Lecture 11 (GU)- Exam 4 Flashcards
Cystitis AKA Urinary Tract Infection (UTI)
* What are the predominate lower urinary tract symptoms?
* 1/3 of patients have what?
* One-third of patients with symptoms of cystitis do not what?
- Lower urinary tract symptoms predominate: dysuria, urgency, frequency, suprapubic discomfort, low back pain
- One-third of patients have silent upper UTI
- One-third of patients with symptoms of cystitis do not have bacteriuria using strict definition of >105 bacteria/ml
Cystitis AKA Urinary Tract Infection (UTI)
* What should you suspect with men with UTI sxs?
* How do elderly patients present?
- Suspect underlying prostate disease in men with UTI symptoms and signs
- Bacteriuria in elderly patients often asymptomatic; may not warrant antimicrobial treatment
Cystitis AKA Urinary Tract Infection (UTI)-Etiology
* More common in who?
* What is the most common organism for both uncomplicated and complicated UTI? ⭐️ What are some other bacteria?
- More common in women
- Most common organism is still Escherichia coli for both uncomplicated and uncomplicated UTI
* Staph. saprophyticus or Klebsiella/Enterococcus/Yeast are common
Cystitis AKA Urinary Tract Infection (UTI)-Etiology
* What are predisposing factors that may produce more serious infections or complication, or require longer treatment? (5)
- Catheterization
- Pregnancy
- Anatomical abnormalities
- Diabetes mellitus
- Use of spermicides
UTI categorization:
* What is acute simple cysitis?
* What are the sxs of acute complicated cysitis?
* What are special populations?
Risk factors for UTI
Risk Factor: Iatrogenic/drugs
* Indwelling goly catheters provide what?
* What does recent antibiotic use cause?
* What does spermicides cause?
Risk factors of UTI: Behavioral
* What can voiding dysfunction cause?
* What can frequent or recent secual intercourse?
Risk factors of UTI: Anatomic/physiologic
* Vesicoureteral reflus causes what?
* Why are females at risk?
* What does pregnancy result in?
Risk factors for UTI: Genetic
* UTI occurences tends to do what?
* Susceptible urepithelial cells secrete what? What does this cause?
* What about the properties of vaginal mucus?
Simple UTI PE findings? (6)
- Suprapubic pain, discomfort and burning sensation during urination
- Increased frequency of urination
- Hematuria frequently observed
- Back and flank pain and fever suggest kidneys and prostate involvement
Clinical dx of cysitis:
* How is dx made?
* Standard of care dictates that uncomplicated UTI treatment does not need what?
* Order cultures when?(5)
- The clinical diagnosis of cystitis is made in a patient who has classic signs and symptoms (ie, dysuria, urinary frequency, urgency, and/or suprapubic pain).
- Standard of care dictates that uncomplicated UTI treatment does not require culture prior to initial treatment.
- Order culture when failed empiric therapy, recurrent or worsening symptoms, with any signs of pyelonephritis, pregnant or hospitalized patients
Clinical dx of cysitis:
* For women who have atypical urinary symptoms, the diagnosis is supported by what?
* What are other DDXs? (3)
* Smell alone is not what?
- For women who have atypical urinary symptoms, the diagnosis is supported by the presence of pyuria and bacteriuria on urinalysis and/or culture
- DDX includes vaginitis, urethritis, PID
- Smell alone is not a reliable indicator of infection, could just be stress incontinence
- Urethritis can be caused by what? What does it cause?
- Cystitis is caused by what?
- Urethritis is caused for STI, causes frequency/dysuria and vaginal discharge but not bladder pain
- Cystitis is caused by enteric bacteria invading bladder
Pocket medicine:
* Cystisit: Dysuria, urgency, freq, Hematuria, suprapuber pain, no fever
* Urethritis: Dysuria, urethral discharge
Pertinent Questions to Aid Diagnosis of Cystitis (8)
When patient describes pain or difficulty in urination ask following:
* “How long have you noticed burning on urination?”
* “How often do you urinate each day?”
* “How does your urination feel different?”
* “Is your urine clear?”
* “Does it smell bad?”
* “Do you have a discharge from the penis?”Does the urine seem to have gas bubbles in it?”
* “Have you noticed any solid particles in your urine?”
* “Have you noticed pus in your urine?”
Pneumaturia:
* What is it?
* When does it occur?
* How do you get this? (3)
Passage of air or gas in urine
Usually occurs at end of urination
Etiologies
* Introduction of air by instrumentation
* Fistula to the bowel
* UTI by gas-forming bacteria such as E.Coli or clostridia
Fecaluria:
* What is it?
* Results from what?
* What are the causes? (3)
Presence of fecal material in urine and is rare
Pesults from either an intesinovesicular fisula or a urethorectal fistual
Etiologies:
* Diverticulitis
* Carcinoma
* Crohn’s disease
Laboratory Diagnosis of cystitis:
* What is commonly used?
* Dipsticks are commercially available strips that detect the presence of what?
* The dipstick test is most accurate for predicting UTI when?
* However, results of the dipstick test provide little useful information when?
- Urinalysis (either by microscopy or by dipstick) for evaluation of pyuria is a valuable laboratory diagnostic test for UTI.
- Dipsticks are commercially available strips that detect the presence of leukocyte esterase (an enzyme released by leukocytes, reflecting pyuria) and nitrite (reflecting the presence of Enterobacteriaceae, which convert urinary nitrate to nitrite).
