Urology Flashcards
RF for urinary incontinence
women increases with age childbirth pelvic surgery pelvic radiotherapy neurological disorders
Causes of temporary incontinence
DIAPPERS D - delirium, dementia I - infection A - atrophic vaginitis P - pharmaceuticals - diuretics, opiates, Ca antagonists, anticholingergics P - psychological - depression, anxiety E - endocrine, excess fluid - CCF, polyuria R - restricted/ reduced mobility S - stool impaction (constipation)
What drugs may cause incontinence?
diuretics, opiates, Ca antagonists, anticholingergics
What are the two phases of urine physiology?
what happens at each stage?
Storage phase - urine collects in bladder -> sphincter tone gradually increases
- NO significant change in vesicle pressure, detrusor pressure, intra-abdominal pressure
Voiding phase - intravesical pressure increases due to detrusor contraction and sphincter relaxes allowing urine to leave bladder
What examinations are important in urinary incontinence?
Exam
- Neurologic assessment of abdo, pelvis and rectum
Perineal sensation; sphincter tone
- Cough test - observe leakage
- Women - abdominal and pelvic exam
Sims speculum exam - assess for pelvic prolapse
Vaginal mucosal atrophy; cystoceles; rectoceles
What Ix are important in urinary incontinence?
U&Es
MSSU/urinalysis
- Rule out infection, haematuria
Flow studies
Bladder diary - amount of fluid taken in, amount of urine per void, number of voids, number of incontinent episodes
Other if needed- persistent/severe or symptoms of concern - USS, cystoscopy
Definitive Ix = urodynamics
- Examine intravesical pressure obtained with bladder filling as assess both leaking from stress incontinence (increased abdo pressure) and from urge (increase in detrusor pressure)
Video urodynamics - visualise movement of bladder neck & urethra
Suspected fistula or abberant anatomy -> contrast studies e.g. cystograms
Signs of chronic retention with incontinence
- what will patient notice after passing urine?
- what symptoms will patient complain of?
- causes?
- what is the patient at risk of?
non-painful bladder - palpable after passing urine
HUGE PALPABLE BLADDER
Incontinent - at night, insensible incontinence
BOO
Kidney impairment - due to back flow of urine up to kidneys
Urge incontinence
- what is this?
- what may patients describe?
- what is this commonly associated with?
- Ix?
- Tx?
Involuntary urine leakage accompanied by or immediately proceeded by urgency
Urgency = sudden compelling desire to pass urine, which is difficult to defer
Urgency, frequency, nocturia, unable to reach toilet with urge
Provocation - latch key, sound of water, standing up, coughing, laughing
Usually associated with over active bladder syndrome
- Detrusor over activity (neurogenic [spina bifida; MS] vs non-neuorgenic origin/idiopathic)
Ix: history/exam, frequency-volume chart
- Trial meds
- Urodynamics - to confirm if have overactive bladder
Tx:
Lifestyle - reduce caffeine & alcohol intake; smoking cessation; weight loss
Pelvic floor exercises
Bladder drill/ retraining - improve urgency
- Consciously delay voiding and increase intervals between voids
Meds
Anticholinergics - block post-synaptic muscarinic receptor
- SE: urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia, drowsiness, confusion
Beta-3 adrenergic agonist = mirabegron - induce relaxation by increasing sympathetic tone
Neuromodulation - posterior tibial nerve stimulation or implantation of sacral neuromodulator
Surgery - last resort CLAM ileocystoplasty Augmentation cystoplasty Detrusor myectomy Urinary diversion
Overactive bladder
(1) meds
(2) intravesical injection of botulinum toxin (repeat injections 6 monthly)
Treatment for overactive bladder
(1) meds
2) intravesical injection of botulinum toxin (repeat injections 6 monthly
How do anticholinergic works?
- what effect will they have?
- SE?
Anticholinergics - block post-synaptic muscarinic receptor
SE: urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia, drowsiness, confusion
Stress incontinence
- what is it?
- what causes it?
