Week 8: GU, Sexual Health & Renal Flashcards
What is stress incontinence
Involuntary loss of urine with increased intra- abdominal pressure
What is urge incontinence
= the urge to void immediately preceding or accompanying involuntary urine leakage
Patients are aware of the intense need to avoid but are unable to hold back urine
What is the difference between urge incontinence and over active bladder (OAB)?
“Overactive bladder” is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by nocturia and urinary frequency
The terms “urgency incontinence” and “overactive bladder with incontinence” are often used interchangeably.
T/F with urge incontinence, the person typically piddles a little
False
typically the entire contents of the bladder are lost rather than a few drops.
**although up to date says it can be either
Risk factors for urge incontinence (includes many associated medical conditions)
Urgency urinary incontinence is more common in older women and may be associated with comorbid conditions that occur with age.
May be idiopathic or secondary to other conditions…
Medical: CHF, DM, diuretics
Neurogenic: MS, PD, CVD, dementia, SCI
Bladder outlet obstruction: Previous bladder neck surgery, pelvic organ prolapse
Gyne: UTI, pregnancy, pelvic mass, urethral diverticulum, child birth
Psychosomatic: habits, anxiety, high fluid consumption
Obesity
Smoking
Stroke
Prior radiation to pelvis
Prostate: BPH, CA
What is thought to cause urge incontinence? Basic patho
Thought to result from detrusor overactivity, leading to uninhibited contraction during bladder filling
Bladder hypersensitivity
What the heck is the detrusor muscle?
The wall of the bladder is comprised of smooth muscle fibers oriented in multiple different directions. These smooth muscle fibers are collectively known as the detrusor muscle
S&S of urge incontinence
-You have a sudden, intense urge to urinate followed by an involuntary loss of urine.
Frequency
Nocturia
Diagnostics we may order for someone with urge incontinence?
-UA (UC if indicated)
-PVR
-Bladder stress test
What are considered bladder irritants & should be avoided with urge incontinence?
caffeine
smoking
alcohol
acidic, spicy foods
carbonated beverages
What are the 1st line treatments for urge incontinence?
Non pharm (1st line, try for 6+ weeks)
- PELVIC FLOOR PHYSIO!
-Reduce bladder irritants (caffeine, smoking, alcohol, carbonated)
-Fluid restriction
Bladder training: Regular voiding schedule
- Voiding diary
-Distraction techniques when urge comes on: deep breathing, crosswords…
-Encourage double voiding/ complete emptying.
-OTC products (pads, incontinence underwear, urine wicking devices)
How should you instruct a patient to carry out a regular voiding schedule for stress incontinence?
Start timed voiding q1 hour, then increased by 15-30min/ wk or until 2d without incontinence
goal 3-4 hour without leaks
*want to avoid last minute rush to bathroom./
If 6 or so weeks of nonpharmacologic strategies doesn’t fix urge incontinence, we can start to consider drugs. What are our typical pharm treatments?
Anticholinergics (oxybutynin, tolterodine, fesoteriodine, …) - These act at detrusor smooth muscle to reduce over activity.
B3 adrenergic agonist (mirabegron) (increases bladder capacity)
Vaginal estrogen in estrogen deficient females
If pharm management of urge incontinence is inadequate. What kind of procedures can be helpful?
**once has failed 2 adequate trials of meds (4-12 weeks each):
Sacral neuromodulation (SNM)
Detrusor botox injection
Laser therapy
Intravesicular instillations
Red flags warranting referral for incontinence
recurrent incontinence, incontinence assoc with pain, UT abnormalities, hematuria, recurrent infection, fistulas, prostate/ pelvic irradiation, previous radical pelvic sx, pelvic mass, lack of tx response
What is the most common cause of incontinence in Canada?
stress (~50%)
How common is urge urinary incontinence/OAB in Canada?
~16% of those with incontinence
Which kind of urinary incontinence is typically the most responsive to pharm tx?
Urge/OAB
What is the basic patho of stress incontinence?
-Thought to be related to lack of mechanical support of urethra/ insufficient resistance to outflow of urine with increased abdo pressure
-Sphincter incompetence
Risk factors for stress incontinence?
