W1 Non-Obstructive Lower Urinary Tract Uropathies

Question 1

Urinary incontinence
What is urge, stress, mixed and overflow?

Answer 1

Urge Incontinence (UUI):
—UUI is a urinary incontinence as a direct result of excessive urinary urgency (can’t hold long enough)
—This may be d/t bladder hypersensitivity / overactivity, or may be d/t excessive storage

Stress Incontinence (SUI):
—SUI is an incontinence primarily as a result of a poorly compliant bladder neck, typically 2/2 either Intrinsic Sphincter Deficiency (ISD) or Urethral Hypermobility (often the bladder itself is function ok - the PF is not)

Mixed Incontinence (MUI):
—A combination of UUI and SUI, often this starts as pt having UUI, then pt subsequently develops a component of pelvic floor laxity (either 2/2 age, pelvic floor injury, among others)

Overflow Incontinence (OUI):
—An incontinence type that is a sequelae of storage problems, either 2/2 bladder outlet obstruction or UAB

Question 2

Overactive bladder (OAB)
What is it?
What are 3 intrinsic factors?
What are some extrinsic factors?

Answer 2

Overactive Bladder is a voiding dysfunction syndrome that comprises of persistent and chronic bothersome urinary urgency that leads to significant impact on pt’s quality of life

Causes:

Intrinsic Factors that may contribute:
○ Bladder lining hypersensitivity
○ Excessive bladder contractions
○ Decreased bladder compliance, not as stretchy

Extrinsic Factors
○ Excessive PO fluid intake, or excessive intake of spicy or acidic food or beverages
○ Caffeine and sugar intake
○ Meds that make you urinate more (like diuretics)
○ Anxiety

Question 3

Overactive Bladder - Presentation, Signs, Symptoms
What is the key to the patients symptoms?

Answer 3

Symptoms:
—Urgency
—Frequency
—Incontinence (UUI, MUI)
—Nocturnal
—Polyuria (subjective)

⭐️Bothersome all day long and night, not just daytime or nighttime

DDX:
—pregnancy
—UTI
—GI issues

Question 4

Overactive bladder — PE

Answer 4

Question 5

Overactive bladder — work up 2
What tests would you order?
What do you need to rule out? 4
What can you use to definitely diagnose OAB but probably wouldn’t because it is so invasive?

Answer 5

CMP: assess kidney function
UA: rule out UTI if leuks, esterase and nitrites present

Renal bladder U/S to rule out hydronephrosis
Post void residual (PVR — to see if the bladder is emptying correctly/fully) to rule out urinary retention/ incomplete bladder emptying as contributory to sx <50cc

Rule out
—infection
—malignancy
—kidney injury
—hematuria

Urodynamic studies: definitive but invasive

Question 6

Overactive bladder
Treatment — 1st approach?
Pharm agents?
Which class and an example of each

Answer 6

—conservative approach first, avoid triggers
—keep a bladder diary

Pharm:
Anticholinergics:
—Affordable but have a lot of side effects
—oxybutynin
(cholinergic, ACh, parasympathetic, effect is to contract the detrusor so you can pee, if you take an anti-cholinergic, you block this and don’t pee as much)

Beta-3 agonists:
—T10 SNS trunk: norepi agonism of beta-3 receptors, relaxation of the bladder to balloon and store urine = no pee.
⭐️mirabegron ⭐️
(think: beta: balloons out to hold the pee. Or sympathetic = store)

Question 7

Anti-cholinergic side effects, list 6
Avoid in which cases?

Answer 7

They are not specific and selective to the bladder. They can hit receptors all over the body.

Remember: MR. T BF HD
tachycardia earliest and most reliable sign!!

Dry mouth
Bronchial secretions
Decrease sweating
Increase pupil size
Increased HR
Difficulty urinating

Avoid:
—elderly
—narrow/closed angle glaucoma
—arrhythmia
—fall risk

Question 8

Oxybutynin vs Trospium
Which crosses the BBB?

