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
