Urology Flashcards
2 most common forms of male incontinence
- Stress urinary incontinence (SUI)
- Overactive bladder (OAB) with concomitant urge urinary incontinence (UUI)
AFP 2017
6 categories of persistent, non-neurogenic urinary incontinence
- Stress urinary incontinence (SUI)
- Overactive bladder (OAB) with concomitant urge urinary incontinence (UUI)
- Mixed incontinence (e.g. mix of SUI and UUI)
- Overflow incontinence (or paradoxical)
- Continuous urinary incontinence (eg fistula)
- Functional incontinence
AFP 2017
Pathophysiology and causes of Stress Urinary Incontinence (SUI)
Pathophysiology: underlying dysfunction of urethral sphincter complex and/or change in urethral axis. Other bladder conditions such as detrusor underactivity/overactivity and poor bladder compliance co-exist and contribute
Causes:
- complication following prostate surgery, e.g. radical prostatectomy or TURP -> anastomotic stricture and scarring
- iatrogenic sphincter injury, e.g. sphincterotomy in spinal patients
- neurological conditions
- pelvic floor trauma, e.g. pelvic trauma in MVA
AFP 2017
Name some risk factors for post-prostatectomy Stress Urinary Incontinence (SUI)
- age
- BMI
- pre-operative bladder function and urinary continence status
- prior radiotherapy
- pre-operative length of membranous urethra
- prior TURP
- vascular co-morbidities
- stage of disease
- surgical technique employed, include nerve sparing
- surgeon’s experience
AFP 2017
What is Overactive Bladder (OAB)?
syndrome characterised by unstable bladder contractions, resulting in urinary urgency, frequency and nocturia in the absence of detectable disease (diagnosis of exclusion)
OAB is frequently associated with urinary urge incontinence (UUI). Classically, patients with OAB report difficulty suppressing the urge to urinate.
AJGP 2020
5 pathological categories of differential diagnoses for Overactive Bladder (OAB)
(think surgical seive)
- Neurological (neurogenic detrusor overactivity)
- Malignancy
- Lower urinary tract
- Systemic pathologies
- Medications
AJGP 2020
7 neurological ddx for overactive bladder (OAB)
- Stroke
- Multiple sclerosis
- Dementia
- Diabetic neuropathy
- Spina bifida
- Spinal trauma
- Reversed diurnal rhythm
AJGP 2020
Malignancy ddx for overactive bladder (OAB)
Bladder cancer (majority caused by urothelial carcinoma including carcinoma in situ)
AJGP 2020
4 lower urinary tract ddx for overactive bladder (OAB)
- Recurrent urinary tract infection
- Bladder outlet obstruction (including benign prostatic hyperplasia, urethral stricture)
- Foreign body in lower urinary tract (eg eroded synthetic mesh, urolithiasis)
- Overflow incontinence
AJGP 2020
3 systemic pathologies ddx for overactive bladder (OAB)
- Obstructive sleep apnoea
- Congestive heart failure
- Diabetes resulting in polyuria
AJGP 2020
3 medications causing symptoms of overactive bladder (OAB)
- Diuretics
- Anticholinergics
- Narcotics
AJGP 2020
Outline clinical assessment of patient with symptoms of overactive bladder (OAB)
History:
- qualification/quantification of local symptoms (e.g. urinary freuqnecy = ≥ 8 voids over 24 hrs, nocturia = ≥ 1 void per night, urinary urgency = Inability to defer voiding, urge incontinence = inability to defer voiding, severity (number and size of pads used, preferably pad weights) )
- obstetric history
- Exclude other types of incontinence, e.g. stress, mixed, overflow, etc.
- Impact on QOL: can use validated questionnaires for ax of severity and burden + establishment of baseline, e.g. OAB-q, ICIQ-OAB (international consultation on incontinence questionnaire)
- Rule out sinister and reversible conditions, e.g. UTI, urolithiasis, bladder ca, neurological conditions
- sexual function
- PMHx
- medication history
O/E:
- Abdominal exam to detect any abdominal or pelvic mass (eg palpable bladder), perineal examination for sensory loss, digital rectal examination for prostate size and nodules, and pelvic floor tone.
- Neurological (gross/relevant) to exclude
Bedside test:
urinalysis, bladder scan (post-void residual >200ml considered significant), pad test (ie weighing the pad to measure the volume of urinary incontinence) can diagnose the severity of urinary incontinence and may be used to indicate treatment outcome.
Ix:
- FBP
- UEC
- Fasting BSL
- PSA
- urine MCS (? UTI ? haematuria ? glycosuria ? pyuria)
- +/- urine ACR depending on presence of proteinuria and eGFR
- urine cytology (particularly in patients at high risk of bladder cancer if there has been a recent onset of symptoms)
- USS KUB with post-void residual
- bladder diary: useful objective information regarding fluid
intake (including irritants such as caffeine and alcohol) and urinary volumes, as well as assist in quantifying incontinence episodes and identifying reversed diurnal rhythm.
- CT KUB: could assist in the identification of
fistulas, strictures, bladder diverticulae or tumours
Referrals:
- urology review for specialised investigations e.g. cystoscopy or urodynamics or if history of haematuria, neurological or prior genitourinary surgery, radiation or trauma
AFP 2017; AJGP 2020
How does one do a bladder diary?
A three day frequency–volume chart or bladder diary is often very useful in men who report mixed incontinence.
The patient should be advised to keep a bladder diary
to record the number and time of voids in a 24-hour period,
volumes voided, incontinence episodes, fluid intake, degree of urgency and incontinence over a three-day period. The bladder diary allows documentation of functional bladder capacity, and checks for nocturnal polyuria (where nocturnal voided volume is >33% of the 24-hour volume) and incontinence
AFP 2017
3 pathophysiological mechanisms for overactive bladder (OAB)
Proposed pathophysiological mechanisms include
age-related changes in smooth muscle, leading to:
• hyper-excitability of muscarinic receptors in the detrusor
smooth muscle, urothelium and neurovascular structures, and atropine resistance
• increased afferent (sensory group C fibres) nerve activity and hypersensitivity of other ion channels
• denervation at the spinal and cortical levels, resulting in hyperactive voiding that is secondary to spinal micturition
reflexes
AFP 2017
What is the role of urodynamic studies?
- role in patients with suspected voiding difficulties or neuropathy, failed treatment, or those considering surgical treatment.
- physiological assessment of bladder and outlet function, and demonstrate dyssynergia of bladder contraction and outlet opening, such as seen in bladder denervation.
- E.g. Urinary Urge Incontinence (UUI) is detrusor overactivity, which is a urodynamic observation of involuntary bladder contractions that are commonly associated with a corresponding sensation of urgency during bladder filling. Enlarged prostate and ensuing bladder outlet obstruction can
result in bladder adaptations and abnormal bladder contraction (ie detrusor overactivity).
AFP 2017
