Genitourinary symptoms CBM and Oxford Flashcards
1
Q
Common GU symtoms in malignancy
A
- Pain - nociceptic and neuropathic
- Constipaton in limited pelvic capacity
- bowel / bladder fistula
- skin breakdown and infection
- Anaerobic infection
- Bleeding
- RT
- TXA
- Ureteric obstruction
- hydronephrosis
- renal failure
- Lower limb lymphedema
- DVT
- Bowel obstruction
- particularly ovarian ca
2
Q
Sexual function in malignancy
A
Men
- erectile dysfunction
- prostatectomy
- Brachytherapy reduces likeliohood of nerve damage
- androgen deprivation (reduces libido and potency)
- urinary difficulties
Approach
- Permission to discuss (reassurance normal, do not make assumptions)
- Limited Information : assess how much information the would like. Refer prn.
- Specific Suggestions : alternatives to vaginal intercourse, sexual aids, lubricants, different positions, etc.
- Intensive Therapy : sildafenil, urethral alprostadil, vaccum device, intracorporeal injections, penil implant. Referral to sexual therapist.
3
Q
Lower urinary tract obstruction
A
- Lower Urinary tract obstruction
- Prostate ca, BPH, bladder ca, urethral stricture, bladder neck contracture
- invasive gynecologic or colorectal ca
- Symptoms
- urinary retentionm suprapubic pain, frequency, urgency, dysuria, UTI
- bladder dysfunction, bladder stones, kidney injury
- Physical exam:
- abdominal / pelvic tenderness
- DRE, pelvic exam
- Ix
- PVR > 90-100 ml
- US, urodynamic studies, MR, CT
- cystoscopy
- Management:
- treat constipation
- medications
- catheterization (post obstructive diuresis > 200 cc/hour)
- TURP, DVIU, urethral dilation, suprapubic catheter.
- radiation
- surgery: ileal conduit, cystectomy/pelvic exenteration
- Ureteric stents via the bladder
- prone to infection, blockage
- GA to place and replace q3-4 months
- Reasonable if newly dx ca with treatment options
- Percutaneous nephrostomy tubes
- leaking, infection, stigma of tubes
4
Q
What are the 4 types of Urinary incontinence
A
Stress Incontinence
- urethral sphincter unable to prevent flow of urine in setting of increased intraabdominal pressurre
- coughing, laughing, running
- pelvic surgery, radiotherapy, childbirth
- modest volumes of urine
Urge Incontinence
- inability to control urine when detrusor muscle contracts
- no warning, large volumes
- cysitis, tumour invasion, drugs, radiation
- Anticholingergic medications
Overflow Incontinence
- Bladder fills and cannot contract properly
- loss of contractile function due to neurologic damage or drugs or obstructed outflow tract
- Constipation can cause
- Small volumes passed frequently
- Sphincter tone relaxed by alpha-adrenergic drugs
Total incontinence
- complete loss of sphincter function
- Tumour invasion or SCC
- timed self cath or indwelling cath
5
Q
Anatomy and Physiology of Urinary Function
A
INTERNAL SPHINCTER
- layers of detrusor muscles around entrance to urethra
- autonomic control
UPPER URETHRAL SPHINCTER
- circumferential smooth muscle in wall of urethra
- autonomic control
LOWER / EXTERNAL SPHINCTER
- pelvic floor muscles
- voluntary control
- T11-L2 and S1-4
- S1-S2 nerve roots separate from spinal cord at L1-2
- Spinal cord lesions L1 down cause lower motor neuron pattern of micturition problems
- Sympathetic activity - prevents urine from exiting
- internal urethral sphincter contraction
- detrusor muscle to relax
- Parasympathetic - allows bladder to empty
- relaxation of sphincter and contraction of detrusor muscle
6
Q
Pharmacological management of incontinence
A
Alpha blockers
- bladder outlet obstruction
- Terazosin or doxazosin 1mg po od - 10 mg
Tricyclic antidepressants
- detrusor instability
- Imipramine 10-25 mg po qhs
Smooth Muscle relaxants / anti-ACH, muscarinic, local anesthetic effects
- Detrusor instability
- Oxybutynin 2.5-5 mg tid
Antimuscarinic Drugs
- Stress incontinence
- Tolterodine (Detrol) 2-4 mg po od
7
Q
Management of bladder spasm/ pain
A
- Invasive bladder mass / extrinsic compression
- smaller catheter size
- check for obstruction
- rule out / treat infection
- change the catheter and take sample from new bag/catheter
- don’t treat asymptomatic bactiuria
- belladonna and opium suppositories
- oxybutynin
- Ach - hyoscine butylbromide
- palliative cystectomy +/ nephrostomy tubes
- Neuropathic pain from compression of lumbosacral plexus: usual medical treatment
8
Q
GU Fistulae
A
- Risk factors for vesicoenteric and vesicovaginal fistula
