Functional Urology Flashcards
Pollakisuria?
Increased daytime frequency
What should an interview of a patient with LUTS contain?
- General health status
- Identify main complaint
- Get a full picture of all of the patients micturial complaints
- Explore pelvic function (sexual, digestive, pain)
- Explore domains that can interfere with micturation (neurological, diabetes, heart disease etc)
- Symptoms quantification
- Impact on QOL and patients expectations
Give examples of storage symptoms:
Urinary incontinence
Urgency
Frequency
Nocturia
Give examples of Voiding symptoms:
Poor urinary stream Hesitancy Straining Intermittent flow Urinary retention
What should a physical examination of a patient with LUTS include?
General physical
Abdominal and lumbar examination
Pelvic examination
Sacral neurological
Prolapse stage classification
Stage 0: Stage 1: upper half of vagina Stage 2: lower half of vagina Stage 3: outside of vagina Stage 4: inversion of vagina
What tools can be used to evaluate a patient with LUTS?
Bladder diary
Pad test
Uroflow
PVR (post voidal residuary)
Urine analysis/blood analysis
Abdo-pelvis US or CT
Give examples of neurological diseases that can be suspected with LUTS as a signal symptom:
MS
Normal pressure hydrocephaly
Multiple system atrophy (MSA)
Occult dysraphisms
For what period of time should a voiding/bladder diary be completed?
3 days
What is the limitation of Uroflowmetry?
It is unfit for diagnosing obstruction
How long does a normal mictation take?
20-25 s
What is a normal Qmax as measured in Uroflowmetry for a young patient?
> 22-25
What is the percentage of women with symptoms suggesting stress incontinence that actually have detrusor overactivity?
11-16%
What is the percentage of women with storage LUTS that actually have stress incontinence?
up to 22%
When should invasive Urodynamic studies (UDS) be performed?
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
Definition of Overactive Bladder syndrome:
Urgency
With or withour urgency incontinence
Usually with frequency
and nocturia
IF no proven infection or other obvious pathology
What factors increas the prevalence of OAB?
Age
Diabetes
Rising BMI
Common comorbidities in patients with OAB symptoms:
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%
What is the effect of weight loss on UI (urinary incontinence) symptoms?
weight loss >5% gave 50% reduction in UI
What is the effect of OAB diagnosis and medical treatment on elderly?
improves mental scores
quality of life
activity
with UI there is a greater risk for falls and fractures
When should a pad test NOT be used?
when quantification of UI is required
What is the first line medical treatment for OAB?
Antimuscarinic drugs (Solifenacin, Tolterodin)
What is the second line medical treatment for OAB?
Mirabegron (Betmiga)
OBS check blood pressure
When should antimuscarin treatment for OAB be used with caution?
Elderly patients
What lifestyle advice/behavioural approaches can be tried for OAB?
Regular voiding schedule
Pelvic floor muscle exercises
voiding by abdominal straining
triggered reflex voiding
intermittent self-catheterisation
What are some more invasive treatments for OAB when drugs have failed?
Neurostimulation
(peripheral tibial or sacral)
Augmentation cystoplasty
Urinary deviation
What are common side effects from Beta 3 agonists (Mirabegron)?
Hypertension
UTI
nasopharyngitis
Headache
What are common side effects from antimuscarins (Tolterodine, Solifenacin)?
Dry mouth
Hypertension
UTI
What symptoms will most likely lessen with antimuscarinic drugs?
Urgency
Nocturia
Will not affect
Incontinence and Frequency as much
What nerves affect the bladder?
Th10-L2 Hypogastric nerve (bladder)
S2-S4 Pelvic nerve (bladder)
Pudendal nerve (sfinkter)
Tibial nerve inhibits pudendal nerve at S2-S4 level
What did the Rosetta trial study?
Sacral neuromodulation vs Botulinum toxin
higher risk for UTI and intermittent self catherisation with Botox
How effective can Percutaneous Tibial Nerve Stimulation be compared to placebo?
PTNS ~55%
placebo ~20%
What is obligatory exams for a Stress Urinary Incontinence diagnosis?
Cough test
Urinalysis
Bladder diary
Optional:
cystoscopy
urodynamics
How do you perform a cough test?
