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GU > Lecture 10: Bladder and Urinary Incontinence COPY > Flashcards

Lecture 10: Bladder and Urinary Incontinence COPY Flashcards

1
Q

What is the 2nd MC urologic cancer?

A

Bladder cancer.

MC in men and older pts.

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2
Q

What are the risk factors for bladder cancer?

A
  • Cigarettes
  • Industrial solvents
  • Chronic inflammation
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3
Q

What is the most common form of bladder cancer?

A
  • Epithelial cell malignancies
  • Specifically: Urothelial cell carcinoma
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4
Q

What is the #1 presenting s/s in bladder cancer?

A

Hematuria

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5
Q

What would appear on urine cytology for bladder cancer?

A

Abnormal shed epithelial cells

Highly sensitive in high grade cancers

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6
Q

What is the gold standard for diagnosing bladder cancer?

A

Cystoscopy with biopsy

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7
Q

What imaging finding is commonly seen in bladder cancer?

A

Filling defect

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8
Q

What is the treatment for superficial bladder cancer?

A
  • Transurethral tumor resection
  • BCG weekly for 6-12 weeks

TIS, Ta, T1

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9
Q

What is the treatment for invasive bladder cancer?

A
  • Radical cystectomy
  • Urinary diversion
  • Chemo, immunotherapy, radiation

T2+

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10
Q

What is the prognosis for superficial bladder cancer?

A

81%

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11
Q

What is nocturnal enuresis?

A

Repeated urination into clothing or bedding during the night.

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12
Q

What is monosymptomatic enuresis?

A
  • No LUTS
  • No hx of bladder disorders
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13
Q

Define primary nocturnal enuresis.

A
  • Young children 5-6yo
  • Never achieved urinary continence.
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14
Q

Define secondary nocturnal enuresis.

A
  • Previous continent for 6 months prior.
  • Often associated with a stressful time in a child’s life.
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15
Q

Who is nocturnal enuresis MC in and what does increased duration of it suggest?

A
  • MC in males
  • The longer it goes, the less likely it will spontaneously resolve.
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16
Q

What is the classic presentation of nocturnal enuresis?

A
  • 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.

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17
Q

What is the main purpose of diagnostics in regards to nocturnal enuresis?

A

UA and UC are generally used to r/o other possible causes.

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18
Q

What are the behavioral and pharmacological treatments for nocturnal enuresis?

A
  • Enuresis alarm
  • Desmopression (1st line)
  • Imipramine, oxybutynin (2nd line)
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19
Q

What is the primary etiology of interstitial cystitis?

A

Unknown

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20
Q

What is the typical onset of interstitial cystitis?

A
  • Women in their 40s
  • Fibromylagia or IBS
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21
Q

What is the classic presentation of interstitial cystitis?

A
  • Pain/discomfort with bladder filling
  • Pain relieved with urination
  • +/- irritative voiding symptoms
  • Suprapubic tenderness
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22
Q

How do labs typically present for interstitial cystitis?

A

Normal

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23
Q

What imaging modalities may be useful in interstitial cystitis?

A
  • Postvoid residual bladder US to r/o retention.
  • Cystoscopy to r/o bladder cancer
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24
Q

What is the diagnostic criteria for interstitial cystitis?

A

Unpleasant sensation related to the bladder, with other LUTS, for > 6 weeks without any identifiable cause.

It is a diagnosis of exclusion

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25
Q

What procedure involving a cystoscope can help improve symptoms of interstitial cystitis?

A

Hydrodistension

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26
Q

What are the cystoscopy findings associated with interstitial cystitis?

A
  • Hunner’s lesions/ulcers
  • Glomerulations (non-specific)
  • Increased mast cells on biopsy
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27
Q

How do you treat interstitial cystitis?

A
  • Lifestyle modifications
  • Self Care
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28
Q

What medications may be used for interstitial cystitis?

