Genitourinary Flashcards
1
Q
Issues Common to Pelvic malignancy
A
- Pain
- Often has a neuropathic component
- Important to prevent constipation (limited pelvic capacity) - Skin irritation
- Fistula formation if the tumour invades into bowel or bladder
- Chronic discharge of stool or urine from the vagina can be an issue - skin hygiene and barrier creams, also consider use of a colostomy proximal to the fistula - Infection
- Pelvic tumours may become colonized with anaerobes - if foul smelling discharge, consider metronidazole topical or oral - Bleeding
- Low-dose palliative rads
- Cauterization
- Tranexamic acid (PO or vaginal) - not useful for slow bleeding, but may be helpful for slow oozing
- Arterial embolization for severe bleeding - Ureteric obstruction
- May cause hydronephrosis - could be asymptomatic if only one kidney obstructed
- Loss of a solitary kidney or bilateral hydronephrosis can result in rapidly progressive renal failure
- Ureteric stents have higher failure rates (inability to traverse site of blockage or malignant compression), requires change q3-4 months. Associated with colicky pain, pressure, dysuria, frequency.
- Nephrostomy tubes don’t require general anesthetic, still require change q3-4 months - Lower limp lymphedema
- Occurs if pelvic lymphatic drainage can be obstructed
- May require subcutaneous lymphatic drainage (reverse dermoclysis) - DVT
- May be difficult to treat in the case of concomitant vaginal bleeding - consider IVC filter in this case - Bowel obstruction
- Difficult to manage surgically given peritoneal carcinomatosis
- If slow-growing, could consider parenteral nutrition
2
Q
Pelvic Malignancy: Skin irritation
A
Skin irritation
- Fistula formation if the tumour invades into bowel or bladder
- Chronic discharge of stool or urine from the vagina can be an issue - skin hygiene and barrier creams, also consider use of a colostomy proximal to the fistula
3
Q
Pelvic Malignancy: Infection
A
Infection
- Pelvic tumours may become colonized with anaerobes - if foul smelling discharge, consider metronidazole topical or oral
4
Q
Pelvic Malignancy: Bleeding
A
Bleeding
- Low-dose palliative rads
- Cauterization
- Tranexamic acid (PO or vaginal) - not useful for slow bleeding, but may be helpful for slow oozing
- Arterial embolization for severe bleeding
5
Q
Pelvic Malignancy: Ureteric Obstruction
A
Ureteric obstruction
- May cause hydronephrosis - could be asymptomatic if only one kidney obstructed
- Loss of a solitary kidney or bilateral hydronephrosis can result in rapidly progressive renal failure
Management:
- Ensure patient is aware of consequences of ureteric obstruction
- Consider decompression via ureteric stents or percutaneous nephrostomy (may be complicated by leaking and infection)
- Ureteric stents have higher failure rates (inability to traverse site of blockage or malignant compression), requires change q3-4 months. Associated with colicky pain, pressure, dysuria, frequency.
- Nephrostomy tubes don’t require general anesthetic, still require change q3-4 months
- Some patients may opt for death by renal failure
6
Q
Pelvic Malignancy: Lower limb lymphedema
A
Lower limb lymphedema
- Occurs if pelvic lymphatic drainage can be obstructed
- May require subcutaneous lymphatic drainage (reverse dermoclysis)
7
Q
Pelvic Malignancy: DVT
A
DVT
- May be difficult to treat in the case of concomitant vaginal bleeding - consider IVC filter in this case
8
Q
Pelvic Malignancy: Bowel Obstruction
A
Bowel obstruction
- Difficult to manage surgically given peritoneal carcinomatosis
- If slow-growing, could consider parenteral nutrition
9
Q
Management of prostate cancer
A
Staging and Prognostication
- TNM staging
- Microscopic appearance (Gleason score)
- PSA (some prostate cancers do not secrete PSA, but many do and can be used as a tumour marker for disease progression/treatment response
Management
- Surgery or radiotherapy, depending upon patient age
- Androgen deprivation therapy (orchiectomy or drugs that suppress testosterone production)
- Chemotherapy (particularly in cases of disease progression despite androgen deprivation)
10
Q
Sexual impact of prostate cancer
A
- Erectile dysfunction and urinary difficulties are common
- Risk of impotence determined by tumour size and extent of local invasion, with prostatectomy commonly causing impotence
