Urological diseases Flashcards
Describe stress urinary incontinence
- leakage on effort or exertion, sneezing or coughing
- occurs as a result of bladder neck / urethral hypermobility and or neuromuscular defects causing intrinsic sphincter deficiency
- urine leaks whenever urethral resistance is exceeded by increased abdominal pressure
Describe urge urinary incontinence
- leakage accompanied by or immediately preceded by urgency
- may be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone)
What is mixed urinary incontinence?
A combination of urge urinary incontinence and stress urinary incontinence
Bedwetting in elderly men usually indicates what?
High pressure chronic retention
Post micturition dribble can be due to what?
Bulbar urethra
A constant leak of urine suggests what?
- a fistulous communication between the bladder (usually) and vagina (e.g. due to surgical injury at the time of hysterectomy or caesarian section)
- or rarely due to the presence of an ectopic ureter draining into the vagina
Name risk factors for incontinence
- female
- caucasian
- genetic predisposition
- neurological disorders; spinal cord injury, stroke, MS, parkinsons
- anatomical, vesicovaginal fistula, ectopic ureter, urethral diverticulum, urethral fistula, bladder extrophy, epispadias
- childbirth; vaginal delivery, increasing parity, pregnancy
- pelvic, perineal and prostate surgery
- radical pelvic radiotherapy
- diabetes
Name promoting factors for incontinence
- smoking; causing cough
- obesity
- infection; UTI
- increased fluid intake
- poor nutrition
- ageing
- cognitive deficit
- poor mobility
- oestrogen deficiency
Name red flags of an incontinence history
- pain
- haematuria
- recurrent UTI
- significant voiding / obstruction symptoms
- history of pelvic surgery / radiotherapy
Name the basic investigations for incontinence
- bladder diary (frequency/ volume chart)
- urinalysis +/- culture
- flow rate and post void residue
- pad testing
Describe the conservative treatment of incontinence
- pelvic floor exercises
- lifestyle modifications
- biofeedback
- medication; duloxetine (inhibits reuptake of both serotonin and noradrenaline, acts to increase sphincteric muscle activity during bladder filling)
- electrical stimulation of pelvic floor
Describe injection therapy for treatment of incontinence
- the injection of bulking materials into the bladder neck and periurethral muscles to increase outlet resistance
- main indication is for female stress incontinence secondary to demonstrable intrinsic sphincter deficiency in the presence of normal bladder muscle function e.g. macroplastique or teflon
What are the contraindications and complications of injection therapy for treatment of incontinence?
Contraindications;
- UTI
- untreated bladder overactivity
- bladder neck stenosis
Complications;
- temporary urinary retention
- de novo urge incontinence
- UTI
- haematuria
What is retropubic suspension?
- used to treat female stress incontinence predominantly caused by urethral hypermobility
- aim is to elevate and fix the bladder neck and proximal urethra in a retropubic position in order to support the bladder neck
An artificial urinary sphincter is a closed pressurised system with what three components?
- an inflatable cuff placed around the bulbar urethra or bladder neck
- a pressure regulating balloon placed extraperitoneally in the abdomen
- an activating pump in the scrotum or labia majora
What is overactive bladder?
A symptom syndrome that includes urgency, with out without urge incontinence, usually with frequency and nocturia. Usually caused by bladder (detrusor) overactivity
Describe the conservative treatment of overactive bladder
- MDT approach
- pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy may provide some benefit
- behavioural modification; modify fluid intake, avoid stimulants (caffeine, alcohol), bladder training
What is the most common cancer in men in the UK?
Prostate cancer
75-85% of prostate cancers arise in which zone?
The peripheral zone
Prostate cancer affecting ‘waterworks’ tends to occur in which lobe of the prostate?
Median lobe
What tests can be used to stage prostate cancer?
- MRI
- bone scan
Name treatments for prostate cancer
- radical prostectomy
- external beam radiotherapy
- brachytherapy
What is brachytherapy?
Seeds of radioactive substance implanted inside tissue
LHRH agonists have what role in prostate cancer treatment?
Stop the production of testosterone from the testis thereby slowing the growth of prostate cancer
Is bladder cancer more common in men or women?
Men
If a patient presents with painless frank haematuria, what must be excluded?
Urinary bladder cancer
Name investigations for bladder cancer
- CT urogram
- flexible cystoscopy
Describe the treatment of bladder cancer
- transurethral resection
- low risk; cystoscopy, urine cytology every 6 mnths for 3-5 years
- high risk; intravesical therapy, cytoscopy, urine cytology; every 3mnth for 1 year, every 6mnth for 5 years and every 12mnths for 10 years
Name causes of bladder outflow obstruction (BOO)
- benign prostatic hyperplasia
- urethral stricture
- prostate cancer
- bladder stones
- extrinsic; cystocele, pelvic non-urological cancers
- drugs such as anticholinergic and nasal decongestants
What symptoms are associated with storage problems (when the bladder if filling with urine)?
- frequency
- urgency
- nocturia
What symptoms are associated with voiding (when the patient is trying to pass urine)?
- hesitancy
- poor flow
- intermittent flow
- sensation of incomplete emptying
- post micturition dribbling
What questionnaire can be used to assess incontinence symptoms?
IPPS - international prostate symptom score
When is a renal ultrasound indicated?
- impaired renal function
- loin pain
- haematuria
- renal mass on exam
When is cystoscopy indicated?
- previous urological surgery
- haematuria
- profound symptoms
- pain
- recurrent UTIs
When is transrectal ultrasound indicated?
- elevated PSA, abnormal DRE
- surgical treatment planning
- TRUS volume >100mls - significant
Describe medical management for LUTS
- bladder; bladder muscle relaxants, anticholinergics
- prostate; drugs to relax prostate (alpha blockers), drugs to shrink prostate (5 alpha reductase inhibitors)
