Urinary Incontinence and Obstruction Flashcards
What are the history and PE findings for acute cystitis?
much more common in women, acute onset of irritative voiding sx (frequency, urgency, dysuria), often without fever, may have suprapubic discomfort; PE often unremarkable aside from suprapubic discomfort; for men evaluate prostate for enlargement or irregularity
What are the lab findings for acute cystitis?
dipstick (UA) + pyuria, hematuria; microscopy +pyuria, bacteriuria, RBC; microbiology E coli MC
What is the imaging for acute cystitis?
rarely required for women; for men obtain bladder US, prostate US, post void residual
What is the hx for BPH?
Hesitancy, decrease force of stream, incomplete emptying, double voiding, straining to urinate, post void dribbling; get complete abd exam, male genital, rectal exam neuro exam
What lab/imaging should be done for BPH?
Dipstick/UA shows POC, microscopy, gram stain with C&S for any abnormal; US (bladder scan with PVR and transrectal US specific for prostate); cystoscopy (direct visualization of bladder)
Review
flow charts/diagrams
What is urge incontinence?
detrusor muscle overactivity; more common in women; leaking following an urgent need to urinate that cannot be forestalled; similar in men but commonly also in the presence of BPH; evaluate or correctable causes such as acute cystitis or prostatitis
What is the treatment for urge incontinence?
Bladder training, Kegel exercises, anticholinergics, B3 agonists
What is stress incontinence?
Urethral incompetence; instaneous leakage of urine in response to increased intra-abd pressure (coughing, lifting, laughing)
What are some possible causes of stress incontinene in women?
Secondary to childbirth (cystocele, vaginal prolapse, etc) or decreased estrogen associated with menopause
What is the treatment for stress incontinence?
lifestyle modifications such as limiting caffeine and fluids, Kegel exercises, pessaries or vaginal cones, no meds available, surgical correction may be required (most effective)
What are possible causes of stress incontinence in men?
secondary to TURP or radical prostectomy
What is overflow incontinence?
secondary to urethral obstruction and urinary retention; more common in due to BPH, relatively rare in women
What is the hx for overflow incontinence?
dribbling incontinence after voiding, urge incontinence due to detrusor overactivity (frequency, nocturne, leaking frequent small amounts), or incontinence without bladder emptying
UTI in men may be the first presentation for what?
urinary retention secondary for urethral obstruction (any male UTI needs to be evaluated for pathology)
What is the tx for overflow incontinence?
foley catheter for decompression; intermittent self catheterization + alpha antagonist (terazosin, prazosin, tamsulosin); men with BPH may benefit from additional tx with Finasteride
What is always the initial lab testing for acute cystitis, BPH, urge, stress and overflow incontinence?
dipstick
What additional testing should be done for acute cystitis?
microscopy, gram stain, C&S for any positive result
What additional testing should be done for BPH?
none
What additional testing should be done for urge incontinence?
none
What additional testing should be done for stress incontinence?
Rarely bladder stress test (physician observes pt standing, performs Valsalva maneuver)
What additional testing should be done for overflow incontinence?
US bladder scan, PVR
Any positive dipstick result requires what?
microscopy, gram stain, C&S
What is the initial imaging for acute cystitis?
none for women, men imaging for prostate (trans rectal US, CT pelvis) and/or cystoscopy
What is the initial imaging for BPH?
transrectal US, possible bladder scan with PVR
What imaging should be performed for urge and stress incontinence?
none
What initial imaging should be performed for overflow incontinence?
bladder US with PVR (>200); additional testing includes CT pelvis (case specific based on PE)
What investigations should be done for acute cystitis?
none unless fails to resolve, or cystoscopy
What procedural investigations should be done for BPH?
cystoscopy (and/or CT pelvis)
What procedural investigations should be done for urge and stress incontinence?
none
What procedural investigations should be done for overflow incontinence?
cystoscopy (and/or CT pelvis
What are the lifestyle modifications recommended for BPH?
limit fluids before bedtime and travel, limit mild diuretics such as caffeine and alcohol, avoid constipation, Kegel exercises at time urinary urgency, timed voiding rather than waiting for sensation, double voiding technique
What medications can be given for BPH?
A-adrenergic receptor blockers, phosphodiesterase type 5 inhibitors, 5-alpha reductase inhibitors to prevent progression; concurrent overactive bladder sx (B-3 adrenergic agonists, anticholinergics)
What surgical options exist for BPH?
transurethral ablation (TURP) to total prostatectomy
What is the MOA for alpha-adrenergic blockers?
affect on prostatic smooth muscle leading to relaxation of smooth M of the bladder neck and prostatic urethra
What are the side effects for alpha adrenergic blockers?
dizziness, rhinitis, hypotension
What are the side effects for PDE5 inhibitors?
relatively rare (HA, flushing)
What is the MOA for 5-a reductase inhibitors?
Prevent progression; blocks conversion of testosterone to DHT
What are the side effects for 5-a reductase inhibitors?
suppression of PSA level, sexual dysfunction
What is the MOA for B-3 adrenergic agonists?
effective with overactive bladder sx via detrusor relaxation
What are the side effects for B3 adrenergic agonists?
elevated BP
What is the MOA for anticholingerics (antimuscarinic)?
decrease involuntary detrusor contractions triggered by ACh; contraindicated gastric retention and agile closure glaucoma
What are the side effects for anticholingergics?
dry mouth, blurred vision for near objects, tachycardia, drowsiness, decreased cognitive function, consitpation
What is the MOA for OTC Saw Palmetto?
unclear and not recommended
What are the lifestyle recommendations for acute cystitis?
regular bladder emptying, particularly after intercourse, increase free water to maintain clear to light yellow urine
What additional tx exists for acute cystitis?
Abx, phenazopyridine (urinary analgesic OTC such as AZO or pyridium), topical estrogen for post menopausal women with >3 UTI/year
What makes pt high risk?
Any one of the following in 3 months prior to presentation of acute cystitis: inpatient stay in a health care facility, use of fluoroquinolone, TMP/SMZ, or broad spectrum beta lactam, presence of MDR urinary isolate, travel to parts of the world with high rates of MDR organisms
Follow up is required for pts with what initial presentation?
hematuria; asymptomatic hematuria may indicate pathology anywhere in the urinary system ranging from glomerular disease to occult cancer
What are the characteristics for extraglomerular hematuria?
red or pink in color, clots may be present, proteinuria of <500mg/day, RBC morphology normal, RBC casts absent
What are the characteristics for glomerular hematuria?
Red, smoky brown or Coca-cola color, clots absent, proteinuria may be >500mg/day, some RBCs are dysmorphic, RBC casts may be present
What is the tx + procedures for urge incontinence?
- bladder training (scheduled voiding) + Kegels; 2. medications if behavior approach fails (anitmuscarinic agents or B3 agonists)
What are the Tx + procedures for stress incontinence?
Lifestyle modifications (limit caffeine, fluid intake), Kegels; pessary or vaginal cones; surgery has a high cure rate of 96%
What are the tx + procedures for overflow incontinence?
bladder decompression (catheter placement); mediation admin with or wo intermittent self catheterization (MC meds are alpha blockers); surgery for cystocele, uterine prolapse, or BPH if medical management fails; sacral nerve stimulation for neurogenic underactivity
What is the chapman point for the bladder?
anterior is immediately surrounding the umbilicus and on pubic symphysis; posterior point on the superior edge of L2 TP
What is the chapman point for the urethra?
anterior point superior pubic symphysis, posterior point superior edge of L2 TP