-20-30% of F (F>M)
increased age
obesity
pregnancy/ vaginal delivery
post menopause
smoking/ chronic cough
neurological
genetics
high impact exercise
-Can also occur in M post prostate Ca tx (or rarely surgical tx BPH)
S&S of stress incontinence
Leakage of urine with state increased intra abdominal pressure (cough, sneeze, laugh, sex)
The urine leakage may be an occasional drop or dribble if the condition is mild. In severe cases, you may leak a stream of urine
*I don’t think it usually involves irritative signs like dysuria or frequency, but some sources say it may…
What investigations might you order for stress incontinence?
UA (if hematuria and irritative voiding symptoms: cytology; if pyuria/ bacteria: UC)
-PVR
What is a normal PVR?
normal is <1/3 total volume, abnormal is >1/3 and indicates poor bladder contractility or bladder outlet obstruction
Nonpharm treatment of stress incontinence
-urinary diary
-weight loss, smoking cessation
-Pelvic floor PT (kegels) (x8-12 weeks, then r/a)
-Devices for biofeedback or electrical stimulation (vaginal electromyography probe for biofeedback, vaginal cones, non implantable electrical stimulation)
-Pessaries to decrease leakage (or for pelvic organ prolapse)
pharm treatment of stress incontinence
***No meds have official indication - generally not recommended
-Can consider vaginal estrogen if GU sx of menopause (not oral!)
-Duloxetine, midodrine
Possible surgical/procedure treatments for stress incontinence
-Treat pelvic organ prolapse, if existing
-Vaginal laser, urethral bulking
-urethral slings
____% of those in Canada with urinary incontinence have mixed urinary incontinence
32%
What is mixed UI
How is it treated generally?
Characteristics or both OAB and SUI
**TREAT AS PER THE MOST DOMINANT CATEGORY
What is overflow incontinence? What is it caused by?
means that you have the urge to urinate but can release only a small amount. Since your bladder doesn’t empty as it should, it gets too full. It then leaks urine later, even though you feel no urge to urinate
caused by detrusor underactivity (weak bladder muscle) or bladder outlet obstruction.
How does overflow incontinence typically present?
**typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying.
May be position dependent
- Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia.
When the bladder is very full, stress urinary leakage can occur, or low-amplitude bladder contractions can be triggered, resulting in symptoms similar to stress and/or urgency urinary incontinence.
Causes of overflow incontinence
- Conditions that affect nerves such as DM or MS. These make it hard to tell when bladder is full or make it harder for bladder to contract
- Blockage of urinary tract: stone, tumor, enlarged prostate, narrowing of the urethra
- detrusor weakness
- Some meds
Treatment of overflow incontinence
Treat constipation
Stop or decrease meds (especially if anticholinergic)
Double voiding
A-blocker (Tamsulosin) trial in men
Intermittent catheterization
How does GSM (genitourinary syndrome of menopause) contribute to incontinence?
In postmenopausal women, low estrogen levels result in atrophy of the superficial and intermediate layers of the urethral mucosal epithelium. Atrophy results in urethritis, diminished urethral mucosal seal, loss of compliance, and possible irritation, all of which can contribute to incontinence
Name some meds can contribute to urinary incontinence (up to date has a great table)
Antihistamines: Decreased contractility via anticholinergic effect
Decongestants (such as Pseudoephedrine): Increased urethral sphincter tone
Benzos: Impaired micturition via muscle relaxant effect
Opioids: Decreased sensation of fullness and increased urethral sphincter tone
Anticholinergics: Decreased contractility via anticholinergic effect
- Antimuscarinics *used to treat OAB
- splasmolytics (glyco, hyoscyamine, scopolamine)
- antiparkinsons meds
And many many others:
cardiac meds
antidepressants
antipsychotics
estrogens
alcohol
caffeine….
What is the DIAPERS acronym for incontinence in the elderly?
Describes transient causes of reversible urinary incontinence
DIAPERS
Delirium
Infammation/Infection
Atrophic vaginitis/urethritis
Pharmaceuticals/Psychological
Excess U/O
Restricted mobility/Retention
Stool impaction
Describe the pathogenesis of ABP(acute bacterial prostatitis)
-microorganism enter prostate gland via urethra (migrate from urethra or bladder)
-can also occur from direct innoculation after transurethral prostate biopsy or other procedures (i.e., catheterization, cystoscopy)
Who do we see stress incontinence in most often?