- advanced malignancy
- prior pelvic surgery
- radiation
- poor nutritional status
- poor wound healing ability
- infection
- Causes
- colon cancers
- diverticulitis
- Chrohn’s
- gyne cancers
- PID
- Symptoms
- pneumaturia
- UTI
- Suprapubic pain
- incontinence
- faeceluria
- diarrhea
- tenesmus
- skin breaktdown, rash, ulcers, infection
- Investigations
- pelvic exam,
- UA
- CT cystogram
- CT urogram
- CT with rectal contrast or MR
- Endoscopy with cystoscopy
- Treatment
- foley
- suprapubiu catether
- Bilateral nephrostomy tubes
- ileal conduit
- fistula repair
- diverting colostomy, rectal stents
9
Q
Upper Urinary Tract Obstruction
A
- Intraluminal : masses / transitional cell carcinoma / stricture / stones
- Extraluminal : pelvic or retroperitoneal malignancy/ fibrosis/ RT
- flank pain, nausea, vomiting, loss of renal function, pyelonephritis, urosepsis
- UA, renal ultrasound, Cr, GFR
Ureteric stents
- prone to infection, blockage, failure
- GA to place and replace q3-4 months
- Reasonable if newly dx ca with treatment options
- appealing as not visible, no tubes
- renal colic, urinary sx, pelvic pressure
Percutaneous nephrostomy tubes
- leaking, infection, stigma of tubes
- procedural sedation only
- diverting urine proximal to obstruction
- q3months exchange
- bleeding, vascular injury, perinephric hematoma, pain, social stigma
10
Q
Hematuria
A
-
Symptoms
- painful or painless
- L UTI sx
- Clot retention
- obstructive uropathy
- hemorrhagic shock
-
Risk factors:
- bleeding diathesis
- AC meds
- poor wound healing
-
UPPER TRACT bleeding sources (ureters and kidneys)
- RCC, urothelial ca
- AVM, angiomyolipoma, hemorrhagic cysts
- metastatic disease
- ureterovascular, pyelovascular fistula
-
Work up
- cystourethroscopy
- CT urogram, retrograde pyelography
-
Management
- endoscopic fulguration if possible
- selective arterial embolization
- palliative nephrectomy, nephrouretectomy (rare)
- urinary diversion
-
LOWER TRACT BLEEDING
- bladder tumour
- hemorrhagic cystitis (cyclophosphamide, ifosfamide)
- radiation
- bleeding prostatic varices
- urethral trauma
- AC meds
-
Management
- Hand irrigation
- CBI
- prostatic bleeding : gentle traction with foley balloon
- 5 alpha reductase (finasteride) and androgen deprivation
- Surgery : fulguration on cystoscopy, tumour resection, cystectomy, etc.
-
Bladder bleeding treatment:
- EACA (epsilon aminocaproic acid) - IV, oral, intravesical
- SE: rhabdo, monitor for same (CK, myoglobinuria, myoglonemia, LDH)
- Bladder irrigation with alum 1-2% or 1% silver nitrate
- Formalin instillation 2-4% left for 30 minutes then rinsed with NS
- ++ painful
- done in OR
- high toxicity : severe UTI sx, incontinence, fibrosis, perforation
- Rule out vesicoureteral reflux first
- Instillations paired with urinary diversion (nephrostomies) to minimize effect of urokinase (clot inhibitor present in urine)
- Radiation
- Embolization of hypogastric arteries
- Palliative cystectomy with ileal conduit
- EACA (epsilon aminocaproic acid) - IV, oral, intravesical
11
Q
Palliative Urologic Procedures
A
See attached table
12
Q
Urinary catheters
A
- Clean intermittent catheterization preferred over indwelling
- need patient compliance, mental capacity, attentive nursing
- Sx related to catheters: recurrent infection, urethral erosion,irritative bladder symptoms
- Subprapubic reduces sx and risk of infection
Infection
- Bacteruria increases by 10% for each day of indwelling catheter use
- 1-3% risk for CIC’
- Symptomatic CAUTI
- fever, urgency, dysuria, urine culture > 10(5) with no more than 2 organisms
- sterile technique, exchange q3-4 weeks
- Prophylactic antibx if recurrent symptomatic CAUTI
- Encrusting:
- irrigate with saline or neomycin/polymixin solution
- Silicone for long term use or latex allergy
- Coated cathethers (silver, antibiotics) not shown to be better
*
13
Q
Sexuality
A
- giving and receiving sexual pleasure
- feeling of belonging, acceptance
- Intimacy: emotional closeness and communication
14
Q
Benefits of sex
A
- pain relief
- distraction from day to day challenges
- heightened pain threshold
- lower anxiety
- lower depression
15
Q
List impacts cancer/life limiting illness have on sexuality
A
- Still important until last days
- direct impact of cancer on body function
- often decreased levels of desire and frequency of intercourse
- chemo –> infertility
- premature menopause symptoms
- decreased androgens from treatment