- Brachytherapy has lower risk of nerve damage resulting in impotence
- Androgen deprivation therapy commonly reduces libido and erectile function (and is first line for metastatic disease)
- After prostatectomy, orgasm will be ‘dry’ due to absence of seminal fluid
11
Q
Model to counsel regarding sexuality and sexual function
A
PLISSIT
P - Permission
- Give permission for the patient to discuss concerns
- Direct questioning may help men to overcome embarrassment
- Reassure that they are ‘normal’
- Make no assumptions about sexual function, interest, or orientation
LI - Limited Information
- Amount of information desired may vary from patient to patient
- Provide information in a sensitive manner
- Offer to refer the patient to a colleague of a different sex if requested by the patient
SS - Specific Suggestions
- Alternatives to vaginal or anal intercourse for sexual satisfaction
- Non-sexual ways to demonstrate affection
- Lubricants, sexual aids, different positions to alleviate discomfort may be helpful
IT - Intensive Therapy
- Consider sildenafil, urethral alprostadil pellet insertion, external vacuum device, intracorporeal injections
- Penile implants can be considered for patients cured of cancer
- In case of loss of libido, therapies above may not be helpful
- Despite prostatectomy and androgen deprivation, approx 20% of men can maintain a degree of erectile function
- Consider referral to sexual therapist or counsellor
12
Q
Normal urinary function
A
Urethral sphincter: Three levels
- Internal sphincter
- Layers of the detrusor muscle around entrance to the urethra from bladder
- Autonomic control - Upper urethral sphincter
- Circumferential layer of smooth muscle in the wall of the urethra
- Autonomic control - Lower urethral sphincter
- Striated muscle of the pelvic floor
- Voluntary control
Neurologic control - controlled by T11-L2, S1-S4
- Spinal cord lesions from L1 down can cause micturition difficulty (atonic bladder - retention)
1. Sympathetic activity - Internal urethral sphincter contracts, detrusor (bladder wall) muscle relaxes - prevents urine from exiting
- Parasympathetic
- Relaxation of the internal urethral sphincter, detrusor contraction - allows urination
13
Q
Neurologic control of urination
A
Neurologic control - controlled by T11-L2, S1-S4
- Spinal cord lesions from L1 down can cause micturition difficulty (atonic bladder - retention)
1. Sympathetic activity - Internal urethral sphincter contracts, detrusor (bladder wall) muscle relaxes - prevents urine from exiting
- Parasympathetic
- Relaxation of the internal urethral sphincter, detrusor contraction - allows urination
14
Q
Sphincters involved in urination
A
Urethral sphincter: Three levels
- Internal sphincter
- Layers of the detrusor muscle around entrance to the urethra from bladder
- Autonomic control - Upper urethral sphincter
- Circumferential layer of smooth muscle in the wall of the urethra
- Autonomic control - Lower urethral sphincter
- Striated muscle of the pelvic floor
- Voluntary control
15
Q
Four Types of Urinary Incontinence
A
- Stress Incontinence
- Urethral sphincter unable to prevent flow of urine in the setting of increased intra-abdo pressure
- Can be damaged during pelvic surgery or rads
- In women, often due to external (lower urethral) sphincter damage to the pelvic floor
- Modest incontinence
- Treat with antimuscarinics (Tolterodine 2-4mg PO qDaily) - Urge incontinence
- Inability to control urine flow when detrusor contracts
- Often without warning
- Often caused by bladder wall inflammation (infection, tumour invasion, drugs, radiation)
- Often large volume as bladder may completely empty
- Catheters very uncomfortable
- Treat with TCAs (Imipramine 10-25mg PO qHS, anticholinergic to increase sphincter tone and decrease detrusor contractility) or Oxybutynin 2.5 - 5mg TID-QID (smooth muscle relaxant, decreases detrusor instability) - Overflow incontinence
- Occurs when bladder fills to capacity but cannot contract properly (neuro damage, drugs, outflow obstruction)
- Causes of outflow obstruction include constipation, prostatic hypertrophy, stricture, or tumour
- Small, frequent volumes of urine without control
- High risk of infection with retained urine