Answer 8

Oxybutynin:
—net neutral charge
—lipophilic
—higher BBB penetration
—a/w neuro side effects

Trospium
—slight + charge in solution
—more hydrophilic
—lower BBB penetration
—less neuro s/e

Question 9

⭐️Mirabegron side effect
Route?

Answer 9

Mirabegron, selective for B3 but not specific, as you increase the dose, 50mg and above, can hit B1 and B2 receptors, when this happens, it can exacerbate HTN

Mirabegron 25 - 50 mg PO daily (usually lasts 12- 24 hours)

Question 10

Overactive bladder — other procedural treatments
5

Answer 10

● Botox:
—into the detrusor muscle = decreased muscle contractility
—several weeks effect to take place
—repeat dosing q 3 - 12 months
—Risk: UTI, Urinary Retention
—Costly $$$, insurance wants you to try others first

● Neuromodulation:
—Peripheral: PTNS (posterior tibial nerve stimulation)
—Sacral Neuromodulation (ex: interstim)

Urinary Diversion:
● Foley catheter placement
● Suprapubic Tube Placement
● Cystectomy & urinary diversion via ileal conduit (far more rare, a very aggressive approach for OAB)

Question 11

Interstitial cystitis
A syndrome defined as….
It presents like ________ but more like to have _______
A lot of patients have concomitant _________
Affects _____ more than _______ (gender)

Answer 11

IC is (simply) defined as a syndrome of chronic, persistent suprapubic & pelvic pain a/w irritative voiding sx like urinary urgency, frequency, & dysuria

Presents like overactive bladder but may have pelvic pain and pain w/ urination

A lot of patients have concomitant auto immune diseases (atopy, IBS), lining dysfunction, hypersensitivity pain syndrome, viral syndrome

More common in females

Correlated to mental health issues as well

Question 12

Interstitial cystitis (diagnosis of exclusion)
HPI and work up same as overactive bladder
When would you consider interstitial cystitis?
Which study is warranted in pats w/ persistent urgency?
⭐️ What might you see with this study?
Histopathology might also have ______

Answer 12

Often pts present as classic OAB, frequent UTI, pelvic pain, tried all 1st line therapies but still having symptoms

Cystoscopy often warranted in pts w/ persistent urgency

5-10% of patients have ⭐️ ulcerative, erythematous lesions, called Hunner’s lesions

Histopathology might also have high mast cell concentrations

Question 13

Interstitial cystitis treatment

The goal is to provide _________ and _________

Pain relief is often w/ _________ , _________ and _________

_________ , _________ and _________ are usually NOT helpful

Some other treatments include
1.
2.
3.
4. Last line:

Answer 13

The goal is to provide relief of voiding symptoms and pain relief

Pain relief is often w/ NSAIDs, Pentosan and tricyclics

Kegels, myofasical release and antibiotics are usually NOT helpful

Some other treatments include
1. High pressure hydro distention: goal to stretch bladder lining, repeat Q3-6months
2. Installing: lidocaine, pentosan, heparin, DMSO
3. Botox, PTNS
4. Last line: cystectomy and urinary diversion

Question 14

Underactive Bladder
What is it?
May be a result of what 3 things?
2 associated populations / 2 causes

Answer 14

Underactive Bladder (UAB) is an umbrella term for a syndrome of chronic increased urinary storage, weakened bladder contractility, and delayed / prolonged emptying, all as a sequela of impaired detrusor / bladder function

Typically as a result of:
1. Decreased perception of urinary urgency
2. Decreased detrusor muscle contractility
3. Excessive detrusor compliance

Most commonly found in
1. elderly populations
2. DM patients
3. neurologic injury pts (stroke, spinal cord injury, etc)
4. Chronic Bladder Outlet Obstruction (BOO) → chronic detrusor distention → increased bladder compliance
(“floppy bladder syndrome”) r/t both chronic nerve injury (sensory & motor) and chronic muscle fiber injury

Question 15

Underactive Bladder 2/2 Diabetes
How does this pathogenesis start? Presenting symptoms?
As it progresses, what happens?
What is the late phase presentation?