Full bladder (200-400 cc)
in a gynecologial chair
speculum
visualize meatus
cough forcefully 4 times
What is ureteral vaginal dystopy?
Congenital where vagina and urether is one
How do you classify Stress urinary incontinence?
Classification by McGuire
McGuire Type 0:
neg cough test
typical symptoms
McGuire Type 1:
pos cough test
no significant urethral hypermobility
McGuire Type 2:
pos cough test
significant urethral hypermobility
cystocele
McGuire Type 3:
fixed urethra
intrinsic sphincter insuficiency
low leak point pressure
Treatment options for better sphincter function in patients with Stress urinary incontincence:
Kegels exercise
Duloxetine (SNRI) 80-120 mg
Bulking agents
Artificial urinary sphincters
Treatment options for better pressure transmission in patients with Stress urinary incontincence:
Burch colposuspention:
At surgery the bladder outlet is resupported by 6 permanent sutures suspending the vagina from the pelvic side wall
Treatment options for better bladder neck function in patients with Stress urinary incontincence:
Pubovaginal Fascial slings
Treatment options for better mid-urethral support in patients with Stress urinary incontincence:
mid-urethral slings:
retropubic
transobturator
minislings
What kind of TVT has the best cure rate?
Retropubic tapes
highest risk of bleeding and bladder perforations
What kind of TVT has the least UTI:s and bladder perforations?
Transobturator tapes
BUT gives more voiding LUTS and pain
How well does bulking agents work in stress urinary incontinence?
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
Complications of TVT-surgery:
urethral trauma
bladder perforation
bleeding
perforation of lateral fornix of vagina
obstruction
urgency
infection
erotions to bladder/vagina/urethra
pain
dyspareunia
What can you do if the sling causes obstruction?
Loosen it (ideal timing 10-14 days postop) Cut it
What is gold standard for surgical treatment of Stress urinary incontinence?
Synthetic mid-urethral slings
How many men require pads 2 years after a radical prostatectomy?
28%
How many men undergo surgical treatment for urinary incontinence caused by a prostatectomy?
6-9%
Risk factors for urinary incontinence after prostatectomy:
Age >75 years
BMI > 35
prior bladder neck procedures
larger prostate weight
Factors predicting surgery for incontinence after prostatectomy:
patients age
radiotherapy after surgery
surgeon volume
What should you do with an elderly patient that has asymptomatic bacteriuria and urinary incontinence?
Do NOT treat UTI
What is the role of Pelvic floor muscle training (PFMT) in patients that undergo a radical prostatectomy?
It appears to speed recovery of continence after surgery. No evidence to support pre-operative PFMT
If a patient has moderate/severe urinary incontinence. What different containment regiments can be considered?
Pads
Clamps
Catheters
What is the role of bulking agents for patients who has incontinence after a prostatectomy?
There is weak or no evidence for its use
What is the elevation test?
TRUS can show an elevation of the sphincteric level (positive test)
Who is the ideal male sling patient?
Not irradiated
No previous surgery for urethral stricture/incontinence
Mild/moderate incontinence
Cystoscopy without strictures/bladder neck contracture
Positive elevation test
What is gold standard for surgical treatment of moderate-to-severe incontinence after prostatectomy?
AMS 800
Artificial urinary sphincter
Definition of Chronic Pelvic Pain (CPP):
- 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
Causes of Chronic Pelvic Pain (CPP):
Gastrointestinal 37%
Urinary 31%
Reproductive 20%
Musculosceletal/other 12%
Definition of Bladder Pain syndrome (BPS):
- 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
What investigation is needed to diagnose Bladder Pain Syndrome (BPS)?
RULE OUT OTHER DISEASE urine culture uroflowmetry cystoscopy Micturation diary phenotyping VAS and questionairres
How do you treat Hunner’s lesions?
Hydrodistention of the bladder 80-100 cm H2O
Resection of lesions
Fulguration (burning with laser)
Physical therapy for Bladder Pain Syndrome (BPS)?
Trigger points and connective tissure manipulation
Avoid pelvic floor strengthening exercises
+ stress management
What kind of oral and intravesical treatments are recommended for Bladder Pain Syndrome (BPS)?
