Flashcards in 24 - Urologic Diseases II Deck (69):
Describe the occurrence of UTIs
- Most UTIs are bacterial cystitis, and occur mainly in females.
- Approximately 40% of all nosocomial (hospital acquired) infections are UTIs, and most are associated with the use of urinary catheters.
- There are more than 1 million catheter-associated UTIs/year in the U.S
What do you need to know about the normal state of urine?
Urine is normally sterile
Describe an infection (UTI)
- The combination of a pathogen(s) within the urinary system and human host symptoms and/or inflammatory response to the pathogen(s)
- Treatment and management needed.
Describe a contamination
- Organisms are introduced during collection or processing of urine
- No health care concerns.
Describe a colonization
- Organisms are present in the urine, but are causing no illness or symptoms (asymptomatic bacteriuria)
- Depending on the circumstances, significance is variable, and the patient may not need treatment.
What are the clinical symptoms of cystitis (bladder and lower UTI)?
- Urinary urgency
- Foul-smelling urine
- Suprapubic pain
- May have associated urethritis , prostatitis or epididymitis
What are the clinical symptoms of pyelonephritis (upper UTI)?
- Typical symptoms of cystitis
- Flank or abdominal pain
- Nausea and vomiting
What are the risk factors for UTIs?
- Poor fluid intake/chronic dehydration
- Infrequent voiding
- Incomplete bladder emptying
- Chronic constipation
- Postmenopausal vaginal atrophy
- Staghorn calculi
Describe urine collection for a urinalysis
- Midstream clean catch, catheterization, suprapubic aspiration
What are you looking for in a urinalysis?
- Leukocyte esterase
- Blood, gross or microscopic
- >10 WBCs/HPF (but 5 is suspicious, consider tx)
What are you looking for in a urine culture?
What are the common pathogens for UTI?
- E coli
How do you treat a UTI?
Empiric antibiotic therapy with sulfamethoxazole/trimethoprim or fluoroquinolones
Adjust antimicrobials based on culture sensitivities for persistent symptoms and complicated/recurrent UTIs
Modify any contributing risk factors
May consider low dose antibiotic suppression for recurrent infections if all modifiable risk factors have been addressed
What is urinary incontinence (UI)?
- Any involuntary loss of urine
- Severity varies from a loss of a few drops of urine to complete bladder emptying
- May occur only occasionally or several times/day
- Due to bladder dysfunction, sphincter dysfunction, or both
How common is urinary incotinence?
- Approximately 40% of all women are affected
- More common in women than in men (~2:1)
What are the major types of urinary incontience?
- Urge Urinary Incontinence (UUI)
- Stress Urinary Incontinence (SUI)
Describe Urge Urinary Incontinence (UUI)
- Involuntary urine leak accompanied by or immediately preceded by a strong, sudden desire to urinate
- Occurs when bladder pressure overcomes sphincter mechanism
There must be urgency WITH leaking (might be freqency)***
Side note: what is overactive bladder?
Overactive Bladder (OAB): Frequency and urgency with or without UUI
If you don't leak, it is OAB, not UUI, but MUST have freqency ***
What are the different types of treatment with UUI?
- Behavioral modification
- Lifestyle changes
Describe behavioral modifications for UUI
- Controlling fluid intake
- Timed voiding
Describe lifestyle changes for UUI
- Weight loss
- Dietary changes
- Smoking cessation
Describe the medications that can be used for UUI
Anticholinergics are the mainstay of treatment for UUI/OAB***
- Inhibits involuntary detrusor muscle contraction
- Side effects include dry mouth, constipation, urinary retention, nausea, blurred vision, tachycardia, drowsiness, and confusion.
- Contraindicated in patients with narrow-angle glaucoma
Beta 3 Agonist
- Must monitor for hypertension
What are the surgical options?
What is Stress Urinary Incontinence (SUI)?
