Week 5 - Genitourinary Disorders Flashcards
Urge incontinence
Leakage preceded by/associated with urgency.
- Patho – unable to store urine due to uninhibited contractions of the detrusor muscle
Stress incontinence
Leakage with effort, exertion, sneezing, or coughing. Leakage may be provoked by minimal or no activity when there is severe sphincter damage.
- Leakage coincident with cough, laugh, sneeze, or physical activity suggests failure of sphincter mechanisms. Leakage that occurs seconds after the activity, especially if difficult to stop, suggests a cough-induced uninhibited detrusor contraction.
- Patho – inability to store urine due to inadequate sphinchter closure
Mixed urge/stress incontinence
Presence of both urgency and stress UI symptoms. Patients vary in the predominance, severity, and/or bother of urge versus stress leakage.
Nonspecific incontinence
Inability to void completely because of insufficient bladder contraction and/or bladder outlet obstruction
Overactive bladder
Symptom syndrome (not a specific pathologic condition) consisting of urgency, frequency, and nocturia, with or without urge incontinence.
Risk factors for urinary incontinence
- Female
- Obesity
- Diabetes
- Stroke
- Depression
- Fecal incontinence
- Hysterectomy
Medications associated with urinary incontinence
- Alcohol
- Alpha-adrenergic agonists/blockers
- ACE inhibitors
- Anticholinergenics
- Antiphsychotics
- CCB
- Cholinesterase inhibitors
- Estrogen
- Gabapentin
- Loop diuretics
- Narcotics
- NSAIDS
- Selective hypnotics
- Thiazolidinediones
- TCAs
What controls continence?
Continence is mediated by the central and autonomic nervous system
- Voiding occurs with parasympathetic stimulation
HPI for Incontinence
- Frequency and volume of leakage
- Type of UI symptoms
- Review PMH and medications that may impact UI
- Relationship beween illness (stroke) and UI
- Screen for depression and functional status
- Assess functional impairment
- Cognitive screening
Physical exam for urinary incontinence
Cognition, mobility, neuro, rectal, urnalysis, bladder diary, wet checks, PVR
Pelvic exam for women
1. Prolapse, masses, tenderness, urethral hypermobility, cystocele, rectocele
Genital exam for men
1. Digital rectal exam for prostate changes/nodules/masses/stool impaction
Urinalysis with reflex for UTI (if likely) – check for hematuria and glycosuria in diabetic patients
Types of urinary incontinence
- Urgency/OAB
- Stress
- Mixed
- Other/unclear
Management of incontinence
- Address comorbidities, lifestyle, medications
- Assess changes to QOL
Acute onset pelvic pain is a red flag for…
Neurologic or neoplastic disease, place urgent referral to urology or urogynecology
Nocturnal polyuria
> 1/3 of total 24-hour urine production occurring during the hours of sleep
Causes of nocturia
- Excessive fluid intake (caffeine or alcohol)
- Pedal edema
- CHF
- OSA
Using a bladder diary for evaluation of nocturia
Document time, amount of urine voided, amount of leakage
Treatments for UI in older person
- Address contributing comorbidity and medications
- Lifestyle interventions
- Behavioral treatment
- Pharmacological treatment
- Minimally invasive and surgical procedures
Lifestyle modifications for all types of urinary incontinence
- Weight loss
- Avoid excessive fluid intake, caffeine, alcohol, minimize night intake of fluids
- Quit smoking (stress UI)
- Afternoon loop diuretics
Behavioral modification for urinary incontinence
Urge, stress, mixed - usually more effective than medication.