A
  • TCAs (amitriptyline first line among TCAs)
  • Antihistamines - hydroxyzine
  • CCBs - nifedipine
  • Pentosan polysulfate sodium
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29
Q

What is the only FDA-approved drug for interstitial cystitis and what does it do?

A
  • Pentosan polysulfate sodium
  • Improvement of glycosaminoglycan layer over the urothelium
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30
Q

What are the SEs of pentosan polysulfate sodium?

A
  • GI upset, hair loss, LFT elevations
  • Minor sedation
  • Retinal toxicity
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31
Q

What allergy contraindicates pentosan polysulfate sodium?

A

Heparin

32
Q

What is third-line treatment for interstitial cystitis?

A
  • Hydrodistension
  • Electrocauterization of hunner’s lesions
  • Intravesical lido, heparin, or DMSO
33
Q

What is the last resort treatment for interstitial cystitis?

A

Cystectomy with urinary diversion

34
Q

What two urinary drugs can be used as adjuncts in interstitial cystitis?

A
  • Azo-short term
  • Methenamine
35
Q

What is the usual cause of urethral strictures in developed countries?

A

Iatrogenic

36
Q

What are the risk factors for urethral strictures?

A
  • Hx of GU surgery or instrumentation
  • Hx of pelvic trauma or irradiation
  • Hx of GU infection or cancer
37
Q

What are the typical S/S of urethral strictures?

A
  • Obstructive voiding s/s are the MC
  • Spraying of the urinary stream
  • Recurrent UTIs/prostatitis
  • 10% are asymptomatic
38
Q

How do labs for urethral strictures typically present?

A

Normal unless infection present.

39
Q

What imaging modalities are useful in diagnosing urethral strictures?

A
  • Uroflometry
  • US
  • Cystourethrogram
  • Cystourethroscopy
40
Q

When should urethral strictures be treated?

A
  • Recurrent UTIs
  • Problematic symptoms
  • Urinary retention
  • High PVR
  • Bladder stones
41
Q

How are urethral strictures treated?

A
  • Urethral dilation
  • Urethrotomy
  • Reconstruction (urethroplasty +/- replacement graft)
  • Urinary diversion
42
Q

What are the two etiologies that generally predispose someone to urethral prolapse?

A
  • Malformation of the urethra
  • Weak pelvic floor structures
43
Q

What is urethral prolapse?

A

Protrusion of the distal urethra through the external urethral meatus

44
Q

What demographics is urethral prolapse MC in?

A
  • Prepubertal
  • Postmenopausal
45
Q

What are the risk factors for urethral prolapse?

A
  • Chronically increased intra-abdominal pressure
  • Post-menopausal status
  • Traumatic vaginal delivery
46
Q

How does prepubertal urethral prolapse typically present?

A
  • Asymptomatic
  • Vaginal bleeding
  • Bloody spotting on underwear
  • Donut shaped protrusion
47
Q

How does postmenopausal urethral prolapse typically present?

A
  • Often symptomatic
  • Vaginal bleeding
  • Irritative voiding symptoms
  • Large can involve venous obstruction, thrombosis, or necrosis
  • Donut shaped protrusion
48
Q

When is imaging suggested for urethral prolapse?

A

Concerns over complications. Perform cystourethroscopy.

49
Q

What medical therapy is suggested for urethral prolapse?

A
  • Prepubertal: sitz baths, topical ABX, topical estrogen
  • Post-menopausal: sitz baths, topical estrogen cream, ABX
  • Not recommended if significant necrosis, thrombosis, or bleeding.
50
Q

What are the surgical therapies for urethral prolapse?

A
  • Manual reduction and urethral cath for 1-2 days
  • Ablative therapy (not commonly used)
  • MC: excision of mucosa with short-term catheterization
51
Q

What is the function of the Pons in regards to the bladder?

