Week 6 Flashcards
RFs for bladder CA?
smoking, 2nd hand smoke exposure chemical/carcinogen exposure infrequent urination/dec water intake diet: high beef, pork, fat, coffee (+) FHx radiation exposure low nutrient intake (B6, antioxidants) advancing age >60 yo schistosomiasis infxn leading to SCC cytoxin and opium addiction artificial sweeteners chlorinated water genetics - mutation of p53 high beer consumption physical trauma to bladder epithelium colon CA mets endometriosis chemotherapy chronic cystitis HPV
MC type of bladder CA?
TCC
other types of bladder CA?
adenocarcinoma SCC undifferentiated carcinomas mixed carcinomas secondary bladder CA (mets to bladder from melanoma, lymphoma, stomach, breast, KD, and lung)
presentation of bladder CA?
85-90% present with gross microhematuria, usu painless
potentially nocturia, dysuria, urge incontinence
if advanced will see frequency, urgency, dysuria, flank pn, abd pn, bone pain (if mets), anorexia
dx of bladder CA?
labs will show hematuria, possibly pyuria, possibly azotemia when obstruction
anemia of chronic dz on CBC
cytology will show exfoliated cells from neoplastic epithelium, bx will show dysplastic changes
can also do IVP for tumor detection, pelvic CT will show extent of bladder invasion and enlarged nodes
CXR, bone scans, PET for mets
ddx bladder CA?
IC UTI urolithiasis neurogenic bladder endometriosis
naturopathic management and treatment of bladder CA?
eliminate toxins general multivit seacure - fish protein glutamine for gut healing from chemo B6, Vit C immunomodulating herbs: rhodiola, mushrooms hoxsey tea or essiac tea, allium sativa lactobaccilus casei - increases urinary mutagen excretion
MC causes of neurogenic bladder?
MS spinal cord injury DM ALS parkinson's spinal or pelvic surgery degeneration from aging or inflammation
two types of bladder sphincters?
internal involuntary smooth muscle sphincter at the bladder neck (sympathetic innervation)
external voluntary striated-muscle sphincter
what is the fxn of the uretovesical jxn?
prevents backflow of urine from bladder to upper tract
ANS innervation of ureterovesical jxn?
parasympathetics (S2-4) - cholinergic, enervates bladder base and internal sphincter, allows emptying
sympathetics (T10-12), noradrenergic, enervates bladder base and internal sphincter, maintains sphincter tone
CNS innervation of ureterovesical junction?
somatic (S2-3) control of voluntary sphincter
spastic bladder is dt lesion where? too much what type of activity? common causes?
spastic bladder dt lesion above sacral micturition center (above S2-4)
too much parasympathetic activity: detrusor hyperreflexia leads to loss of bladder capacity
common lesions above brainstem affecting voiding include dementia, vascular accidents, MS, tumors, inflammation (encephalitis, meningitis)
ssxs of spastic bladder?
voluntary urination, frequent, spontaneous, triggered by spasm, decreased volume, residual urine, recurrent UTIs, increased pressure, bulbocavernosal, knee, ankle or toe reflexes increased
reduced bladder capacity
diagnosis of spastic bladder?
periodic IVUs and retrograde cystograms will show low bladder volume, bladder wall hypertrophy
U/S or urethral catheterization to determine pos-void residual volume
cystoscopy to evaluate for strictures or stones
where is the lesion with flaccid bladder? injury to what 4 potential areas?
lesions at or below the sacral micturation center
injury to detrusor motor nucleus (S2-4, anterior horn damage), afferent feedback pathways, injury causing poor detrusor distensibility (peripheral nerve injury), injury to external sphincter (pelvic fx, radical perineal surgery)
ssxs of flaccid bladder?
increased volume, decreased P
retention w/overflow incontinence, lack of erections, loss of sensation in dermatomes
LMN changes: hypoactive reflexes, diminished sensation
dx of flaccid bladder?