- First line of treatment for older patients with UI
- Bladder retraining
- Frequent voluntary voiding to keep volume low (start Q2 hours)
- Urgency suppression using CNS and pelvic mechanisms
- When urgency occurs, stand still, sit down, do pelvic muscle contractions, concentrate on making urgency decrease with deep breathing, visualize urge as a wave that peaks and falls
- After 2 days with no leaks, increase time between voiding by 30-60 minutes (goal of Q4 hour voiding) - Pelvic muscles exercise
- Contract for 6-8 seconds, repeat 8-12 times (one set) complete 3 sets, 3-4 times per week for 15-20 weeks
- Increase intensity and duration as able
- Perform contractions white sitting, standing walking
- Alternate fast/slow contractions
- Biofeedback - For patient with dementia the only available behavioral therapy is prompted voiding – every 2-3 hours, positive feedback with voiding, should improve within 3 days, if not check and change is advised
Pharmacological treatment for stress incontinence
- No FDA approved medications although duloxetine is effective but not approved for this indication
- Worsened with estrogen & progesteronep
Pharmacological treatment for urge incontinence and OAB
- Antimuscarinics (risk of cognitive impairment)
- oxybutinin
- tolterodine
- fesoterodine
- trospium - Beta 3 Agonists (increases BP)
- Mirbegrone (urge only)
Minimally invasive and surgical procedures for urinary incontinence
- Botox injection in detrusor muscle during cystoscopy
- Sacral nerve modulation – percutaneous implantation of an electrode at the S3 sacral root connected to external stimulator (permanent lead inserted if trial goes well)
-
Surgery - gold standard for stress incontinence
- Colposuspension
- Slings
Treatment for stress incontinence
- Behavioral therapy - bladder training
- Duloxetine
- Urethral slings
Treatment for urge incontinence
- Behavioral therapy
- Anticholinergics
- Onaboulinum toxin A
- Neuromodulation
Treatment for Overactive bladder
- Anticholinergics
- Antimuscarinics or oral beta3 adrenoceptor agonist
- Prescribe ER over IR (less dry mouth)
- Manage constipation and dry mouth prior to trying another medcation
- Transdermal oxybutinin
Criteria for diagnosing a UTI in older adults
- Localizing GU symptoms and + urine culture
- Acute confusion then treat for UTI
Asymptomatic bacteriuria
Presence of significant pyuria (>10 WBCs per low power field).
30% of asymptomatic older adults have significant and persistent pyuria
1. Found in nephrolithiasis, diverticulitis, IBD, intraabdominal abscess
Do not treat with no urinary symptoms.
Symptoms of UTI in older adults
Lower UTI
- Suprapubic pain, dysuria, frequency, urgency
Upper UTI
- Flank pain
- Fever
Treat with significant bacteriuria, pyuria and symptoms including confusion
Treatment for uncomplicated UTI
Patient is healthy, no DM or immunosuppression
- Nitrofurantoin
- Fosfomycin
- TMP/SMZ
- Pivmecillinam
Treatment for complicated UTI
Pyelonephritis
- Ciprofloxacin
- Levofloxacin
- TMP/SMZ
- Beta lactam
Diagnosing UTI in a patient with a chronic foley
Diagnosis of exclusion
Recurrent UTIs with the same organism
Should prompt a search for anatomic defects that can be repaired
What type of diagnosis is BPH?
A diagnosis of exclusion
What part of the prostate is BPH usually found?
The transitional zone
What questionnaire can assist in diagnosing BPH?
- International Prostate Symptom Score IPSS –
Score of 7 or less mild, 8-19 moderate, 20-25 severe (not diagnostic for BPH)
- Incomplete emptying
- Frequency
- Intermittency
- Urgency
- Weak stream
- Straining
- Nocturia
Conditions that contribute to BPH
- Poorly controlled diabetes
- Neurogenic bladder
- UTI
- Previous urological conditions
Diagnostic testing for BPH
- Assess for contributing factors (neuro/endocrine/etc)
- Digital rectal exam
- Urinalysis
- PVR
- Serum creatinine (assess kidney function)
- Pressure/flow studies
- PSA
Lifestyle modifications for BPH
- Reduce nighttime fluids (2 hours before bed)
- Eliminate dietary diuretics (caffeine, alcohol)
- Behavioral interventions (bladder retraining)
- Avoid bladder irritants like artificial sweeteners and carbonation
- Bladder dietary to document frequency, volume and circumstances surrounding symptoms
Pharmacological management of BPH
- Alpha blockers (terazosin, doxazosin, (first two require BP monitoring) tamsulosin, silodosin) - relax smooth muscle in prostate and bladder to decreasing resistance to urinary flow
- 5-alpha reductase inhibitors (finasteride, dutasteride) - reduce dihydrotestosterone levels to reduce size of prostate gland
- Combo of both
Surgical treatment for BPH
- TURP,
- open prostatectomy,
- transurethral microwave thermotherapy
- laser ablation
Current treatment options for prostate cancer
- Brachytherapy – radiation by internal implant
- EBRT – external beam radiation therapy
- Hormonal treatment
- Mainly used for metastatic disease - Cytotoxic chemo
- Only used for treating symptomatic metastatic disease that has become resistant to hormonal agents
- Treatment is not curative - Surgical removal
- For over 70 years with well differentiated tumor
- Active surveillance
How often should you check a PSA level in prostate cancer patients?