Answer 15

DM Cystopathy commonly starts with symptoms of OAB and polyuria

Diabetics pee out a lot of glucose, can have a lot of acidity, impaired blood flow can cause peripheral nerve injury (like diabetics get in their feet) — can happen in the bladder as well.

Regenerating nerves are hyperactive, takes years for regeneration to occur. So diabetics have a lot of sensory issues, feel like they need to pee a lot.

After a while, goes numb, so can’t perceive it. So then become underactive

DM cystopathy ends as underactive bladder

Question 16

Underactive bladder
Why might a patient come in?
They may present with ______, ________, frequent ________

Other signs include _______ / ________

May also present as a ________ patient with elevated ________

Neuro history that predisposes a pt to underactive bladder include ________, ________, ________ and ________

On PE, may be able to palpate _______

Answer 16

Patient most likely coming in because another person in their life has noticed decrease in urination

They may present with overflow/OUI, stress/SUI, frequent UTIs

Other signs include decreased flow rate / weak stream

May also present as a CKD/AKI patient with elevated PVRs (incomplete bladder emptying)

Neuro history that predisposes a pt to underactive bladder include MS, Parkinson’s, CVA and DM

On PE, may be able to palpate distended suprapubic region/full bladder

Question 17

Underactive bladder
Which 4 diagnostic studies?
What is the definitive test?

Answer 17

Diagnostic studies
RBUS
PVR
Uroflow (usually low flow rate)
+/- straight cath (high volume)

Cystoscopy (doesn’t often change plan much but may see significantly distended bladder)

urodynamic study (UDS) super helpful at giving insight on detrusor & pelvic floor pressure and is the definitive test

Question 18

Underactive bladder
What are the three non-pharm options?
What is the main pharm option?
a medication that would relax the lower muscles/ to decrease pelvic floor pressure
Who would be a candidate for procedural treatment?
What are 3 options?

Answer 18

1. Timed voids (scheduling bathroom trips q4 hours)
2. Crede maneuver (placing hands over suprapubic region while sitting on the toilet, then flexing at the hips to increase abdominal pressure on the bladder)
3. ⭐️Clean Intermittent Catheterization (CIC), usually at least BID - QID, in addtn to timed voids

Pharmacologic
— Alpha 1a blocker like FLOMAX may help decrease bladder outlet pressure through smooth muscle relaxation, and therefore decrease the pelvic floor pressure needed to overcome to start urination, easier passage of urine
—remember alpha receptors want to constrict so if you block them, they relax. This medication is counterintuitive!

Procedural
—for pts who cannot perform CIC
—Posterior tibial nerve stimulation (PTNS)
—Suprapubic tube (SPT)
—Sacral neuro modulation

Question 19

Just for reference
Slide 39

Answer 19

Question 20

Stress urinary incontinence

Examples of causes (many)
MCC of SUI is __________
A temporary cause is _______
2 medications that could be responsible

Answer 20

Stress Urinary Incontinence is defined as unintentional leakage of urine commonly as a direct result of unexpected changes in intra abdominal and bladder pressure (common examples: coughing, sneezing, laughing, climbing stairs, exercising, running, picking up heavy objects / children)

The most common cause of SUI is Intrinsic Sphincter Deficiency (ISD)

Temporary changes to intra abdominal pressure and pelvic floor muscles (ex: *pregnancy!)

1. Sedatives
2. Alpha blockers

Question 21

Internal Sphincter Deficiency (ISD) and Stress Urinary Incontinence

Main symptom is ________
Patient will share the trigger that causes it, such as ________

Work up should pay special attention to ________ and ________

Conditions that predispose a pt to pelvic floor dyskinesia: ________(6)

GU exam may be notable for: ________
Patient may also experience a ________ when asking them to bear down or pushing on their ________

Answer 21

Main symptom is urinary incontinence (SUI)
Patient will share the trigger that causes it, such as smaller volume leakage with coughing, sneezing, laughing, climbing stairs, exercising, running, picking up heavy objects / children, etc

Work up should pay special attention to PVR and pelvic floor

Conditions that predispose a pt to pelvic floor dyskinesia: MS, Parkinson’s, CVA, DM, trauma, pregnancy/delivery