Common in middle aged
and older women, and
men following prostate
cancer treatment, or rarely
surgical treatment of BPH
Risk factors for ABP
-can occur in setting of cystitis, urethritis, or other urogenital tract infections
-conditions that predispose to urogenital tract infections (i.e., urethral stricture)
-urogenital instrumentation (including chronic indwelling bladder catheterization, intermittent cath, prostate biopsy)
-HIV
-Anecdotally- trauma (bike riding), dehydration, sexual abstinence
What is perimenopause? How long does it start before menopause?
years leading up to menopause characterized by irregular menses, +/- vasomotor (VMS) and other symptoms; may begin up to 10 yrs before LMP
Describe the clinical presentation (symptoms) of ABP
-LUTs (frequency, urgency, urge incontinence)
-voiding symptoms may be caused by inflamed prostate (dribbling, hesitancy, acute urinary retention)
-dysuria
-Pelvic pain
-Pain at tip of penis
-Systemic symptoms- fever, chills, malaise, myalgia
What time period if considered menopausal transition?
perimenopause and the first 12 months post LMP
Describe PE findings of ABP
-On DRE, prostate if firm, edematous, exquisitely tender
-Pyuria, bacteriuria
-Elevated WBC, CRP
-May have positive blood cultures
-Note that inflammation of prostate can also lead to elevated PSA (defer serum PSA for prostate cancer screening by 1 mo following resolution of ABP)
Do you still need contraception during the perimenopausal period?
Yes, until 55 or 12 months with no period. Consider progestin only contraceptive or low dose CHC
- Rxfiles recommneds that women 50 and older use a non-hormonal contraceptive. Continue until 12 months with no period.
- Women 55 years and older stop contraception as conception is very rare
(I feel like these guidelines goes out the window when we start treating vasomotor symptoms with estrogen/progesterone because we won’t know when menses has truly stopped naturally)
Potential complications of ABP?
-bacteremia
-epididymitis
-chronic bacterial prostatitis
-prostatic abscess (need TR-US to ID- s&s would be similar to those of ABP but persist despite appropriate abx therapy, and fluctuance of prostate on DRE)
-metastatic infection (spinal or sacroiliac)
-endocarditis (if valvular heart disease or valvular prosthesis)
Average age of menopause?
Average age of menopause is 51 years
Occurs in 90% of females between 45-56
How do you diagnosed ABP?
-Symptoms of ABP
-DRE findings of edematous, tender prostate establishes diagnosis in context of hx
-ensure you collect UA, urine C&S
-blood cultures only if sepsis (and in this case, they should be in the ED)
S&S of menopause
Risk of what diseases increases at this time?
- urogenital tract: atrophy, vaginal dryness/itching, urinary frequency/urgency/incontinence, bleeding
- vascular: vasomotor instability (hot flashes, night sweats), increased risk of heart disease
- bones: bone loss, joint/muscle/back pain, fractures, loss of height
- brain: depression, irritability, mood swings, memory loss
Ddx for ABP?
-UTI/ cystitis (no constitutional symptoms, no overt prostate inflammation/ no prostate tenderness on DRE)
-epididymitis (again, no tenderness of prostate on DRE)
-BPH/ OAB (may present with LUTS, but do not have fever, pyuria, other S/S infection)
What % of AFAB individuals in menopause experience GSM?
GSM symptoms in 45-77%
When would a patient with ABP require hospitalization?
-s&s sepsis
-unable to tolerate oral abx
-acute urinary retention (up to date states that passage of urinary catheter through inflammed urethra is CI in those with ABP; cath would need to be done suprapubic!)
Vasomotor symptoms occur in ______% of individuals during menopause?
How long do these symptoms persist?
VMS in 80%
persist for 7-11 years
From sigma pocket guide: Although 50% of women experience VMS for 7 years or less, 15% may experience VMS for 15 years or longer.
Tx of ABP?
-abx
-empiric therapy to cover gram negative organisms
-fluroquinolones (i.e., ciprofloxacin or levofloxacin) first line or TMP-SMX (UTD, B&D)
-men <35 who are sexually active and men 35+ engaging in high risk sexual behavior should be tx with regimes covering GC & CT
What lifestyle/nonpharm treatments are available for menopausal symptoms?