Every 2 years
Prostate cancer staging
A – no palpable lesion, biopsy only - observation
B1 – palpable nodule 1 lobe -prostatectomy, EBRT or brachytherapy
B2 – palpable nodules both lobes or one nodule >1.5cm - prostatectomy, EBRT or brachytherapy
C – locally advanced, invading the capsule - radiation/hormonal therapy
D1 – Extracapsular involves pelvic lymph nodes - LND and hormonal therapy
D1.5 – cmenical recurrence, rising PSA after prostatectomy- hormonal thearpy
D2 – extensive retroperitoneal lymph node involvement, distant metastisis -hormones
D2.5 – rising PSA after definitive treatment -cytotoxic therapy
Risk factors for prostate cancer
- Age
- Black
Risk factors for erectile dysfunction
- CV – HTN, CAD, HLD, PAD,
- DM
- Depression
- Obesity
- Alcohol
- Meds
- Neurological disease
- History of pelvic surgery/trauma
- Hypo/hyperthyroidism, steroid use
- hypogonadism
Causes of erectile dysfunction
- Vascular disease (most common cause)
- Neurological disease (second most common cause)
- Medications
- Antidepressants
-. Antipsychotics
- Antihistamines
- Anti hypertensive (almost all)
- OTC meds – cimetidine, ranitidine - Psychogenic
- Performance anxiety
- Fear of STDs
- Widower syndrome (rigid erection with masturbation) - Hypogonadism, hypothyroidism, hyperprolactinemia
- Serum testosterone <200ng/dL in a symptomatic man - Endocrine (hypo/hyperthyroidism) – rare
Evaluating a patient for ED
- Cause - decreased libido, inadequate erection, orgasmic failure
- Onet/duration (sudden - psychogenic, gradual - hypogonadism/neuro, vascular)
- Sleep associated erections?
- Medication review
- History - sexual, living, alcohol, stressors
- Risk factors
- PE
- Labs
Vascular risk factors for ED
- Hypertension
- CAD
- PAD
- HLD
- Smoking
Neuro risk factors for ED
- DM
- Pelvic injury
- Surgery
- Radiation
- Spinal injury or surgery
Physical exam for ED
- Signs of vascular, neuro, endocrine disease
- Femoral bruit and diminished/absent pedal pulses suggest arterial
- Palpation of penile plaques suggest venous etiology
- Orthostatic hypotension/bulbocavernosus reflex suggest neuro etiology
- Small testes/gynecomastia suggest hypogonadism or hyperprolactinemia
Lab testing for ED
- 2 morning serum testosterone levels
- CBC, CMP, TSH,
Treatments for ED
- Phosphodiesterase inhibitors
- Vacuum
- Testosterone replacment
- Surgical prosthesis
Pharmacological treatment for ED
Phosphodiesterase inhibitors
1. Sidenafil – improves rigidity and duration
* Transient color blindness
- Vardenafil – more potent, lower effective dose, fewer side effects
- Tadalafil – like vardenafil but with muscle pain, longer duration of action
- Avanafil – take 30 min prior (rapid onset)
* Prolonged erection
When is a vacuum appropriate for ED treatment?
- Effective for psychogenic, neurogenic, venogenic ED
- Requires a lot of manual dexterity
When would you replace testosterone in patient with low T?