- The dipstick test is most accurate for predicting UTI when positive for either leukocyte esterase or nitrite, with a sensitivity of 75 percent and a specificity of 82 percent.
- However, results of the dipstick test provide little useful information when the clinical history is strongly suggestive of UTI, since even negative results for both tests do not reliably rule out infection in such cases.
What are the 3 types of urinalysis? What do they look at?
From pocket medicine:
When is urinalysis and urine culture + in cystitis?
- Urinalysis: Pyuria, +/- bacteriuria, +/- hematuria, +/- nitrates
- Culture: over 10^5 CFU but over 10^2 may still indicate UTI if highly suspected
Treatment of cystitis:
If simple uncomplicated with no MDR risk factors, then start what? For how long?
- nitrofurantoin
- TMP-SMX
- Amoxicillin w/w/o clavulanic acid
- cephalexin
- Fosfomycin ($$)
- for 7-10 days
Treatment of cystitis:
* What are some other options?
If no reason to avoid fluoroquinolones, then Cipro or Levofloxacin
* According to Pharm: these are the first lines/2nd lines, the only time she mentioned fluros in cystitis is males
Treatment of cystitis:
* who needs a 14 day treatment>
* IV therapies extend across the same spectrum for complicated UTIs (3)
* Follow up when?
- In an elderly, diabetic or those with concurrent renal involvement, extend therapy to 14 days
- IV therapies extend across the same spectrum for complicated UTIs: 3rd generation or 4th generation cephalosporins, fluoroquinolones etc.
- Follow-up with urologist in 2-6 weeks if UTI is recurrent/nonresolving to r/o strictures vs stones vs abscess
Picture of Dr. V slides for UTI: complicated/catheter related
Asymptomatic Bacteriuria
* What is it?
* Often seen in who?
* Who does and does not need to be treated?
- Positive urine culture in absence of urinary tract symptoms
- Often seen in elderly or middle-aged individuals and in absence of structural disease or diabetes and does NOT require treatment
- This condition must be treated in pregnant and immunocompromised patients due to high risk of pyelonephritis
Asymptomatic Bacteriuria
* Pyuria with the absence of bacterial growth (sterile pyuria) and presence of the clinical picture of UTI usually suggests what?
* Alternatively, 30% of women with acute dysuria do not have what?
* 30% of those with mild bladder limited symptoms have what?
- Pyuria with the absence of bacterial growth (sterile pyuria) and presence of the clinical picture of UTI usually suggests chlamydial, gonococcal, herpes simplex infection
- Alternatively, 30% of women with acute dysuria do not have significant bacteriuria
- 30% of those with mild bladder limited symptoms have clinically silent upper tract disease
Asymptomatic Bacteriuria
* Who does not need to be treated and screened?
ACOG: Screening for and treatment of asymptomatic bacteriuria is not recommended in non-pregnant, premenopausal women
* you should treat Preg patients and renal transplant patients
Asymptomatic Bacteriuria
* What does the treatment do and not do?
UTI in Pregnancy (even asymptomatic)
* What contributes to urinary stasis and reflux?
* Associated with what? (3)
* Who should be admitted for parenteral therapy?
- Beginning in week 6 and peaking during weeks 22-24, approx. 90% develop ureteral dilatation; increased bladder volume and decreased bladder tone contribute to urinary stasis and reflux.
- Associated with premature labor and delivery, increased fetal loss, and prematurity
- Pregnant women with overt pyelonephritis should be admitted for parenteral therapy
UTI in Pregnancy (even asymptomatic)
* What can you use for txt? What should you avoid?
- Ampicillin: historically drug of choice, but E. coli increasingly resistant
- Cephalexin (Keflex)
- Nitrofurantoin (Macrobid)
- Sulfonamides should be avoided near term because of risk of kernicterus in newborn
- Avoid fluoroquinolones or tetracyclines
Nosocomial Urinary Tract Infection
* MCC is due to what?
* What is the percent rate that pt develop bacteruria?
* What is the risk of infection with catheterization?
* UTI accounts for how much of nosocomial bacteremias?
- Most common nosocomial due to Foley
- Bacteriuria develops in at least 10-15% of hospitalized pts with indwelling urethral catheters
- Risk of infection about 3-5 % per day of catheterization
- UTI accounts for 15% of nosocomial bacteremias
Nosocomial Urinary Tract Infection
* What are Factors predisposing to UTI in catheterized patients?
- Chronic indwelling catheters
- Open drainage (vs. closed bag drainage)
- Interruption of closed drainage
- Use of broad-spectrum antibiotics
Pyelonephritis
* What are the sxs?
* How do you dx?
- Symptoms include fever, chills, back, or flank pain, nausea and vomiting; urine may show WBC casts
- A clean-catch or catheterized urinalysis with culture and sensitivity identifies the pathogen and determines appropriate antimicrobial therapy
Pyelonephritis
* Elderly patients have what?
* What will guide therapy?
* All patients should have what after treatment?
- Elderly patients may have altered mental status or hypotension with sepsis or Acute renal failure
- Gram’s stain of urine in hospitalized patients will guide therapy;
- All patients should have repeat culture 1 to 2 weeks after treatment and oral antibiotics are typically continued through the results of that culture
What are the most common organisms for Pyelonephritis?