CBT, mindfulness, hypnosis, weight loss, cooling techniques, avoiding triggers, physical activity
George, age 50, has been taking ciprofloxacin 750mg BID for 3 days for suspected ABP. His symptoms of fever, dysuria, urgency, and pelvic pain are not improving. What do you do?
Suspect abscess
Bugs and Drugs: - if lack of clinical improvement with culture-guided antibiotic therapy, consider CT to identify structural abnormalities or prostatic abscess +/- urology referral. NB: transrectal US is NOT recommended.
Up To Date: TR-US (TN also states do US if suspect abscess) or CT
T/F you can use low-dose vaginal estrogen for GSM, even if contraindications to estrogen use exist
True! Just can’t use systemic estrogen
**black box warnings for breast CA/CHD
generally do not apply
What is chronic bacterial prostatitis (CBP)?
chronic or recurrent urogenital syndrome with evidence of bacterial infection of prostate (UTD_
Bugs and drugs- sx 3+ mo, subacute presentation
T/F if you start a patient on vaginal estrogen and they have a uterus, you need to also prescribe progesterone for endometrial protection
False - Low-dose vaginal estrogen does
not require a progestogen for endometrial protection
Pathogenesis of CBP?
-same as ABP
-entry of microorganisms into prostate gland, usually via urethra
-can be a complication of acute prostatitis following inadequate/ too short tx
You prescribe a patient systemic estrogen. They also have a uterus. What else do you need to prescribe? Examples of this?
Progesterone
examples: MIRENA IUD, PROMETRIUM, PROVERA
Risk factors for CBP?
-ABP
-hx manipulation of urinary tract
-DM
-smoking
-higher prostate volumes
-prostate stones
T/F combined hormonal contraceptives (CHCs) are a good treatment option for VMS in menopause
False
Avoid CHCs for
treatment of VMS in post-menopausal, as the estrogen
dose is ~3-6x higher vs MHT
What organism is the most common causative agent in CBP?
gram negative rods (e.coli most common)
Linda is having VMS. She asks you to check her hormone levels so you can decide if you need estrogen therapy. What’s your next step?
Don’t do it…
Measuring
serum estradiol, estrone, or SHBG is not recommended as
they do not correlate with menopausal symptoms
Presentation of CBP?
-can be subtle
-recurrent UTI (frequency, dysuria, urgency, perianal discomfort, low grade fever) with repeated isolation of same organism in urine
-may be asymptomatic with recurrent bacteriuria
-may have pain in perineum, lower abdo, testicles, penis, with ejactulation), bladder outlet
-may have blood in semen
Key 6 questions you should ask your patient in perimenopause (basically what symptoms are you asking about)
- Any changes in your periods?
- Are you having hot flashes?
- Any vaginal dryness, pain or
sexual concerns? - Any bladder issues or
inconfinence? - How is your sleep?
- How is your mood?
Findings on DRE of person with CBP?
-may have prostatic hypertrophy, tenderness, edema, nodularity
-frequently NORMAL prostate exam (UTD)
Your patient recently went through menopause and complains of low mood. What are some pharm treatment options?
MHT may benefit peri- and
early post-menopausal with low mood irrespecfive of VMS
Otherwise can treat anxiety/depression as you normally would
Lab findings in CBP?
-usually unremarkable
-normal leuks, inflamma markers
-elevated PSA only in 25% of pts
Your perimenopausal patient complaints of poor sleep. How to approach treatment?
Treat underlying cause (e.g. VMS, OAB, OSA).
Sleep hygiene
CBT-I
aerobic exercise; medications (e.g. venlafaxine 75mg/day; gabapentin
300mg QHS)
may try menopause herbal product (e.g. black cohosh
20mg/day; valerian root 530mg BID).
Dx of CBP?
The diagnostic standard for bacterial prostatitis is the finding of bacteria at higher levels in prostatic fluid compared with urethral and bladder specimens. However, maneuvers to express prostatic fluid can be cumbersome and are rarely performed in clinical practice. Instead, chronic bacterial prostatitis is often presumptively diagnosed and empirically treated with antimicrobials when men present with chronic (eg, longer than three months) or recurrent urogenital symptoms, particularly if bacteriuria is also present.