<200ng/dL
Given via:
1. IM injection
2. Transdermal patch
3. Gel
ED assessment tools
- International Index of Erectile dysfunction – 15 questions addressing all domains of male sexual dysfunction
- Sexual health inventory for men – short version – 5 questions from international index question
When to follow up with a patient being treated for ED?
- Every 6-8 weeks after initiation of treatment
- Failure for at least 4 sexual attemps prior to changing medication or treatment
- Refer for complicated cases
Stages of menopause
- Premature menopause – starts early
- Perimenopause – changes in cycles prior to menopause
- Menopause
- Post menopause
Pharmacological treatment for menopause symptoms
- Estrogen (increased risk for endometrial cancer)
- progesterone (increased risk for blood clots)
Non-pharmacological management of menopause symptoms
- Hot flashes
- avoid triggers like spicy foods, hot drinks, alcohol and caffeine
- Maintain cool environment, layer clothing
- Increase exercise - Vaginal dryness
- Vaginal estrogen
- Vaginal moisturizer
- Lubricants during sex - Mood changes
- SSRIs - Osteoporosis
- Calcium and vitamin D supplements
- Bone density scans
Causes of uterine bleeding
- Endometrial atrophy –-> treat with short course of systemic estrogen
- Endometrial polyps –-> surgical removal
- Uterine fibroids –-> surgical removal
- Endometrial hyperplasia – medical management to prevent progression to endometrial cancer –-> treat with systemic progesterones or IUD to thin uterine lining
- Cancers – endometrial, ovarian, cervical, vaginal –>TAH ro radiation
Genital tract bleeding in non-HRT women or menopausal women on HRT is most commonly caused by…
Benign vaginal atrophy.
o Physical exam reveals thin, pale epithelium and narrowing of the introitus
o Woman may have post coital bleeding
Genitourinary syndrome of menopause (GSM)
Includes vulvovaginal atrophy, atrophic vaginitis, urogenital atrophy due to estrogen deficiency
1. Education
2. Local estrogen
- Creams (Premarin, estrgyn, estriol, rings, ovules
- vaginal moisturizers
Why is HRT prescribed?
For severe symptoms and prevention of bone loss
How are HRT hormones delivered?
Systemically
1. Tablets, patches, injections
Locally
1. Creams, vaginal rings
What are the risks associated with HRT therapy?
Risks of therapy
1. Blood clots
2. Stroke
3. Breast cancer
Estrogen only HRT
Increased risk of breast cancer/blood clots
Estrogen plus progesterone HRT
Used for women who have not had hysterectomy to prevent uterine cancer
Selective estrogen receptor modulators (SERMs)
Block or activate estrogen receptors in certain areas of the body and used as alternative for women with a history of breast cancer or those with concerns about HRT
Types of SERMs
- Tamoxifen – prevents breast cancer, increased risk uterine cancer
- Maloxifen/avista – prevent bone loss and fractures and prevent breast cancer, increased risk of hot flashes
- Bazedoxifene w/estrogen– combine with systemic estrogen, protects against bone lose, treats hot flashes, no bleeding
- Ospemifene – vaginal atrophy and dryness, oral tablet only
Causes of ED in older men
- Vascular disease (gradual onset)- MOST COMMON
- Neurologic disease (gradual onset)
- Medication (sudden onset)
- Psychogenic (sudden onset)
- Hypogonadism (Gradual onset)
- Endocrine problem (hypothyroidism, hyperthyroidism) – RARE
Medications associated with ED
- Anticholinergic
- Antidepressants
- Antipsychotics
- Antihistamines
- Antihypertensives
- Clonidine and thiazide diuretics have higher incidence rates
- ACES/ARBS lower rates
Age associated sexual symptoms in women
- Symptoms
- Vaginal dryness
- Burning
- Irritation due to decreased lubrication
- Pain with sex - Treatment
- Vaginal gel/moisturizer
- Topical estrogen for severe symptoms
Tests for STIs
- Speculum assessment
- Bimanual pelvic exam
- Nucleic acid amplification test (NAAT)
- Potassium hydroxide (KOH) prep
Treatment for chlamydia
- Doxycycline
- With gonorrhea – ceftriaxone 250mg IM dose once