- does it affect males or females more often?
- how is it graded? describe each stage
- Ix
- Tx
Involuntary leakage on effort /exertion - sneezing/coughing
Causes
- Passive bladder pressure exceeds urethral pressure
- Urethral sphincter fails to protect against urinary loss - intrinsic failure; failure to contract
- Intrinsic sphincter deficiency - dysfunction of proximal smooth muscle sphincter at bladder neck
- Urethral hyper-mobility (anatomic incontinence)
- Poor pelvic floor support
- Women - damage to pelvic floor or urethral function; Childbirth; increasing parity; vaginal delivery - wakening/stretching of muscles and connective tissue during delivery; damage to pudendal and pelvic nerves
- Men - post prostatic surgery
Females > males
Grades
0 - reports leakage but no definitive evidence clinically
1 - leakage occurring during stress with <2cm descent of bladder base below upper border of symphysis pubis
2 - leakage on stress accompanied by marked bladder base descent (>2cm) occurring only during stress (2a) or permanently present (2b)
3 - bladder neck and proximal urethra are already open at rest (+/- descent) = Intrinsic sphincter deficiency
Ix: urodynamics
- Bladder neck mobility
- Positive stress test in women
Tx
Lifestyle - Weight loss; Stop smoking (chronic cough - raised intra-abdominal pressure)
Pelvic floor exercises
- 12-18 months for maximal effect; continue long term
- Physio - vaginal cones; devices for reinforcement; biofeedback
Pharma
Duloxetine
- serotonin/noradrenaline reuptake inhibitor (SNRI)
- Increased levels of serotonin/noradrenaline in sacral cord (Onuf’s nucleus)
- Increased contraction of urethral sphincters (improves sphincter muscle tone) during storage phase of micturition cycle
- SE: n+v
Post-menopausal women -> local oestrogen therapy
Severe/ intractable cases -> surgery with urethral bulking agents or sling/suspension surgeries
Urethral injection - bulking material injected into bladder neck & periurethral muscles increases outlet resistance (i.e macroplastique)
- 50-70% success
- Best outcomes in those without urethral hypermobility
- May need repeat injections
Retropubic suspension - used if related to urethral hypermobility
- Aims - elevate and fix bladder neck and proximal urethra in elevated position
- CI: if have significant sphincter weakness - Marshall-Marchetti-Kranz (MMK); Burch colposuspension; Vagino-obturator shelf repair
Pubovaginal slings
- Used if have poor urethral function
- Placed at bladder neck - used when have intrinsic sphincter deficiency and anatomic stress incontinence
- Autologous - rectus fascia, fascia lata
- Non-autologous - cadaveric fascia
- Synthetic - TVT, TVT-O
Artificial urinary sphincter
- Used if have sphincter deficiency (e.g. post prostatectomy)
- Pressure cuff placed around either bladder neck or bulbar urethra. Pressure regulating balloon placed extraperitoneally. Activating pump placed in the scrotum/ labia majora. The cuff provides a constant pressure, squeezing the urethra.
To void the pump is activated which transfers fluid from the cuff to the extraperitoneal balloon. The cuff reflates passively over a period of 2 – 3 minutes.
Surgical correction
Overflow incontinence
• Bladder abnormally distended with urine
○ Frequency, nocturia, urgency, leakage with physical activity
○ High post void residual
• Typically present with chronic retention and dribbling incontinence
○ Due to incomplete bladder emptying
• Classic = new nocturnal incontinence
○ Palpable bladder
• 30% - have back pressure on kidneys which leads to renal impairment overtime
○ AKI (high pressure chronic urinary retention)
• Associated with BOO and chronic urinary retention (esp. elderly men)
○ Failure of detrusor muscle
§ Atonic bladder - idiopathic or damage to pelvic nerves from surgery like hysterectomy or rectal excision
§ Trauma
§ Infection
§ Compression of cauda equina
○ Women - obstruction - severe pelvic prolapse, post surgery for stress incontinence
○ Males - urethral stricture, prostatic obstruction, BPH
• Ix:
○ U&Es
§ Associated renal impairment will improve with decompression via catheter, although often suffer from diuresis after catheterisation due to disruption in concentrating gradient in collecting systems
• Tx
○ Catheterise!