UTD suggests referral to urology to obtain prostate fluid samples for dx before starting on long term abx.
Mildred, 55, says her memory and concentration is poor since menopause. Treatment recommendations? Is hormone treatment useful for this?
↑ aerobic exercise and vegetable intake
MHT not proven helpful
ddx for CBP?
- chronic prostatitis (no clear evidence bacterial infection)/ chronic pelvic pain syndrome
-non inflammatory disorders of prostate/ bladder/ urinary tract
Hormonal treatments in menopause best treat which symptoms?
VMS: hot flashes, night sweats
Tx for CBP?
Prolonged abx therapy- at least 6 weeks! (UTD)
Infection frequently recurs
Fluroquinolone drug of choice.
Needs to have good penetration into prostatic tissue (fluroquinolones, sulfonamides, tetracyclines, macrolides)
Your patient is on systemic estrogen for VMS. She is also having vaginal dryness. T/F: it’s not safe for you to add topical estrogen to treat this symptom
False! Can add it for GSM symptoms
You treat George, 60 years old, for CBP with a 6 week course of ciprofloxacin. 1 month later, his symptoms recur. What do you do?
Up To Date- recurrences of CBP common and warrant 2nd course of abx. Assess for causes of tx failure (abx resistance, incomplete adherance, impaired drug absorption).
For recurrent CBP episode, tx with fluoroquinolone (i.e., repeat cipro course) regardless of initial abx choice unless suspected resistances.
Would personally refer to urology before starting 2nd course of abx, esp. if did not previously collect prostatic fluid for culture.
T/F it’s normal for a person who has started MHT to experience vaginal bleeding within the first 6 months
True
Rxfiles: Vaginal bleeding (e.g. breakthrough bleeding, prolonged menses on cyclical regimen, etc.): May
occur within first 6mo of MHT. Assess adherence; may ↓ estrogen dose; ↑ progestogen
dose; switch to DUAVIVE; switch progestogen regimen (confinuous → cyclical). Invesfigate
AUB if new onset after 6mo on tx or if abnormal uterine bleeding persists > 6mo.
Compare and contrast clinical features of ABP and CBP
Both: LUTs, pelvic pain, leukocytosis in prostatic fluid, positive bacterial cultures
ABP: Systemic signs (fever, chills, malaise), v tender prostate on DRE
CBP: NO systemic signs, may have asymptomatic DRE
T/F once a person starts MHT, they will likely be on it lifelong.
False
Anficipate 3-5yrs of MHT for many;
however, some may require shorter or
longer durations.
Tim, 50 years old, presents to clinic with dysuria, urgency, frequency, fever, chills, and lower abdominal pain. How would you diagnose ABP and what differentials would you consider?
-ABP- LUTs, acutely ill (fever, chills, malaise), pelvic pain, dysuria, irritative symptoms. PE- firm prostate, edematous, very tender. Positive UA and UC. Labs- elevated WBC, CRP.
-UTI/ cystitis- would likely not have systemic sx. No DRE prostate abnormalities.
-Pyelonephritis- (given LUTs, fever)- would have flank pain
-BPH, OAB- would not have systemic sx, insidious onset; negative UA
-epididymitis- presence of LUTs, systemic sx, but would have testicular/ scrotal pain, palpable swelling of epididymis, no tenderness of prostate on DRE
At what age must MHT be stopped?
Trick question!
There is no set age at
which MHT must be discontinued. Reevaluate need for MHT annually and with
any changes in health status.
What abx are first line for both ABP and CBP?
Fluroquinolones (ciprofloxacin)
What are the absolute contraindications to MHT
- Unexplained vaginal bleeding
- Acute liver disease
- Clotting disorder
- Hx of CHD (CAD, stroke, TIA, unprovoked VTE, PAD) or at high-risk
of CHD* - Personal hx of estrogen-dependent CA (breast, endometrial, ovarian) or at
high-risk of breast CA** - Moderate risk of CHD*/breast CA**
AND age ≥60yrs AND ≥10yrs since LMP
What is the difference in tx a patient with abx for ABP and CBP?