A
  • Sympathetic, which relaxes the detrusor muscle and closes the internal urethral sphincter.
  • Somatic nerves, which contract the external urethral sphincter
52
Q

What triggers inhibition of the sympathetic and somatic systems of the pons in the bladder?

A

Stretching of the detrusor/trigone stretch

53
Q

What nerve is used to voluntarily stop urination?

A

Pudendal nerve.

54
Q

What are the risk factors for urinary incontinence?

A
  • Female
  • Advanced age
  • Obesity
  • Parity
  • Prostate disease
  • Neurologic disease
  • Immobility
55
Q

What are the transient causes of urinary incontinence?

A
  • Delirium
  • Infection
  • Atrophic urethritis/vaginitis
  • Pharmaceuticals
  • Psychological disorders
  • Endocrine disorders
  • Restricted mobility
  • Stool impaction

DIAPPERS

56
Q

Name all the causes of each type of urinary incontinence.

A
  • Urge incontinence: detrusor overactivity
  • Stress incontinence: Urethral sphincter incompetence
  • Overflow incontinence: detrusor underactivity
  • Mixed: multiple
  • Functional: problems thinking/moving
57
Q

How does urge incontinence present?

A

Strong urge to urinate before or after involuntarily passing urine.

58
Q

What are the two underlying etiologies for stress incontinence?

A
  • Hypermobility of the urethra (prostatectomy/hysterectomy)
  • Intrinsic sphincter deficiency
59
Q

How does stress incontinence present?

A

Involuntary leakage with increases in pressure.

Often seen in young women.

Sneezing, laughing , coughing

60
Q

How does overflow incontinence typically present?

A

Frequent, involuntary leakage of urine.

Need to r/o bladder obstruction first.

61
Q

Who is mixed incontinence MC in?

A

Women

62
Q

What is functional incontinence?

A

Inability to recognize need for urination or inability to get to the restroom in a timely fashion.

63
Q

What are the 3 Ps of urinary incontinence history taking?

A
  • Position
  • Protection
  • Problem
64
Q

What simple physical test can be used to test for stress incontinence?

A

Bladder stress test

Stand and cough.

Instant = stress
Delayed = bladder contraction due to coughing

65
Q

What is considered an abnormal postvoid residual and the management suggested?

A
  • > 200 cc = refer to urology
  • > > 400 cc = overflow highly likely.
66
Q

What would be a good initial lab test for someone with suspected urinary incontinence?

A

UA to screen for UTI and hematuria

67
Q

What are good exercises for urinary incontinence?

A

Kegel exercises (6 weeks to benefit)

68
Q

What are the suggested treatments for stress incontinence?

A
  • Pessaries for women if bladder prolapse
  • Urethral bulking agents
  • Duloxetine (off-label)
  • Surgery (last resort but most effective)
69
Q

What medications work for urge incontinence?

A
  • Anticholinergics
  • B3 agonists
  • TCAs
  • Alpha blockers for men
70
Q

What are the SEs of anticholinergics?

A
  • Dry mouth
  • Constipation
  • Urinary retention
  • Dizziness/drowsiness
  • Caution in elderly

Can’t pee, can’t see, can’t shit

71
Q

What conditions contraindicate the use of anticholinergics?

A
  • Gastric retention
  • Glaucoma
72
Q

What is the MC anticholinergic?

A

Oxybutynin

73
Q

When do we use B3 agonists for urinary incontinence and what should we be wary of?

A
  • Cant tolerate anticholinergics
  • Add-on in overactive bladder
  • SE: HTN, tachy, dry mouth, UTI

Mirabegron and vibegron

74
Q

What injection can help with urge incontinence?

A

Botox

75
Q

What is the treatment for overflow urinary incontinence?

A
  • Treat underlying cause
  • Neuromodulation via sacral nerve
  • Indwelling catheter (last resort)
76
Q

What incontinence types do kegels help with?

A
  • Stress
  • Urge
  • Mixed

GU (14 decks)

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