- Treat with alpha adrenergic blockers (Terazosin or doxazosin, 1mg qDaily, increase to up to 10mg qDaily) - Total incontinence
- Complete loss of sphincter function due to tumour invasion or spinal cord injury
- Consider self-catheterization or indwelling catheter
16
Q
Urinary Incontinence: Stress Incontinence
A
Stress Incontinence
- Urethral sphincter unable to prevent flow of urine in the setting of increased intra-abdo pressure
- Can be damaged during pelvic surgery or rads
- In women, often due to external (lower urethral) sphincter damage to the pelvic floor
- Modest incontinence
- Treat with antimuscarinics (Tolterodine 2-4mg PO qDaily)
17
Q
Urinary Incontinence: Urge
A
Urge incontinence
- Inability to control urine flow when detrusor contracts
- Often without warning
- Often caused by bladder wall inflammation (infection, tumour invasion, drugs, radiation)
- Often large volume as bladder may completely empty
- Catheters very uncomfortable
- Treat with TCAs (Imipramine 10-25mg PO qHS, anticholinergic to increase sphincter tone and decrease detrusor contractility) or Oxybutynin 2.5 - 5mg TID-QID (smooth muscle relaxant, decreases detrusor instability)
18
Q
Urinary Incontinence: Overflow
A
Overflow incontinence
- Occurs when bladder fills to capacity but cannot contract properly (neuro damage, drugs, outflow obstruction)
- Causes of outflow obstruction include constipation, prostatic hypertrophy, stricture, or tumour
- Small, frequent volumes of urine without control
- High risk of infection with retained urine
- Treat with alpha adrenergic blockers (Terazosin or doxazosin, 1mg qDaily, increase to up to 10mg qDaily)
19
Q
Urinary Incontinence: Total Incontinence
A
Total incontinence
- Complete loss of sphincter function due to tumour invasion or spinal cord injury
- Consider self-catheterization or indwelling catheter
20
Q
Bladder spasms: Manifestations, causes, management
A
Bladder spasm
- Intermittent, sharp, suprapubic pain with the sensation of needing to pass urine
Causes
- Catheter irritation
- Infection/UTI
- Bladder hemorrhage
Treatments
- If catheterised, consider change to size of catheter or reduction in size of balloon
- Ensure catheter not blocked (irritate with NS as necessary)
- Rule out UTI - do not treat asympthatic bacteruria, but new fever, pain, or evidence of infection should prompt rx. Be especially cautious with patient on steroids
- PO Tranexamic acid if bladder hemorrhage is an issue (note increased risk of DVT)
- Belladonna and opium suppositories
- Smooth muscle relaxant (e.g. oxybutynin 2.5-5mg TID to QID)
21
Q
Management of bowel to bladder fistula
A
- Divert bowel from fistula with a colostomy - however, major surgery with risks, though lower risk with laparoscopic approach
- May also divert urine with a foley, suprapubic catheter, bilateral nephrostomy tubes as ‘conservative management’
- Note that spontaneous closure is rare
Symptoms:
- Recurrent UTIs
- Fecal matter in urine
- Urine through the rectum
- Fecal odour in the urine
- Pneumaturia
Investigations
- Pelvic exam
- Urinalysis
- CT cystogram with contrast
- CT with rectal contrast
- CT urogram
- May also require cystoscopy
22
Q
Lower Urinary Tract Obstruction Causes and Diagnosis
A
- BPH
- Invasive bladder/prostate cancer
- Urethral stricture (especially if prior rads, TURB, urethral dilatation, bladder tumour)
- Bladder neck contracture (esp if prior prostatectomy)
- Invasive gyne or colorectal malignancy
- Neurogenic causes of urinary retention (e.g. pelvic trauma, surgeries, neuro disease)
Diagnosis:
- PVR > 90-100mL
23
Q
Choice of catheter for chronic bladder outlet obstruction
A
- Clean intermittent catheterization
- Intermittent catheterisation generally preferred, but requires patient compliance, capacity, and physical dexterity (or nursing care) - Indwelling urethral catheter
- Increased risk of recurrent UTIs, irritative bladder symptoms, urethral erosion with chronic usage
- Requires routine change q3 weeks
- In case of recurrent, symptomatic UTIs, may consider prophylactic low dose antibiotics
- Intermittent catheterisation generally preferred, but requires patient compliance, capacity, and physical dexterity (or nursing care) - Suprapubic catheter
- Reduced risk of infection, urethral erosion, trauma, epididymitis
- Requires surgical intervention
24
Q
Sexuality - definition
