Lecture 10: Bladder and Urinary Incontinence Flashcards
What is the 2nd MC urologic cancer?
Bladder cancer.
MC in men and older pts.
What are the risk factors for bladder cancer?
- Cigarettes
- Industrial solvents
- Chronic inflammation
What is the most common form of bladder cancer?
- Epithelial cell malignancies
- Specifically: Urothelial cell carcinoma
What is the #1 presenting s/s in bladder cancer?
Hematuria
What would appear on urine cytology for bladder cancer?
Abnormal shed epithelial cells
Highly sensitive in high grade cancers
What is the gold standard for diagnosing bladder cancer?
Cystoscopy with biopsy
What imaging finding is commonly seen in bladder cancer?
Filling defect
What is the treatment for superficial bladder cancer?
- Transurethral tumor resection
- BCG weekly for 6-12 weeks
TIS, Ta, T1
What is the treatment for invasive bladder cancer?
- Radical cystectomy
- Urinary diversion
- Chemo, immunotherapy, radiation
T2+
What is the prognosis for superficial bladder cancer?
81%
What is nocturnal enuresis?
Repeated urination into clothing or bedding during the night.
What is monosymptomatic enuresis?
- No LUTS
- No hx of bladder disorders
Define primary nocturnal enuresis.
- Young children 5-6yo
- Never achieved urinary continence.
Define secondary nocturnal enuresis.
- Previous continent for 6 months prior.
- Often associated with a stressful time in a child’s life.
Who is nocturnal enuresis MC in and what does increased duration of it suggest?
- MC in males
- The longer it goes, the less likely it will spontaneously resolve.
What is the classic presentation of nocturnal enuresis?
- Involuntary urination during sleep in a person who NORMALLY has voluntary urinary control.
- Occurs 3-4 hours past bedtime.
Voiding diaries may help track it.
What is the main purpose of diagnostics in regards to nocturnal enuresis?
UA and UC are generally used to r/o other possible causes.
What are the behavioral and pharmacological treatments for nocturnal enuresis?
- Enuresis alarm
- Desmopression (1st line)
- Imipramine, oxybutynin (2nd line)
What is the primary etiology of interstitial cystitis?
Unknown
What is the typical onset of interstitial cystitis?
- Women in their 40s
- Fibromylagia or IBS
What is the classic presentation of interstitial cystitis?
- Pain/discomfort with bladder filling
- Pain relieved with urination
- +/- irritative voiding symptoms
- Suprapubic tenderness
How do labs typically present for interstitial cystitis?
Normal
What imaging modalities may be useful in interstitial cystitis?
- Postvoid residual bladder US to r/o retention.
- Cystoscopy to r/o bladder cancer
What is the diagnostic criteria for interstitial cystitis?
Unpleasant sensation related to the bladder, with other LUTS, for > 6 weeks without any identifiable cause.
It is a diagnosis of exclusion
What procedure involving a cystoscope can help improve symptoms of interstitial cystitis?
Hydrodistension
What are the cystoscopy findings associated with interstitial cystitis?
- Hunner’s lesions/ulcers
- Glomerulations (non-specific)
- Increased mast cells on biopsy
How do you treat interstitial cystitis?
- Lifestyle modifications
- Self Care
What medications may be used for interstitial cystitis?
- TCAs (amitriptyline first line among TCAs)
- Antihistamines - hydroxyzine
- CCBs - nifedipine
- Pentosan polysulfate sodium
What is the only FDA-approved drug for interstitial cystitis and what does it do?
- Pentosan polysulfate sodium
- Improvement of glycosaminoglycan layer over the urothelium
What are the SEs of pentosan polysulfate sodium?
- GI upset, hair loss, LFT elevations
- Minor sedation
- Retinal toxicity
What allergy contraindicates pentosan polysulfate sodium?
Heparin
What is third-line treatment for interstitial cystitis?
- Hydrodistension
- Electrocauterization of hunner’s lesions
- Intravesical lido, heparin, or DMSO
What is the last resort treatment for interstitial cystitis?
Cystectomy with urinary diversion
What two urinary drugs can be used as adjuncts in interstitial cystitis?
- Azo-short term
- Methenamine
What is the usual cause of urethral strictures in developed countries?
Iatrogenic
What are the risk factors for urethral strictures?
- Hx of GU surgery or instrumentation
- Hx of pelvic trauma or irradiation
- Hx of GU infection or cancer
What are the typical S/S of urethral strictures?
- Obstructive voiding s/s are the MC
- Spraying of the urinary stream
- Recurrent UTIs/prostatitis
- 10% are asymptomatic
How do labs for urethral strictures typically present?
Normal unless infection present.
What imaging modalities are useful in diagnosing urethral strictures?
- Uroflometry
- US
- Cystourethrogram
- Cystourethroscopy
When should urethral strictures be treated?