Amitriptyline (Tricyclic antidepressant)
Pentosane Polysulphate Sodium PPS
Hydrozine (against anxiety)
DMSO (coctail: lidocain, sodium bicarbonate, intravesical PPS)
Hydrodistention
Botulinum toxin A
Definition of nocturia
waking up 1 or more times to void
each time preceeded and followed by sleep
Definition of polyuria
> 40 ml/kg body weight
Nocturnal polyuria:
> 33% during the night
> 20% age <35
Can nocturia be treated with anticholinergics?
NO,
only if it is associated with urgency
What is important in taking the history of a patient with Nocturia?
LUTS General medical Surgical Sleep disturbances Medications Fluid intake behavior
What is the patophysiology behind nocturia in patients with diabetes?
hyperglycemia –>osmotic diuresis
How high is the prevalence of nocturnal polyuria in patients with nocturia?
76-88%
How do you treat nocturnal polyuria?
Desmopressin CPAP compression stockings reduce fluid intake physical activity
What are common symptoms of urethral diverticula?
Palpable mass in vagina
Recurrent UTI
Frequency
How do you diagnose urethral diverticula?
Vaginal exam
Ultrasound
MRI in selected cases
What is the most common cause of Urogenital fistulas?
Obstetric trauma 95%
Surgical
Oncological/radiotherapy
Traumatic
How do you diagnose a urogential fistula?
Direct visualization
cystoscopy
MRI
CT
What are the benefits of vaginal approach in operating a urogenital fistula?
90,8 success rate
avoids laparotomy, splitting of the bladder
recovery is shorter
less morbidity, blood loss and bladder irritability
What is the successrate of abdominal approach in operating a urogenital fistula?
83,9%
What determines the approach in operating a urogenital fistula?
The training and experience of the surgeon
In fistula surgery, should one trim the fistula edges?
It does not influence the outcome
What surgical should be used for post radiation fistulas?
repair with flaps
How is Detrusor Underactivity diagnosed?
urodynamically based on pressure-flow
Causes of Underactive bladder:
Bladder outlet obstruction
Aging
Diabetes
Neurologic disorders
Injury to the spinal cord/ cauda equina/ pelvic plexus
Infectious neurologic problems
How do your treat Under Active Bladder (UAB)?
Physiotherapy Drugs -α-adrenoceptor antagonists -muscarin receptor agonists -achetylcholinesterase
What part of the anatomy does the Pelvic nerve (S2-S3) affect?
the ureter
detrusor muscle
(in the voiding phase)
What part of the anatomy does the Hypogastric nerve (Th10-L4) affect?
Stretch receptors
filling phase
What part of the anatomy does the Pudendal nerve (S2-S4) affect?
Sphinkter
filling and voiding phase
Possible effect on Urinary Function if it is a “brain problem”:
Unaware of bladder filling and emptying
“voiding right, timing wrong”
Possible effect on Urinary Function if it is a “brain/upper spinal cord problem”:
affects co-ordination/relaxation
autonomic dysreflexia
Possible effect on Urinary Function if it is a “lower spinal cord/ peripheral nerves problem”:
retention, sphincter denervation
poor compliance
What are the symptoms of a Upper motor neuron lesion?
Overactive bladder
Overactive sphincter
What are the symptoms of a Lower motor neuron lesion?
Underactive bladder
Underactive sphincter
What level is tested with the Cremaster reflex?
L1-L2
What level is tested with the bulbocavernosus-reflex?
L5-S5
What level is tested with the knee reflex?
L2-L4
What level is tested with the ankle reflex?
L3-S2
What level is tested with the anal reflex?
S4-S5
What does a positive Bulbocavernosus-reflex correlate with?
a suprasacral lesion
detrusor-sphincter/bladder neck-dyssynergia
What does a negative Bulbocavernosus-reflex correlate with?
a defect in the sacral reflex arc:
in the pudendal nerve
segment L5-S5
What is autonomic dysreflexia?
and how do you treat it?
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
What is the prevalence of neurogenic bladder in MS-patients after 10 years?
80%
What is NLUTD?
nerogenic lower urinary tract dysfunction
What is the prevalence of neurogenic bladder in parkinsson-patients at onset and after 5 years?
onset 30%
after 5 years 70%
What is more important, cleanliness och frequency of Intermittent self catheterization?
Frequency
How do you treat detrusor overactivity (NDO)?
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