- Escherichia coli
- Klebsiella or Enterobacter (commonly hospital acquired)
- Proteus, Morganella, or Providencia (Urea-splitting Proteus common with staghorn renal calculi)
- Pseudomonas aeruginosa (indwelling catheters, relapsing after multiple antibiotic courses)
- Staphylococcus saprophyticus
- Enterococcus
Risk factors of Pyelonephritis
* What are the risk factors?(5)
Same for UTI seen previously, as well as:
* Pregnancy
* diabetes mellitus
* Polycystic
* hypertensive kidney disease
* insult to the urinary tract from catheterization, infection, obstruction or trauma
Dx of Pyelonephritis:
* What should you do for the PE?
* CBC shows what?
* UA shows?
* What else do you need to do?
* If very complicated pyelonephritis, then you can do what?
* In a male, what do they need do?
- Physical exam: CVAT/CMT/PID/DRE
- CBC with leukocytosis with left shift
- UA shows pyuria, bacteriuria, and possible hematuria. WBCs casts can be shown.
- Urine culture
- If very complicated pyelonephritis, then renal U/S may show hydronephrosis secondary to obstruction.
- In a male, IVP or VCUG needs to be performed following pyelo
- CVAT – costovertebral angle tenderness
- CMT 0- cervical motion tenderness
- PID – pelvic inflammatory disease
- DRE – digital rectal exam
What is the txt of Pyelonephritis? (low and high risk)
- Empiric IV ABX covering typical expected pathogens for risk factors/age group (Rocephin or Cefepime; adjust based on C/S)
- Treat with ESBL and MRSA coverage-Imipenem or meropenem or doripenem plus vancomycin
txt of pyleo:
* Most likely admission, esp with what?
* Additionally, inpatient management is warranted when?
* What is rare?
- Most likely admission, esp. with fever (eg, >38.4°C/>101°F) or pain, marked debility, or inability to maintain oral hydration or take oral medications.
- Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence.
- Oral ABX for outpatient therapy for stable patients only (rare)
Interstitial Cystitis
* What is it?
* Acts like what? But not what?
- Interstitial cystitis/bladder pain syndrome (IC/BPS) is a condition involving chronic bladder pain or discomfort that can have a profound detrimental impact on quality of life.
- Acts like a UTI, but is NOT an infection
Interstitial Cystitis
* Challenges in developing a treatment plan stem from what?
from a lack of clear understanding of the etiology of the disorder, symptom variation across patients, and a paucity of high-quality data regarding the efficacy and safety of IC/BPS treatments (eg, few randomized trials, variation in the definition of the condition and outcome measures)
Interstitial Cystitis
* What are the sxs?
- Suprapubic/pelvic floor pain
- Bladder discomfort that is better with voiding
- Dysuria, hematuria, frequency
- Anterior vaginal wall tn on manual exam
- Dyspareunia
- Pain at tip of penis for men
- Painful ejaculation (2nd to muscular contractions)
Interstitial Cystitis
* How do you dx?
* What is the txt?
* who should you refer to?
* What is last resort?
- No tests
- Treatment: NSAIDs, PT for pelvic floor exercises, amitriptyline
- Botox vs sacral neuromodulation vs Urinary diversion surgery
- Urology referral
- Cystectomy as last resort
Nephrolithiasis/Urolithiasis (Renal Calculi)
* Common cause of what?
* What is common risk factor?
- Common cause of pain, infection, and obstruction
- DM is a common risk factor
What is:
* Urolithiasis –
* Nephrolithiasis –
* Ureterolithiasis –
- Urolithiasis – general urological system stone
- Nephrolithiasis – in the kidney
- Ureterolithiasis – in the ureter
Important distinction – nephrolithiasis does not cause symptoms of pain or discomfort as the stones are simply sitting on the renal calyces. Once they drop into renal pelvis and ureter, they cause symptoms
What are the different types of kidney stones? Rank them from most to least common(6)
- Calcium oxalate/Calcium phosphate – 70 - 80 %
- Calcium phosphate – 15 %
- Uric acid – 8 %
- Cystine – 1- 2 %
- Struvite (UTI) – 1 %
- Mixed (calcium oxalate and uric acid) – 2%
Epidemiology of kidney stones
* How many people are dx with a kidney stone by age 70? (male vs female)
* Race dominate? Less common?
* Highest in what region of the US?
- Kidney stones are a common problem.
- A study based upon the National Health and Nutrition Examination Survey (NHANES) estimated that 19 percent of men and 9 percent of women will be diagnosed with a kidney stone by the age of 70 years.
- Most common in non-Hispanic whites then Hispanics
- Least common in African American and Asian patients.
- Highest in the SE region of USA.
Risk factors of kidney stones
* What are the dietary RFs?high(5)? low (3)?
- Animal protein, oxalate, sodium, sucrose, and fructose.
- Dietary factors associated with a lower risk include calcium, potassium, and phytate.
Risk factors of kidney stones
* What are the nondietary RFs?
- Age, race, body size (wt gain), and environment
- Incidence of stone-highest in middle-aged white men, but stones can form in infants as well as in the elderly
- Geographic variability, with the highest prevalence in the southeastern United States.
- Environmental and occupational influences that may lead to lower urine volume, such as working in a hot environment or lack of ready access to water or a bathroom, are important considerations
Risk factors of kidney stones
* What are the urinary RFs?