○ Empty bladder
○ If cause is obstruction -> treat this
§ Men - intermittent self catheterisation or TURP
○ Urethral stricture -> urethral dilatation, internal urethrotomy, urethroplasty
Poor detrusor contractility -> clean intermittent catheterization
Mixed urinary incontinence
• Combo - urge & stress
• Urgency, frequency, nocturia, unable to reach toilet with urge & leakage with physical activity
• Bladder neck mobility
• Positive stress test
• Aetiologies and Ix same as for SUI and UUI
Tx - Ask what symptoms causing most distress & target them
Over active bladder syndrome
• Symptom complex - urgency +/- urge incontinence, usually accompanied by frequency + nocturia ○ Main symptom = urgency ○ May have detrusor overactivity • Common esp. aging population - 40% over 70s ○ Affects quality of life • Tx ○ Meds § Anticholinergics § Beta-3 agonist ○ Sacral neuromodulation ○ Intravesical botulinum toxin A - risk of inability to void so need to be able to self-catheterise prior to receiving treatment ○ Surgery § Augmentation cystoplasty § Urinary diversion
Over active bladder and urge urinary incontinence = clinical diagnoses
Detrusor overactivity = diagnosis made upon cystometric assessment.
What part of the prostate is most commonly affected in prostate carcinoma?
Peripheral zone
What part of prostate does BPH originate in?
Transition zone
What is a scrotal swelling that you cannot get above?
Inguinal hernia
What is a scrotal swelling that you can get above?
hydrocele
Left renal vein received blood from what veins?
- what does it empty into?
Where does the right renal vein drain into
left adrenal vein
gonadal veins
Empties into IVC
On the right side - renal vein, adrenal vein and gonadal veins drain directly into IVC
Recurrent UTIs in woman.
USS KUB is normal.
What is the next type of investigation that should be done?
Cystoscopy
53 year old woman with recurrent UTIs complains of haematuria. Smokes a lot.
What Ix should be done?
cystoscopy
- rule out bladder cancer
What should you suspect in pyelonephritis that does not respond to antibiotics?
- what Ix should be done?
Pyonephrosis - obstructed kidney.
Ix = Renal tract USS - evidence of obstruction and dilatation of renal pelvis and calyces.
How should urethritis be investigated?
- pain on passing urin, thin discharge after micturition. Number of sexual partners - no condoms
Urethral swab culture and microscopy
- gonococcus, chlamydia
What test is important to do in someone with urinary frequency urgency, fatigue and thirst?
Blood glucose
- think diabetes
What is the most common presentation of bladder carcinoma?
painless haematuria
58 year old man with number of episodes of fresh haematuria. No pain on passing urine and otherwise feels well.
What could be wrong with the patient?
What investigation should be done?
suspect bladder carcinoma.
Ddx
- cystitis
- bladder diverticulae
- prostatic hypertrophy
Ix = flexible cystoscopy
What is pneumaturia a symptom of?
fistulae between bladder and colon or rectum.
Urinary infections due to gas-forming organisms - may occur in patients with diabetes
Which route does cancer spread from left testicle to rest of body?
From left testicular vein to…..
Left testicular vein
Left renal vein
IVC
How does torsion of testicular appendage present?
- what Ix is needed?
- what is the Tx?
develops over 24 hours
results in tender, pea-sized nodule in upper pole of testis.
Oedema, nausea and vomiting are rare.
Ix = USS
Tx = surgical intervention only needed if there is a lot of pain.
When are epididymal cysts common?
- are they transilluminable?
- are they palpable separate from testis?
40-50 year olds.
Transilluminates
Palpable separately from testis
What reflex is absent in testicular torsion?
Cremasteric reflex
- when inner thigh is tickled, testis does not rise