KUB to look for fx, calculi
IVU to look for hydronephrosis, obstruction
cystogram to assess detrusor, vesicoureteral reflux
cystoscopy will show lg capacity with some wall hypertrophy
urodynamic studies will show low bladder filling P, weak detrusor activity, lg vol of residual urine, dec tone of external sphincter
ddx of neurogenic bladder?
cystitis, anterior vaginal wall prolapse, chronic urethritis, bladder outlet obstruction, IC
goals of treatment of neurogenic bladder?
restore low P activity to the bladder, preserve renal fxn, continence, control infxn
tx options for spastic bladder?
pharm agents such as parasympatholytics and anticholinergics, TCAs, C-fiber afferent neurotoxins
neurostim: bladder pacemaker
instrumentation: indwelling catheter, condom catheter and leg bag
surgical: sphincterotomy, rhizotomy, urinary diversion
naturopathic: tx underlying neuro condition if possible, prevent UTIs and stones, antispasmodics, anticholinergics, neurorestoratives, antioxs, HP remedies
tx options for flaccid bladder?
suprapubic P (crede’s maneuver) to increase intra-abd P
pharm: acetylcholine derivatives
instrumentation: intermittent catetherization q 3-6 hrs
surgical: implant or TURP
naturopathic: above tx options, support nerve tone and re-growth, neurorestoratives, HP
complications of neurogenic bladder?
infection
calculus dt low fluids, bed rest, immobilization
renal amyloidosis
sexual dysfxn
RFs for urinary incontinence?
female advancing age abd or pelvic surgery pelvic radiation BPH
types of urinary incontinence?
urge stress overflow mixed functional
ssxs of urge incontinence?
abrupt, strong urge, delayed incontinence after cough or increased intra-abdominal P
causes of urge incontinence?
BPH, stroke, MS, alzheimer’s, parkinson’s, supra sacral spinal cord lesion, neurogenic, aging
sxs of stress urinary incontinence?
incontinence immediately after cough, sneeze, laugh or increase abd pressure
causes of stress urinary incontinence?
urethral architecture, pelvic trauma, neurologic lesions, drugs (alpha adrenergic antatagonists)
sxs of overflow incontinence?
feeling of fullness, frequent dribbling
causes of overflow incontinence?
drugs (alpha adrenergic agonists, anticholinergics, CCBs, loop diuretics), fecal impaction, diabetic neuropathy, MS, organ prolapse, BPH, PCA, urethral stricture, neurogenic
ssxs of functional incontinence?
feel urge ok just can’t make it to the bathroom
diagnosis of incontinence?
voiding diary PE: suprapubic tenderness, DRE, male genitalia, pelvic exam cystometrogram EMG stress cystourethrogram uroflowmetry urethral P profilometry urinary stress test
treatment and management considerations of incontinence?
pharm: urge - anticholinergics, antimuscarinics; stress - alpha adrenergic agonists, estrogen
surgical
naturopathic: discont causative medications, bladder retraining, pelvic MS exercises, exercise-based behavioral therapy
identify and eliminate food allergies
avoid caffeine, tea, alcohol
anti-inflams: flax, bromelain, vit C, vit E
botanicals: soy, zea mays, gallium, anticholinergic/UR, ephedra, pygeum and serenoa (OR), st. john’s wort (UR)
biofeedback
acupuncture
hypnosis
yoga
changes you see in IC? what is seen on cystoscopy specifically? what is IC?
changes seen with IC include fibrosis of the bladder wall, loss of bladder capacity, chronic inflam with mucosal disruptions, cellular infiltrates and sub-urothelial hemorrhages
Hunner’s ulcers seen on cystoscopy
hypersensitive bladder syndrome, leaky bladder
etiological theories of iC?
inflammation
uroepithelial dysfunction
food allergies
deficiency of GAG coating in bladder epithelium
chronic infxn, instrumentation, urinary calculi
toxins from food additives
pathological organisms dormant in bladder
deficiency of NO
trauma
genetics: HLA-DR6, FZD8
presentation of IC?
urinary frequency, urgency, progressively worsening bladder pn w/filling, better w/voiding
possible non-specific pelvic pn, mb dyspareunia, usu normal PE but mb suprapubic tenderness
diagnosis of IC?