- Lower urine volume results in higher concentrations of lithogenic factors and is a common and readily modifiable risk factor
- A randomized trial has demonstrated the effectiveness of higher fluid intake in increasing urine volume and reducing the risk of stone recurrence.
What are common symptoms and more atypical sxs of Kidney stone?
- Patients may present with the classic symptoms of renal colic and hematuria.
- Others may be asymptomatic or have atypical symptoms such as vague abdominal pain, acute abdominal or flank pain, back pain, nausea, urinary urgency or frequency, difficulty urinating, penile pain, or testicular pain.
What is a red flag for hydronephrosis with a kidney stone?
CVA tenderness is a red flag for hydronephrosis
Diagnosis of kidney stones -Labs + imaging
* What are the labs? (4)
* What is golf standard for imaging?
* What is preferred choice for pregnancy? What are the limitions?
- CBC, Chemistry
- U/A & Urine culture
- Gold standard=CT Scan without contrast
- Renal U/S (Can only identify stones within in the kidney, proximal ureter or UVJ) - useful to detect hydroureter/hydronephrosis and is a preferred choice in pregnancy
Diagnosis of kidney stones - imaging
* What can miss small stones?
* What is rarely indicated? (unless when)
- Plain-film (Can only detect LARGE radiopaque stones but will likely miss small stones) – do not use
- Intravenous pyelogram (IVP) is rarely indicated (unless looking for uric acid stones. If needed, make sure there is good renal function since contrast is used
3 places where most kidney stones happen:
How can the stones show up on imaging?
Radiopaque and Radiolucent Stones
* Uric Acid stones are radiolucent
Treatment of Ureteral Calculi:
* What is the cause of emergency therapy?
Urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated in spetic patients with obstructing stones, bilateral obstrucation with acute kidney injury, and unilateral obstruction with acute kidney injury in a solitary kidney
Treatment of Ureteral Calculi
* What is cause of medical therapy?
In a patient who has newly dx urteral stone <5mm and whose sxs are controlled, without sepsis/sirs and with normal renal fxn, observation with periodic evaluation is an option for initial treatment
Treatment of Ureteral Calculi
* What is cause of surgical therapy?
In patients in whom emergency therapy is not indicated, stone removal may be performed in the presence of persistent obstruction, failure of stone progression, or in the presence of increasing or unremitting colic. In patients who require stone removal, the two most commonly applied techniques are ureteroscopy and shock wave lithotripsy (SWL). Ureteroscopy produces better stone-free rates and a reduced need for retreatment
Treatment of Kidney Stones:
* All stones should undergo what?
* Outpatient vs Hospitalization based on what?
* What size pass spontaneously?
* Hx of frequent stones or scarring inside of the ureter lumen inversely affects what?
- All stones should undergo chemical analysis (urinate through strainer)
- Outpatient vs Hospitalization based on clinical presentation, V/S, labs
- Most stones ≤5 mm in diameter pass spontaneously.
- Hx of frequent stones or scarring inside of the ureter lumen inversely affects the size of the stone and chances of spontaneous passage of stone
Treatment of kidney stones:
* Who should be referred to urology for potential intervention?
* What should be used if renal function is jeopardized?
- Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, those with urosepsis/AKI/ nausea/vomiting, or who have not passed the stone after 72hrs should be referred to urology for potential intervention.
- Ureteral stent or Percutaneous nephrostomy (Gold standard) should be used if renal function is jeopardized
Treatment of kidney stones:
* What drugs increase the likelihoof of stone passage?
* What do you give with a patient with stones >5 and ≤10 mm in diameter?
* What is KEY?
* What tends to work better than narcotics?
* What do you give for infected stones?
- Both tamsulosin and nifedipinehave been shown to increase the likelihood of stone passage, with tamsulosin showing slightly better results.
- In patients with stones >5 and ≤10 mm in diameter, treatment with tamsulosin for up to four weeks to facilitate stone passage.
- Hydration is key! IV or PO depending on clinical presentation
- NSAIDs tend to work better than narcotics.
- IV ABX for any infected stones
Explain the flow chart of nephrolithiasis?
Treatment of kidney stones: Calcium oxalate
* What are the risk factors?
* Insensitive to what?
* What should be avoided?
* What is the txt?
*
- Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate.
- This stone type is insensitive to pH in the physiologic range
- Excessive calcium intake (>1200 mg/d) should be avoided.
- A thiazide diuretic, in doses higher than those used to treat hypertension, can substantially lower urine calcium excretion
*
Treatment of kidney stones: Calcium phosphate
* What are risk factors?
* Calcium phosphate stones are more common in who?
- Calcium phosphate stones share risk factors with calcium oxalate stones, but additional factors include:
- Higher urine phosphate levels and higher urine pH (typically ≥6.5) are associated with an increased likelihood of calcium phosphate stone formation.
- Calcium phosphate stones are more common in patients with distal renal tubular acidosis and primary hyperparathyroidism
Calcium oxalate: Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate.
Treatment of kidney Stones: Uric acid stones:
* What are the risks?
* What is going on with the urine pH? What is the prevention?
- Uric acid stones; risks are persistently low urine pH and higher uric acid excretion.
- Urine pH is the predominant influence on uric acid solubility; therefore, the mainstay of prevention of uric acid stone formation entails increasing urine pH
Treatment: Struvite Stones
* Struvite stones may grow how?
* Struvite stones require what?
