Incontinence And Malignancy Flashcards
Which nerve controls the detrusor muscle?
PNS pelvic nerves
S2-4
Involuntary
Which nerve controls the external urethral sphincter?
Somatic pudendal nerve
S2-4
Describe the positions of the external sphincter
Usually contracted
Relaxes when voiding
How does a lower motor neurone lesion affect the bladder and anus?
Low detrusor pressure No action Large volume of residual urine -> overflow incontinence Can't feel the bladder filling Reduced perianal sensation Lax anal tone
How does an upper motor lesion affect the bladder?
Constantly contracting the detrusor muscle
Poor coordination with sphincters
(Detrusor-sphincter dyssynergia)
Urine can go up, dilate the ureters and cause damage to the kidneys
How do we classify lower urinary tract symptoms?
By phase:
Storage
Voiding
Post-micturition
Describe some LUT symptoms of the storage phase
Frequency
Urgency
Nocturia
Incontinence
Describe some LUT symptoms of the voiding phase
Slow stream Spitting/spraying Intermittency Hesitancy Straining Terminal dribble
Describe some LUT symptoms of post-micturition
Dribble
Feeling of incomplete emptying
Define urinary incontinence
The complaint of any involuntary leakage of urine
How does incontinence affect quality of life?
Depression
Social exclusion - don’t want to go out
Sense of shame
What are the different types of incontinence?
Stress
Urge
Mixed
Overflow
Describe stress urinary incontinence
Involuntary leakage on effort/exertion or on sneezing/coughing
Describe urge incontinence
Involuntary leakage accompanied by or immediately proceeded by urgency
Describe mixed urinary incontinence
Associated with urgency and also afford/exertion/coughing/sneezing
Describe overflow incontinence
Bladder accepts more and more urine without any action
Eventually it dribbles out due to the large volume
Describe the symptoms associated with overactive bladder syndrome
Urgency
Frequency
Nocturia
What is more common, overactive bladder or urge incontinence?
Overactive bladder syndrome
Why does the prevalence of urinary incontinence increase with age?
Bladder more sensitive
Smaller
Less able to hold urine
Describe how BPH affects urinary incontinence
Enlarged prostate blocks urine flow
Bladder gets larger and larger until cannot distend anymore
Starts to leak
Overflow incontinence
What is the most common type of urinary incontinence?
Stress
Due to weak pelvic floor muscles
Give some risk factors for urinary incontinence
Family predisposition Anatomical abnormalities Neurological abnormalities Co-morbidities Increased intraabdominal pressure UTI Menopause Pregnancy/childbirth Pelvic surgery Pelvic prolapse Obesity Age Cognitive impairment Drugs Race
What examinations would you do for someone with incontinence?
BMI
Abdominal exam (palpable bladder?)
DRE - check prostate
Females - external genitalia and vaginal exam
What is the mandatory investigation for urinary incontinence?
Urine dipstick
Check for UTI, haematuria, proteinuria, glycosuria etc
After a urine dipstick, what other investigations could you do for incontinence?
Urodynamics: frequency-volume chart, bladder diary, post-micturition residual volume (USS)
Pressure flow studies
Pad tests
Cystoscopy
What different factors does the management of incontinence depend on?
Symptoms
Degree of nuisance
Effects of treatment
Previous/current treatments
What is the general advice for someone experiencing urinary incontinence?
Lose weight
Decreased caffeine intake
Stop smoking
Try to regulate bowel movements
What is contained incontinence?
For patients unsuitable for surgery who have failed conservative/medical management
Condom catheters
Urethral/suprapubic catheter
Incontinence pads
Describe pelvic floor muscle training
8 contractions
3 times a day
For at least 3 months
Patients are not usually very compliant with this
Describe how duloxetine works to treat stress incontinence
Combined adrenaline and serotonin uptake inhibitor
Increased activity in external sphincter during filling so more likely to remain closed
Has many side effects
Describe the surgical options for women with incontinence
Low tension vaginal tapes
Suspension procedures
Classical sling procedure
What are the surgical options for men with incontinence?
Artificial (hydraulic) urinary sphincter
Male sling
How does an intramural bulking agent work for incontinence?
Decrease the lumen of the urethra to help retain urine
Eg. Collage/silicone
What is the short hand for prostate cancer?
CaP
What is the commonest cancer of men in the UK?
Prostate
What is the usual presentation of prostate cancer?