diagnosis of exclusion
hx, pelvic pain/urgency/frequency
variable tenderness of abd wall, buttocks, pelvic floor, urethra
labs show no sxs of infxn, possibly hematuria, normal renal function unless obstruction or reflux
run cytology if high risk for bladder CA
imaging shows normal urogram
cystoscopy w/hydrodistention under anesthesia to visualize bladder - shows chronic wall inflammation, edema, small mucosal disruptions, cellular infiltrates, glomerulations, punctate hemorrhages
special test to run for IC?
potassium sensitivity test or Parson’s test - infiltration of KCl solution causes pain from epithelial leakage
NIH diagnostic criteria for IC?
pts must have either glomerulations on cystoscopic exam OR hunner’s ulcers AND either pain assoc w/the bladder or urinary urgency
when do you start to consider IC?
pts tx for overactive bladder who continues to experience persistent urge w/ associated suprapubic/pelvic discomfort or pn
pt who does not respond to empirical abx therapy for “recurrent UTI”
female pt who cont to have pelvic pn after endometriosis therapy
male pt who has been tx for prostatitis w/multitude of therapies but cont to have pelvic pn perceived to be associated with the bladder and possibly irritative voiding sxs
DDX of IC?
TB of bladder, schistosomiasis, cystitis, urethritis, spastic urogenic bladder, anxiety d/o, colorectal CA, bladder CA
drug effects
F: vaginal wall prolapse, endometriosis, uterine fibroids
M: prostate CA, prostatitis, pelvic floor hypertonicity
tx options for IC?
pharm: prednisone, anti-histamines, general or vesical sedatives, abx, CCBs, TCAs, gabapentin, LDN
procedures to increase bladder size, irrigation, intravesical tx options
surgery: to augment bladder capacity
naturopathic: psychosocial support, avoid activities that flare, guided imagery, avoid allergens, decrease EtOH, coffee, soda, tomato, citrus, MSG, chocolate, bananas, beer, cheese, GACs, quercetin, cystoprotek, melatonin, EFAs, buffered vit C, estriol suppositories, arginine, anti-inflam diet, anxiolytics, immuno-modulators, antispasmodics, vitanica supplement, physical therapy, sitz baths, HP
in both men and women, inquisitive, self-exploration, contraception –> cystitis, often hematuria
dx via plain fill or cystoscopy, stone may form rapidly in alkaline pH
tx: cystoscopic or suprapubic removal
foreign bodies introduced into the bladder and urethra
secondary to either obs distal to the vesical neck or UMN neurogenic bladder
inc intravesical P cz vesical mucosa to push between hypertrophied muscle bundles leading to vesicoureteral reflux and urine retention, risk of CA
tx: may need surgical removal
diverticula
from diverticulitis, Colon CA, Crohn dz, vesical irritability, passage of feces adn gas through urethra, change in bowel habits, sxs of intestinal obstruction and abd tenderness
dx via barium enema, cystoscopy and cystograms
tx: proximal colostomy, defect closure
vesicointestinal fistula
secondary to obstetric, surgical or radiation injury, or invasive CA of the cervix, constant urine leakage
dx: pelvic exam w/cystoscops, radiopaque dye w/x-ray, bx may show carcinoma
tx: electrocautery of the opening, direct surgical repair
vesicovaginal fistula
primarily in 20-40 yo A.A. men, no pathognomonic sxs - soe dysuria, mild obstruction, enlarged pear-shaped bladder
dx: excretory urograms and cystoscopy show dilation of both upper tracts and upward displacement and lateral displacement of the bladder
tx: surgical removal of fat
prognosis: progression to hydronephrosis in most cases; surgery for urinary diversion
perivesical lipomatosis
complete ventral defect of the urogenital sinus and the overlying skeleton
lower central abd occupied by the inner surface of the bladder, whose mucosal edges are fused with the skin
urine spurts onto abd wall
renal infxn and hydronephrosis common
staged surgical reconstruction (may lead to incontinence)
exstrophy
embryonic canal connecting bladder to allantois (umbilicus) persists, becomes a cyst
leakage of urine through umbilicus
adenocarcinoma may occur in the persistent urachal cyst
tx: surgical excision
persistent urachus (cyst)