Length of therapy
ABP requires 10-14 days of cipro
CBP requires 4-6 wks
what is the optimal situation in which MHT is considered?
Age <60yrs or <10yrs
since LMP and low risk (no
cautions or contraindications)
Counselling for pt you initiate on a fluoroquinolone?
Usually well tolerated; common AE are mild GI upset, headache, dizziness, transient change in mood or sleep.
AE: tendinopathy (stop if experience pain/ swelling, and seek care), c. diff (stop and seek care if copious diarrhea, abdo pain, new fever), neuropathy (stop drug and seek care/ switch to diff abx class), QT interval prolongation (assess QT prolonging drugs, consider baseline ECG)
Avoid use in those with pre-existing tendinopathy, neuropathy, prolonged QT, aortic aneurysm, ehler danlos, marfan syndrome, uncontrolled HTN. Avoid in pregnancy and lactation. Avoid in myasthenia gravis (neuromuscular blocking activity can precipitate crisis)
MOA- bactericidal, inhibit bacterial DNA synthesis. Broad spectrum, potent activity against enteric gram negative bacilli.
Take with food (avoid taking with antacid or with dairy products alone)
Your patient is 65 years old and went through menopause 11 year ago. Are they a good candidate for MHT?
Probably not! Would need to look at the situation and risk factors but typically only want to prescribe MHT to
Age <60yrs or <10yrs
since LMP
**Consider non-hormonal treatments for this patient if they are still having symptoms.
Describe age related changes in sexual health for women.
Decreasing estrogen levels due to menopausal changes.
-vaginal dryness and thinning -> dyspareunia
-decreased libido, may take longer to become sexually aroused
-Self esteem issues around body changes.
Name some situations in which prescribing MHT is cautioned (not totally contraindicated but needs close risk/benefit analysis)
- Moderate risk of CHD* and/or CV risk factors (smoking, HTN, DM,
dyslipidemia, obesity) in age <60yrs or <10yrs since LMP - Migraine with aura
- Hx of gallstones
- Moderate risk of breast CA**in age <60yrs or <10yrs since LMP
- Age ≥60yrs and ≥10yrs since LMP
Describe age related changes in sexual health for men
Testosterone levels begin to decrease.
-It may take longer for him to become sexually aroused.
-It may take longer for his penis to become erect.
-Erections may not be as firm or last as long.
-It may also take longer to ejaculate.
T/F transdermal estrogen is considered to have lower risk for VTE & gallstones when compared to oral
Yes! Can be good option for some of these individuals who fit the “caution” criteria.
Observafional data
suggest transdermal may ↓ risk of VTE & gallstones
What medical conditions can reduce sex drive/ reduce ability to become aroused or achieve orgasm?
- Neurovascular conditions are the most common cause of ED (erectile disfunction)
- Arthritis, chronic pain
- Incontinence
- Heart disease, vascular disease, HTN
- Neurologic disease – radiation therapy, spinal cord injury, autonomic dysfunction, surgical procedures
- Diabetes, other endocrine issues (hypo/hyperthyroidism, hyperprolactinemia)
- Obesity
- Dementia
- Stroke
- Depression
T/F MHT must be tapered carefully when discontinuing
False
MHT can be stopped abruptly or tapered
(VMS re-emergence rates similar irrespecfive
of disconfinuafion method). If tapering: ↓
dose preferred over alternate day dosing
due to MHT pharmacokinefics.
Describe some psychosocial factors that may contribute to ED.
-depression, stress, relationship issues
-ED that develops suddenly is typically due to performance anxiety
-fear of STI
-widower syndrome- older man involved in a new relationship feels guilt and develops impotence as a defense against his unfaithfulness to his dead spouse- a man will be able to achieve erection and ejaculation with masturbation if this is the cause of ED
T/F vaginal estrogen can be continued indefinitely
True!
Vaginal estrogen should be continued at
the lowest effective dose for as long as
benefit is noted (may be continued
indefinitely).
Discontinuation leads to the
vaginal mucosa returning to a hypoestrogenic state.
What medications can contribute to sexual dysfunction?
anticholinergics
antihypertensives
antidepressants
cimetidine
Amenorrhea for what time period is diagnostic of menopause?
12 months