Asymptomatic Have localised disease Unlikely to die of it Urinary symptoms of BPH, bladder overactivity Bone pain Unusual to have haematuria
Give some CaP risk factors
Increasing age
Family Hx
BRCA2 gene mutation
Ethnicity (black>white>asian)
What are the issues with PSA screening?
Overdiagnosis Overtreatment Quality of life Cost effectiveness There are other causes of increased PSA
Other than cancer, what causes a raised PSA?
Infection
Inflammation
Large prostate
How do we make a diagnosis of CaP?
Digital rectal examination
And
Serum PSA
What investigations do we do for CaP?
Serum PSA
Transrectal ultrasound-guided biopsy of prostate for histology
MRI/bone scan to look for mets
If the PSA is greater than which number do we rarely consider removal?
> 20
What do we assess looking for cancer with a biopsy of the prostate?
Gleason grade (low magnification) Extent (how involved the core is)
What are the established treatments for localised CaP?
Surveillance (PSA)
Radical prostatectomy
Radiotherapy
Name some developmental treatments for localised CaP treatment
HIFU
Primary cryotherapy
High dose rate brachytherapy
Give some treatments for metastatic prostate cancer treatment
Surgical castration
Medical castration - given LHRH agonists
(LH and testosterone start to decrease)
Give some treatments that can help with palliative care of CaP
Single dose radiotherapy
Bisphosphonates
Chemotherapy
What type of bone metastases does CaP make?
Sclerotic
‘Hot spots’ on bone scans
Under which PSA are bone mets unlikely?
< 10
What are the treatments for locally advanced CaP?
Surveillance
Hormones
Hormones and radiotherapy
Give a differential diagnosis for haematuria
Renal cell carcinoma Upper tract transitional cell carcinoma Bladder cancer Advanced prostate carcinoma Stones Infection Inflammation BPH Nephrological (glomerular)
What do we need to ask about in a Hx with haematuria?
Smoking Occupation Pain Other lower urinary tract symptoms Family Hx
What do we examine if someone presents with haematuria?
BP Abdominal masses Varicocele Leg swelling (lymphoedema) DRE
What investigations would we carry out for someone with haematuria?
Blood - FBC, U+E
Ultrasound - any tumours or stretching
Flexible cystoscopy
Urine - culture and cytology
Is bladder cancer commoner in males or females?
Males
Is the incidence of bladder cancer increasing or decreasing?
Decreasing
What is the commonest type of bladder cancer?
Transitional cell carcinoma
Give some risk factors for bladder cancer
Smoking
Occupational exposure - rubber, plastics, carbon, paint, dyes
Schistosomiasis
Which type of bladder cancer is schistosomiasis linked to?
Squamous cell carcinoma
What is the treatment for bladder cancer?
Resect the tumour
Chemotherapy into the bladder
What percentage of bladder cancers are superficial on diagnosis?
75%
How do we grade bladder cancer?
Traditional high magnification grading system
Mitotic bodies, nuclei size and ratio etc
What is the potentially curative treatment for muscle-invasive bladder cancer?
Radical cystectomy or radiotherapy
+/- chemotherapy
What is a radical cystectomy?
Removal of the bladder
(In women also remove the womb and ovaries)
Redirect urine to come out of the abdominal wall
95% of all upper urinary tract tumours are which type?
Renal cell carcinoma
Is the incidence of renal cell carcinoma increasing or decreasing?
Increasing
Is renal cell carcinoma more common in males or females?
Males
What percentage of renal cell carcinomas have mets on presentation?
30%
What are the risk factors for renal cell carcinoma?
Smoking
Obesity
Dialysis
Describe the different ways renal cell carcinomas can spread
Perinephric
Lymph nodes
IVC spread to right atrium - forms a thrombus
What imaging can we use to diagnose renal cell carcinoma?
Ultrasound
CT
What are the treatments for RCC?
Surveillance
Radical nephrectomy
Partial nephrectomy
Ablation (developmental)
Describe the treatment for metastatic RCC
Palliative
Molecular therapies
What are the causes of upper tract transitional cell carcinoma?
Smoking
Phenacetin abuse
Balkan’s nephropathy
What percentage of upper urinary tract tumours are transitional cell carcinomas?
5%
What percentage of people who develop upper urinary tract cancer develop bladder cancer?
40%
What investigations would we do for upper tract transitional cell carcinoma?
Ultrasound for hydronephrosis
CT urogram
Retrograde pyelogram
Ureteroscopy - biopsy
What is the standard treatment for upper tract transitional cell carcinoma?
Nephro-ureterectomy