- Recurrent UTIs
- Problematic symptoms
- Urinary retention
- High PVR
- Bladder stones
How are urethral strictures treated?
- Urethral dilation
- Urethrotomy
- Reconstruction (urethroplasty +/- replacement graft)
- Urinary diversion
What are the two etiologies that generally predispose someone to urethral prolapse?
- Malformation of the urethra
- Weak pelvic floor structures
What is urethral prolapse?
Protrusion of the distal urethra through the external urethral meatus
What demographics is urethral prolapse MC in?
- Prepubertal
- Postmenopausal
What are the risk factors for urethral prolapse?
- Chronically increased intra-abdominal pressure
- Post-menopausal status
- Traumatic vaginal delivery
How does prepubertal urethral prolapse typically present?
- Asymptomatic
- Vaginal bleeding
- Bloody spotting on underwear
- Donut shaped protrusion
How does postmenopausal urethral prolapse typically present?
- Often symptomatic
- Vaginal bleeding
- Irritative voiding symptoms
- Large can involve venous obstruction, thrombosis, or necrosis
- Donut shaped protrusion
When is imaging suggested for urethral prolapse?
Concerns over complications. Perform cystourethroscopy.
What medical therapy is suggested for urethral prolapse?
- Prepubertal: sitz baths, topical ABX, topical estrogen
- Post-menopausal: sitz baths, topical estrogen cream, ABX
- Not recommended if significant necrosis, thrombosis, or bleeding.
What are the surgical therapies for urethral prolapse?
- Manual reduction and urethral cath for 1-2 days
- Ablative therapy (not commonly used)
- MC: excision of mucosa with short-term catheterization
What is the function of the Pons in regards to the bladder?
- Sympathetic, which relaxes the detrusor muscle and closes the internal urethral sphincter.
- Somatic nerves, which contract the external urethral sphincter
What triggers inhibition of the sympathetic and somatic systems of the pons in the bladder?
Stretching of the detrusor/trigone stretch
What nerve is used to voluntarily stop urination?
Pudendal nerve.
What are the risk factors for urinary incontinence?
- Female
- Advanced age
- Obesity
- Parity
- Prostate disease
- Neurologic disease
- Immobility
What are the transient causes of urinary incontinence?
- Delirium
- Infection
- Atrophic urethritis/vaginitis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
DIAPPERS
Name all the causes of each type of urinary incontinence.
- Urge incontinence: detrusor overactivity
- Stress incontinence: Urethral sphincter incompetence
- Overflow incontinence: detrusor underactivity
- Mixed: multiple
- Functional: problems thinking/moving
How does urge incontinence present?
Strong urge to urinate before or after involuntarily passing urine.
What are the two underlying etiologies for stress incontinence?
- Hypermobility of the urethra (prostatectomy/hysterectomy)
- Intrinsic sphincter deficiency
How does stress incontinence present?
Involuntary leakage with increases in pressure.
Often seen in young women.
Sneezing, laughing , coughing
How does overflow incontinence typically present?
Frequent, involuntary leakage of urine.
Need to r/o bladder obstruction first.
Who is mixed incontinence MC in?
Women
What is functional incontinence?
Inability to recognize need for urination or inability to get to the restroom in a timely fashion.
What are the 3 Ps of urinary incontinence history taking?
- Position
- Protection
- Problem
What simple physical test can be used to test for stress incontinence?
Bladder stress test
Stand and cough.
Instant = stress
Delayed = bladder contraction due to coughing
What is considered an abnormal postvoid residual and the management suggested?
- > 200 cc = refer to urology
- > > 400 cc = overflow highly likely.
What would be a good initial lab test for someone with suspected urinary incontinence?
UA to screen for UTI and hematuria
What are good exercises for urinary incontinence?
Kegel exercises (6 weeks to benefit)
What are the suggested treatments for stress incontinence?
- Pessaries for women if bladder prolapse
- Urethral bulking agents
- Duloxetine (off-label)
- Surgery (last resort but most effective)
What medications work for urge incontinence?
- Anticholinergics
- B3 agonists
- TCAs
- Alpha blockers for men
What are the SEs of anticholinergics?
- Dry mouth
- Constipation
- Urinary retention
- Dizziness/drowsiness
- Caution in elderly
Can’t pee, can’t see, can’t shit
What conditions contraindicate the use of anticholinergics?
- Gastric retention
- Glaucoma
What is the MC anticholinergic?
Oxybutynin
When do we use B3 agonists for urinary incontinence and what should we be wary of?
- Cant tolerate anticholinergics
- Add-on in overactive bladder
- SE: HTN, tachy, dry mouth, UTI
Mirabegron and vibegron
What injection can help with urge incontinence?
Botox
What is the treatment for overflow urinary incontinence?
- Treat underlying cause
- Neuromodulation via sacral nerve
- Indwelling catheter (last resort)
What incontinence types do kegels help with?
- Stress
- Urge
- Mixed
