Overactive sphincter

96
Q

What are the symptoms of a Lower motor neuron lesion?

A

Underactive bladder

Underactive sphincter

97
Q

What level is tested with the Cremaster reflex?

A

L1-L2

98
Q

What level is tested with the bulbocavernosus-reflex?

A

L5-S5

99
Q

What level is tested with the knee reflex?

A

L2-L4

100
Q

What level is tested with the ankle reflex?

A

L3-S2

101
Q

What level is tested with the anal reflex?

A

S4-S5

102
Q

What does a positive Bulbocavernosus-reflex correlate with?

A

a suprasacral lesion

detrusor-sphincter/bladder neck-dyssynergia

103
Q

What does a negative Bulbocavernosus-reflex correlate with?

A

a defect in the sacral reflex arc:
in the pudendal nerve
segment L5-S5

104
Q

What is autonomic dysreflexia?

and how do you treat it?

A

Injury above Th6

Painful stimuli (bladder/bowel distention)–>
transmitted up the spinal cord—>
sympathetic reaction—->
The brain can not start the parasympathetic system to suppress the reaction–>
bradychardia and vasodilation

Treatment: Adrenergic blockade (nifedipine) sublingually

105
Q

What is the prevalence of neurogenic bladder in MS-patients after 10 years?

A

80%

106
Q

What is NLUTD?

A 
nerogenic
lower 
urinary
tract
dysfunction
107
Q

What is the prevalence of neurogenic bladder in parkinsson-patients at onset and after 5 years?

A

onset 30%

after 5 years 70%

108
Q

What is more important, cleanliness och frequency of Intermittent self catheterization?

A

Frequency

109
Q

How do you treat detrusor overactivity (NDO)?

A

Oral drugs: anticholinergics (second line in combination with Mirabegron)
Non Invasive Neuromodulation TNS (posterior tibial nerve stimulation)
Botulinum A-injections
Invasive Neuromodulation SNS
Bladder augmentation
Sacral Deafferentation
Urinary diversion

08. Piso pelvico y Funcional (1403) (11 decks)

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