A
- Process of giving and receiving sexual pleasure and is closely connected to a sense of ‘being’
- Sexuality is a feeling of belonging, being accepted by another, and the conviction that we are worthy to live and enjoy life
25
Q
Intimacy - definition
A
- Sharing of identity, closeness, and reciprocal rapport
- Emphasis on emotional closeness and intimate communication rather than sexual function
26
Q
Health benefits of sexual and intimate expression
A
- Pain relieving effects of sexual expression
- Distraction from day to day challenges
- Heightened pain threshold, especially following orgasm
- Lower anxiety and fewer depressive symptoms
27
Q
Impact of life-limiting diagnosis on sexuality
A
- Sexuality and intimacy remain an important part of patients’ lives even until the last days and weeks of life
- Cancer diagnosis may directly impact body parts traditionally associated with sexual expression
- May be associated with high levels of distress
- Partners generally experience a decrease in levels of sexual expression and frequency of intercourse
- Chemo may result in infertility
- Premature menopause may occur for treatment reasons (e.g. breast CA)
- Reduced circulating androgens due to chemo can decrease sexual desire and arousability
28
Q
Normal ageing processes and sexuality in women
A
- Reduced natural lubrication
- Shortening in the length and width of vagina
- Altered sensitivity to clitoris
- Potentially, loss of libido
29
Q
Normal ageing processes and sexuality in men
A
- Increased time required for erection
- Erection being less rigid for extended periods without ejaculation
- Amount of seminal fluid decreases
- Orgasmic strength and pleasure may decrease
- Increased rates of erectile dysfunction (may be related to medication use, EtOH, depression, etc.)
30
Q
Safe sex while undergoing chemo/rads
A
- Cytotoxic waste can be excreted through bodily fluid, especially in first 48 hours
- Dental dams, condoms recommended during sex to protect partner from cytotoxic irritation
- Note that with external beam radiation, the patient body does not become ‘radioactive’, though certain guidelines are in place for temporary internal radiation implants
31
Q
Sexuality and doctor patient relationship
A
- Patients feel it is the HCPs responsibility to bring up sexuality, but HCPs rarely do
32
Q
Barriers to conversations regarding patient intimacy and sexuality
A
- Lack of time
- Belief that patient is too ill or not interested in sex
- Belief that disfigured bodies are not attractive
- Fear of opening ‘Pandora’s Box’
- Transgressing medico-legal boundaries
- Presence of third parties at the consult
33
Q
Ways to start a conversation regarding sexuality
A
“Many people who have undergone this kind of treatment tell me they experience sexual or intimate changes. How has this been for you?”
“How has your sexual confidence changed since . . . ?
“How do you think this treatment has affected the way you feel about yourself or your relationship with your partner?”
“Sometimes a person’s body image changes with this illness . . . “
34
Q
Management of sexual side effects: Dysparenua
A
- Vaginal moisturizer (Replens)
- Lubricating products (especially water-based or silicone based)
35
Q
Management of sexual side effects: Dyspnea
A
- Well ventilated room, fan
- Encourage ‘gentle’ intimacy (hugging, hand holding, light massage)
- Water bed may conserve energy
- Pursed lip breathing during sex
- Avoid long kisses on the mouth
36
Q
Management of sexual side effects: Fatigue
A
- Use time of day where the patient has the most energy and ‘set the scene’
- Different positions to conserve energy
- Avoid extreme temperature, heavy meals, alcohol
37
Q
Management of sexual side effects: Xerostomia
A
- Education on regular oral hygiene
- Artificial saliva (Moi-Stir)
- Saliva stimulants (lozenges, pilocarpine tablets)
38
Q
Management of sexual side effects: Incontinence
A
- Encourage use of bath and shower for foreplay and post-coital relaxation
- Shower chair, disabled baths, fluffy towel over an incontinent sheet
39
Q
Management of sexual side effects: Privacy on inpatient unit
A
- ‘Do not disturb’ signs for patients
- Setting ‘privacy time’ daily
- Designated sensuality areas (private rooms with double beds, access to music, etc.)
- Double hospital beds