* What is the prevention?
- Struvite stones may grow quickly and fill the renal pelvis (staghorn calculi).-> Can be due to urea splitting organisms (Proteus)
- Struvite stones require complete removal by a urologist
- New stone formation can be avoided by the prevention of UTIs
Composed of Mag ammonium phosphate
Treatment: Cystine
* Not easily what?
* What is unlikely to be successful?
* Cystine stone prevention?
* May tx with what?
- Cystine excretion is not easily modified
- Long-term dietary cystine restriction is not feasible and is unlikely to be successful
- Cystine stone prevention is on increasing cystine solubility
- May tx with medication that covalently binds to cystine and a medication that raises urine pH.
Pance pearls
Stones over 5 and under 10mm diameter:
* What can you do besides tamsulosin?
- Extracorporeal shock wave lithotripsy: may be used to break up larger stones that are less likely to pass spont. May need multiple txts to reduce the size of the stones
- Ureteroscopy with/without stent: provides immediate relief to an obstructed or at risk kidney
- Percutaneous nephrolithotomy: Most invasive, used for large stone (over 10mm), struvite or if other less invasice modalities fail.
What is the normal voiding reflex?
- Stretch receptors within the detrusor muscle send a signal to the brain
- Brain determines if voiding is appropriate
- Detrusor muscle contracts
- External urethral sphincter relaxes and voiding is completed
What is urinary incontinence?
defined as the unintentional leakage of urine at inappropriate times
Stress urinary incontinence (SUI)
* Most common in who?
* What causes it?
* When do you pee?
- The most common type in females
- Loss of pelvic support leads to descension of the bladder neck from the intra-abdominal cavity
- Painless loss of urine concurrent with Valsalva, cough, laugh, sneeze
What is Intrinsic sphincteric deficiency (ISD)?
Intrinsic sphincteric deficiency (ISD) is a form of stress urinary incontinence that results from a loss of intrinsic urethral mucosal and muscular tone that normally keeps the urethra closed.
Pance Pearls
What are the causes of stress incontinence?(2)
- Laxity of pelvic floor muscles (childbirth, surgery, postmenopausal estrogen loss)
- Ureethral hypermobility: insufficient support from the pelvic floor musculature and the vaginal connective tissue to the urethra and the bladder neck
Urgency urinary incontinence (UUI)-
* MC in who?
* Manifests how?
Urgency urinary incontinence (UUI)- the most common type males, manifests as a sudden and compelling desire to pass urine that is difficult to defer and is accompanied by involuntary leakage.
* Have urgency, freq, small volume voids and nocturia
Urgency urinary incontinence (UUI)-
* Explain the patho behind?
* Patient leaks without what?
* Can be stimulated by what?
- Overactive detrusor muscle w/ uninhibited contractions
- Contractions cause a rise in bladder pressure that overrides the urethral pressure
- Patient leaks urine w/o events that increase intra-abdominal pressure
- Urge component can be stimulated by running water
*
Overflow incontinence
* What is happening?
* What is it accompanied by?
* Caused by what?
- Occurs when urine is retained in the bladder due to incomplete emptying after an attempt to urinate. Loss of urine with no warning (as in urge) or no triggers (as in stress) Leakage or dribbing when incomp emptying, weak or intermittent urinary stream, heitancy, freq and nocturia. Leakage with position changes
- Frequently accompanies injury to the bladder and kidneys.
- Caused by detrusor underactivity, bladder outlet obstruction (BOO).
What is mixed urinary incontinence?
a combination of SUI and UUI, is not common among men. It may be seen when both the bladder and urinary sphincter have impaired function, such as in patients with neurologic disorders (eg, spina bifida, spinal cord injury) or sometimes after prostate surgery or radiation’ or as a result of drug side effect.
- What is post void dribbing?
- What is functional incontience?
- What is incontience after prostate txt?
- What is overactive bladder?
Causes of UUI (BOO or overactive bladder) in males include: (2)
- Medications that can increase bladder contractility or exacerbate obstructive effects (Muscarinic agents along with BPH can cause synergistic effect)
- Neurologic conditions affecting the brain and its response on hyperactive contractility (stroke, normal pressure hydrocephalus) that can also cause UUI.
What are the causes of stress incont in males?
prostate surgery (Most common); Spinal cord injury or disease that impairs sphincter function and Medications that can impair it as well.
What are the Causes of Overflow are BOO or detrusor underactivity in MALES?(5)
- BPH
- Urethral stricture disease
- Neurologic disorders (cauda equina or spinal cord lesions)
- Medications that can decrease bladder contractility/cause detrusor underactivity (anticholinergics, sedatives, TCA’s)
- Post-op urinary retention
What are the risk factors for incont?
Epidemiology of Incont
* How many women experience incont?
* how many men?
* Why might patient may not talk about their incont?
Clinical presentation:
* Urge incont?
* Stress incont?
* Overflow incont?
Clinical presentation:
* Post void dribbling?
* UTI?
* What can contribute or be comorbid with urinary incont?
Clinical Presentation (PE) in Males
* What are the Components of physical examinationin males to evaluate urinary incontinence?
Rectal examination to assess prostate size and consistency for a gross estimate of the degree of benign prostatic hyperplasia (BPH) that could cause bladder outlet obstruction (BOO).