GU exam may be notable for: pelvic floor laxity
Patient may also experience a leak when asking them to bear down or pushing on their bladder

Question 22

Internal sphincter dysfunction (ISD) & stress urinary incontinence (SUI(
Diagnosis
______ is often unremarkable.
______ is usually low
______ is often normal

This is usually a ______ diagnosis

No. 1 treatment is ⭐️ ______ ⭐️

Other measures:
—______ to minimise storage
—______

Surgical
—______ which increases the ______ pressure and decreases SUI episodes

Artificial mesh is highly associated w/ ______ and ______

Another risk is ______

Lastly:
1. ______ to promote urethral tone
2. ______

Answer 22

RBUS is often unremarkable.
PVR is usually low
uroflow is often normal

This is usually a clinical diagnosis

No. 1 treatment is ⭐️pelvic floor physical therapy⭐️

Other measures:
—time voids to minimise storage
—clean intermittent catheterisation BID

Surgical
—urethral slings which increases the urethral pressure and decreases SUI episodes

Artificial mesh is highly associated w/ erosion and recurrent UTIs

Another risk is acute urinary retention

Lastly:
1. bulking agents to promote urethral tone
2. artificial urethral sphincter

Question 23

Take away points / final notes, read these well
—If a patient has urgency with incomplete bladder emptying, avoid these two medications
—avoid this medication in a patient who could be a fall risk
—remember all the risks of anticholinergics
—know the main S/E of beta-3 agonists
—know which anti-cholinergic has less BBB penetration
—when in doubt, what is a good medication to start on?

Answer 23

1. Start by treating the most clinically bothersome symptom to the patient (subjective)
2. Assess and treat for the most concerning clinical finding (usually leaning more objective)

avoid giving a pt w/ urinary urgency w/ clinical findings of incomplete bladder emptying an anticholinergic or beta-3 agonist… this may help the sx (for now) but may make their ability to actually void worse (and may even impact renal fnx / AKI)

in a pt who is experiencing chronic urinary urgency, frequency, nocturia w/ clincial w/u concerning for OAB, warranting multiple trips to the bathroom a night, and subsequently experiencing nocturnal falls, try to avoid giving them an anticholinergic (sure, their voiding symptoms may get better, but may increase their fall risk)

● Voiding Diaries (+/- at home I&Os if reliable) are invaluable (in dx and assessing treatment response)
● Not all urinary urgency is OAB… rule out all other causes first before deciding to treat for OAB alone
● In addition to clinic w/u, remember to review pt’s dietary intake, meds, functional status
● Lack of urinary urgency does not mean that the pt has an empty bladder, underactive bladder (sensory & fnx) are common in eldry pts, DM patients, neuro patients - always a good idea to assess PVR, BMP, +/- RUS
● Anticholinergics, while strong, come with their own hefty list of SEs and contraindications (see prior slides), be thorough in your w/u and weigh the risk / benefits before starting a patient on these therapies
● Beta-3 agonists (Mirabegron), while less strong than anticholinergics, do not have the same neurologic and anti-ACH SEs that the anticholinergic class have, however do carry their own sympathetic tone risks (ex. > HTN)
● Trospium is a quaternary amine anti-ACHs that, d/t it’s slight net positive charge in solution, tends to be
more hydrophilic and therefore have significantly lower BBB penetration, so as a benefit often has < neuro
SEs c/t other anti-achs (however on that same note, d/t its charge, trospium also may not be as strong as other anti-ACHs given it’s typical little to no central activity, and systemic / peripheral activity is also further impacted by its < PO bioavailability)
● When in doubt… try a gentle alpha blocker like flomax (if otherwise deemed safe to do so)
● When still in doubt…. Refer to Urology!

Question 24

Make sure you understand these terms
In particular, what does polyuria mean?
Urgency
Frequency
Incontinence
IBE
Nocturia
Polyuria

Answer 24

Polyuria (subjective): sensation that one is having higher volume urine output than norm (not > U.F.)