Abdominal examination after voiding to:
* Assess for a palpable bladder that may be present with incomplete emptying
* Assess for an abdominal mass that could cause pressure on the bladder
Clinical Presentation (PE) in Females-Urinary incont
* Most can be managed how?
* When should a women undergo pelvic exam with special attention to stuctures?
What is the anatomy of a cystocele?
occurs when the wall between a woman’s bladder and her anterior vagina wall weakens and stretches, allowing the bladder to bulge into the vagina
- What are the causes of cystocele? (5)
- How do you need to evaluate?(3)
Diagnosis of Cystocele:
* What should be proformed on all patients? When is Urine culture suggested?
* What do you not routinely check for unless there is what?
- A urinalysis should be performed for all patients, and urine culture performed if a UTI, glycosuria, or hematuria is suggested on screening.
- We do not routinely check renal function unless there is concern for severe urinary retention resulting in hydronephrosis. Other laboratory testing is determined by signs or symptoms elicited on history and physical exam.
What are the clinical tests for dx of cystoceles?(3)
- Bladder stress test
- Post-void residual test
- Urodynamic studies-overflow
What is post void residual?
* What is normal?
* When do you need to insert foley?
- Measure volume of urine left in bladder after voiding by catheter or most typically bladder scanner
* Normal bladder holds up to 500ml pre-void - <50ml is normal in adults (<100 in 65+yo) postvoid
- > 300ml – insert foley
Txt of incontinence:
* What are the lifesyle modifications?
* What do we do in all but overflow?
- Lifestyle modifications: Weight loss (esp. in SUI), dietary changes, constipation treatment, smoking cessation.
- All but overflow: Pelvic floor muscle exercises (Kegel)
Stress incont txt:
* What are other meds?
* What are some surgeries?
- SUI: no FDA meds. Duloxetine, imipramine. Vaginal pessaries
- Topical estrogen (Estrace) for vaginal atrophy in post menopausal women
- Surgery includes urethropexy, midurethral slings (Females), microwave therapy, transurethral radiofrequency ablation, laser vaporization of prostate, transurethral resection of prostate, and open prostatectomy (Males)
Treatment of Incontinence
* UUI/OAB: What can you do?
* Overflow?
* Functional?
- UUI/OAB: bladder training with antimuscarinic (tropium, darifenaccin) and/or Beta 3 agonist medications (mirabergron, virbegron) (Oxybutynin/terazosin/vesicare)
- Overflow: Self-catherization (permanent or temp)
- Functional: Treatment of underlying cause
What is vaginal pessary?
What are the different slings in surgical managment of SUI?
What are the last resort options for overactive bladder?
- Last resort surgical options:
- Percutaneous tibial nerve -> stimulation
- Sacral neuromodulation (Botox)
How does sacral nueromodulation and sacral nerve stimulator work?
When do you need to do patient education or referral in males for incont?
In a small number of cases, referral to a specialist is warranted for patients with urinary incontinence. Indications for referral include the presence of what in FEMALES?
- Associated abdominal or pelvic pain in the absence of UTI
Culture-proven recurrent UTIs (three or more per year or two in six months) - Gross or microscopic hematuria with risk factors for malignancy in the absence of a UTI
- Lifelong incontinence or suspected vesicovaginal fistula or urethral diverticula on vaginal examination
- Other abnormal physical examination findings (eg, pelvic mass, pelvic organ prolapse beyond the hymen, difficulty self cathing)
Geriatric population with Urinary Incontinence and Voiding Dysfunction
* What are the most common causes? (7)
- Transient urinary incontinence
- Detrusor hyperactivity
- Detrusor – underactive or areflexic
- Intrinsic sphincter deficiency
- Bladder outlet obstruction
- Bladder prolapse
- Female pelvic floor disorders
Detrusor Underactivity
* What is it?
* What are the three phases?
- Detrusor underactivity (DU) is reduced strength or duration and/or failure to achieve complete bladder emptying within a normal time span
- Voiding phase: straining, hesitancy, weak stream
- Storage phase: loss of normal urge to void, reduced urination, nocturia
- Post-voiding phase: feeling of incomplete emptying
Detrusor Underactivity
* What does the biopsy of detrusor muscle show?
* May coexist with what?
- Biopsy of detrusor muscle shows axonal degeneration, muscle loss and fibrosis
- May coexist with detrusor overactivity (with impaired contractility)
Intrinsic Sphincter Deficiency
* What are the causes?
Bladder outlet obstruction causes:
* Mechanical intrinsic?
* Wall?
* Extrinsic?
* Neuropathic?
* Drug induced?
- Mechanical Intrinsic: FB, clot, stones
- Wall: Urethral valves (male neonates)spasms, tumor, stricture, fibrosis
- Extrinsic: BPH/CA, prostatitis, pregnancy, constipation, fecal impaction
- Neuropathic: Spinal cord trauma, GBS, MS
- Drug induced: Anticholinergics and antidepressants
Neurogenic Bladder
* What is it?
* What are the types?
What are the causes of neurogenic bladder?
What is the clinical presentation of Neurogenic bladder?
- Overactive and underactive bladder
- Urinary frequency/nocturia
- Stress/urge incontinence
- Urinary retention
Dr V:
* Antimuscarinics or beta 3 agonist: help increase holding capacity
* Alpha blockers may improve bladder emptying in pts who spontaneously void
Vesicoureteral reflux (VUR)
* What is it?
* What is the clinical significance?
- Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder into the upper urinary tract.
- clincal significance: predisposes patient to acute pyelo by transporting bacteria from the bladder to the kidney and recurrent urinary tract infection, which may lead to renal scarring, hypertension and end stage renal disease
Explain the difference between normal and VUR anatomy?
Primary VUR:
* Cause?
* Typically in who?
- From congenitally incompetent closure of incompetent UVJ which forces urine against the flow upon bladder contraction
- Typically found in a newborn
Secondary VUR:
* Cause?
* What is it associated with?
- From abnormally high pressure in bladder that causes UVJ to inadequately close during bladder contraction (inhibiting the urge to void)
- Highly associated with BOO (posterior urethral valves)
Dx of VUR:
* Commonly found in who?
* Dx based on what?
- Primary VUR is the most common urologic finding in children, occurring in approximately 1 percent of newborns.
- The diagnosis of VUR is based upon the demonstration of reflux of urine from the bladder to the upper urinary tract by either contrast voiding cystourethrogram (VCUG) or radionuclide cystogram.
Treatment of VUR:
* What is the medical therapy?
* When do you need surgical therapy?
Medical Therapy
* Daily ABX prophylaxis
* Cotrimoxazole/Nitrofurantoin QHS
* Breakthrough infections based on C/S
Surgical Therapy
* Grades 4/5 OR if recurrent UTI despite prophylactic medical therapy or deterioration of renal function despite treatment
urethral stricture:
* What is it?
* Common in who?
* What ist he most common etiology?
* What accounts for 45% of cases?
- narrowing of the urethra that obstructs the flow of urine
- Urethral strictures are relatively common in men.
- The most common etiology is idiopathic in developed countries and trauma in developing countries.
- Iatrogenic injuries, such as oversized resectoscope at the time of transurethral surgery and traumatic placement of indwelling urinary catheters, account for 45 percent of all cases.
- What is the clinical presention of urethral strictures?
- How do you dx it?
- What is the txt?
Sympotms: Chronic obstruction sx and recurenet UTIs
* Abdominal Pain
* Urinary frequency/Urgency
* Difficulty urinating
* Dysuria
* Hematuria
* Hematospermia
Dx: VCUG
Tx: Meato/urethroplasty or excision/reanastomosis (endoscopic txt)
Common txts of urinary strictures:
* Dilation:
* Urethrotomy:
- Dilation: Stretching the stricture with a medical instrument. This is one of the simplest treatments but often needs to be repeated periodically as strictures tend to recur.
- Urethrotomy: An internal cut is made in the stricture with a special instrument inserted through the urethra. This procedure is typically done under local or general anesthesia
Common txts of urinary strictures:
* Urethral stents:
* Urethroplasty?
- Urethral Stents: Sometimes a stent (a small tube) can be placed in the urethra to keep it open. This approach is less common and usually reserved for specific situations.
- Urethroplasty: This is a surgical repair of the stricture and is considered when other treatments fail or the stricture is long. The affected part of the urethra may be removed, and the urethra is reconstructed. Tissue grafts from the patient or a flap of skin may be used to reconstruct the urethra.
Urethral prolapse
* What is it? Common in who?
* What are the sxs?
- Urethral prolapse is a red papule at the urethral meatus that is seen in premenarchal or postmenopausal individuals.
- Dysuria may be present. The lesion is differentiated from the urethral caruncle by its presentation as a circumferential, bright red nodule around the meatus, making a donut shape around the urethral orifice.
Urethral prolapse
* What is the most common in menopausal women? What is it?
Urethral caruncle is most common in a post-menopausal female and is a fleshy benign outgrowth of posterior urethral meatus. Sometimes presents with bleeding.
Treatment in Premenarchal Females
* Premenarchal girls with symptomatic urethral prolapse can be treated with what?
* What else can be helpful?
- Premenarchal girls with symptomatic urethral prolapse can be treated with topical estrogen therapy (eg, Premarin cream or Estrace cream 0.01%) same as postmenopausal women with this problem.
- Sitz baths twice daily may also be helpful. Topical estrogen cream is applied twice daily after the sitz bath for two weeks, then the urethra is reassessed and treatment is continued if the prolapse has not resolved and is still present.
Treatment in Premenarchal Females
* How long does it take to resolve?
* What can rarely happen?
The prolapse will usually resolve within a few weeks of topical estrogen treatment but can sometimes take longer. Rarely, the distal urethra can be necrotic, and if so, it may require surgery. If there is persistence of the prolapse, assessment for a urethral polyp may be indicated.
Treatment in Premenarchal Females
* What are some other txts?
* What can you do if conservative treatment does not work?
What are some congenital or Pediatric Urinary conditions?
Meatal stenosis:
* MC in who? What it is?
* What are typical sxs?
- Urethral meatal stenosis is almost always a condition of circumcised boys. It is thought that stenosis develops from irritation of the newly exposed meatus, which usually occurs on the ventral lip.
- Typical presentations occur after toilet training and include an upward deflected urine stream, inability to direct the stream into the toilet, or a small stream with prolonged voiding time.
Meatal stenosis:
* Often boys will push their penis where and why?
* What are other less common sxs?
* What does txt involve?
- Often boys will push their penis between their legs to direct the upward pointed urinary stream into the toilet. Other less common presentations include episodes of gross hematuria, dysuria, and UTI.
- Treatment involves office or operating room meatotomy where a few millimeters of the ventral lip of the meatus are divided. Sutures are then usually used to reapproximate the cut edges.
Hypospadias
* What is it?
* How is it dx?
congenital displacement of urinary duct on the underside of penis instead of tip. Degree can vary from just under the rim of head of penis to the scrotum.Glans size can vary as well.
Dx: During newborn exam
* Abnormal foreskin resulting in an incomplete closure around the glans leading to the appearance of a dorsal hooded prepuce.
* Abnormal penile curvature (chordee).
* Ectopic urethral meatus or blind ending urethral pit
Pance pearls:
Hypospadias:
* What is it?
* What is the patho?
* What is the txt
- Congenital: abnormal VENTRAL placement of the uwethral opening, penile curve and abnormal foreskin development
- Patho: Failure of urogenital folds to fuse
- Txt: NOT circumcised in neonatal period because foreskin may be used to repair the defeat. Surgery usually between 6m-1yo
Chordee
* What does it affect?
* What is it characterized by?
* Common in who?
* What is the txt?
- Chordee affects the cosmetic appearance of penis.
- It is characterized by formation of thick fibrous tissue bands that pulls the penis sideward; thereby making it look curvy or bent. It is noteworthy that the curviness of penis becomes particularly prominent during penile erection.
- This condition is frequently observed in young males who have hypospadias.
- Tx: Surgical correction
Epispadias:
* What is it?
* Patho?
* Assoicated with what?
* What is the txt?
- Congenital abnormality in which the urethra is on upper surface (DORSAL) of the penis
- Patho: failure of midline penile fusion
- Often assoicated with bladder exstrophy
- Similar Tx as to hypospadias
* Correct urethral duct and chordee if present
Enureis:
* Urinary incontinence is a common problem in who?
* Most of these children have what?
* Common in who?
What is primary enuresis? What is the cause?
- Definition: This occurs when a child has never been consistently dry at night for an extended period, typically defined as six months or longer. In other words, the child has never achieved nighttime bladder control
- Cause: Developmental Delay or Genetics
What is secondary enuresis? What are the causes?
Definition: This occurs when a child or adult who has been consistently dry for at least six months starts wetting the bed again.
Causes:
* CKD, LUTS, urethral valves
* Constipation, Pinworms
* Sickle Cell Disease
* Seizures
* DM/DI
* OSA
Enuresis:
* What does the PE show? What should you screen for?
* What should be performed?
PE is Usually normal
* Screen for daytime hydration patterns and voiding patterns (some kids tend to not drink at school, but drink most fluids 4-5hrs prior to bedtime at home)
U/A should be performed.
Enuresis:
* What are different things you need to look at?
Daytime incontinence, urgency, holding measures, increased (≥8 times/day) or decreased (≤3 times/day) voiding frequency (possible bladder dysfunction)
* Weak stream, use of abdominal pressure, continuous incontinence, micturition in more than one phase (possible neurogenic bladder or anatomic abnormalities)
* Proteinuria, nausea, weight loss, or fatigue (possible kidney disease)
* Excessive thirst, need for nighttime drinking (possible polydipsia or kidney disease)
Enuresis:
* What is the txt?
Treatment includes CBT (motivational therapy) and bladder training-> enuresis alarm and if failed -> then drug therapy: desmopressin (DDAVP).
What is the alarm system?
Cryptorchidism
* What is it?
- Cryptorchidism is the most common congenital abnormality of the genitourinary tract.
- Most cryptorchid testes are undescended, but some are absent (due to agenesis or atrophy).
What are the risk factors of cryptorchidism
cryptorchidism
* Common age?
* When do most (approximately 70 percent) undescended testes descend spontaneously ?
* Ascending testes (acquired undescended testes) appear
how?
Disease is connected to what?
Clincal presentation of Cryptorchidism
* Most testicles that are undescended at birth complete their descent when?
* Painful or painless? What is not affected?
* If they have not descended by twelve months of age, they are what? What needs to happen?
* What is the goal of management?
What is orchipexy?
Patient Education or Referral/Consult of undescended testes:
* Potential complications and sequelae of true undescended testes (including ascending or acquired undescended testes but not retractile or absent testes) include what?
* Potential complications of ectopic testes include what?
- Potential complications and sequelae of true undescended testes include inguinal hernia, increased risk of testicular torsion and testicular trauma (for intracanalicular testis – from compression against the pubic bone), subfertility, and malignant transformation.
- Potential complications of ectopic testes include blunt trauma from compression against the pubic bone and decreased spermatogenesis
Bladder cancer:
* What is the TNM staging system?
Bladder Cancer
* What is a major red flag?
The presence of unexplained (or painless) hematuria in individuals over 35 years of age requires evaluation for possible malignancy.
What are the risk factors of bladder cancer?
Bladder cancer:
* Most common what?
* What is the most common type?
- Bladder cancer is the most common malignancy involving the urinary system.
- Urothelial (transitional cell) carcinoma is the predominant histologic type
*
Clinical presentation of bladder cancer:
* Most common sxs?
* If pain involved then what?
* Voiding symptoms are most common in patients with who?
* What are sxs of poor prognosis?
Physical exam of bladd cancer:
* What can you revel? (5)
Dx of bladder cancer:
* What do you need to r/o and who?
* How do you r/o cancer?
* What is the only way to make definitive dx?
What is the txt of bladder cancer?