***** KNOW ALL OF THIS *****
- SUI: Involuntary urine leak with any sudden increase in abdominal pressure: cough, sneeze, lifting, straining, exercise
- In women, continence is maintained by combination of striated sphincter tone and passive anatomic coaptation of the urethra by supporting pelvic floor muscle attachments
What are female risk factors for SUI?
Risk factors for female stress incontinence: Pregnancy/child birth, aging, obesity, pelvic surgery, trauma, or radiation, constipation, chronic respiratory problems/smoking, hormone changes
What are male risk factors for SUI?
In men stress incontinence is primarily postsurgical (transurethral prostate resection, radical prostatectomy)
What are the treatment options for SUI?
KNOW THIS ******
- Pelvic floor strengthening exercises
- Formal pelvic floor physical therapy
- Pessary placement
- *****Surgical Treatment
What is the MOST EFFECTIVE surgical treatment of SUI?
***** Midurethral sling placement
- Biologic graft
- Autologous fascia
- Periurethral bulking agent injection
- Not as effective
What are vesical fistulas?
- Vesicovaginal fistulas
- Vesicointestinal (colovesical) fistulas
Describe vesicovaginal fistulas
- Often related to obstetrical trauma, gynecologic surgery, gynecologic malignancies, or pelvic radiation
- Often presents with continuous incontinence
- Treated with fulguration or surgical repair
- May require urinary diversion if due to advanced gynecologic malignancy
Mimics SUI, but it is different because it is not related to an increase in pressure (coughing)
Describe vesicointestinal (colovesical) fistulas
- Due to colonic diverticular disease, colon cancer, inflammatory bowel disease
- Symptoms include pneumaturia and chronic UTI with feculent urine
- Diagnosed with cystoscopy, colonoscopy, or rectal contrast imaging
- Treatment with bowel resection and closure of the bladder opening
What is the incidence of bladder cancer?
- Second most common GU cancer
- Incidence increases with age, - Mean age at diagnosis is 70
- Almost never reported as incidental finding on autopsy (preclinical latency of disease relatively brief)
- Smoking is the #1 risk factor
What is the cystoscopic appearance of papillary urothelial bladder cancer?
Describe the diagnosis and staging of bladder cancer
Transurethral resection of Bladder Tumor
- Obtains tissue for diagnosis of tumor type, grade, and stage
- Determines extent of invasion
Bimanual exam before and after resection
How common is non-invasive bladder cancer (Ta,T1,CIS)?
- 70% of all bladder cancers
- 70-80% of these recur
- 10-20 % progress to invasive disease
- 5 year survival 80-100%
Describe staging of non-invasive bladder cancer
T1 disease may be under staged in up to 25% so repeat TURBT should be considered 4-6 weeks following initial resection
Describe the treatment of non-invasive bladder cancer
- Treatment with resection +/- intravesical immunomodulators or chemotherapy (no systemic therapy)
- Periodic surveillance cystoscopy
Describe muscle invasive bladder cancer and metastatic bladder cancer
If disease invades detrusor muscle must proceed with clinical staging with CT scanning of the abdomen and pelvis, chest radiography, and serum chemistries
Describe metastases in muscle invasive bladder cancer and metastatic bladder cancer
As many as 50% of patients may have occult metastases that become clinically apparent within 5 years of initial diagnosis
KNOW THIS ***
What are the common sites of mets in muscle invasive bladder cancer and metastatic bladder cancer?
Sites of metastasis: pelvic lymph nodes, lung, liver, bone
Metastatic disease has very poor prognosis with 5 year survival 5-30%
What is the treatment of muscle invasive bladder cancer and metastatic bladder cancer?
Treatment for organ confined muscle invasive disease
- Radical cystectomy with urinary diversion is gold standard
- Chemotherapy +/-radiation
Describe the normal prostate growth
- Testosterone produced by Leydig cells in the tesicles
- Free testosterone is converted to DHT by 5 alpha reductase
- **** DHT is a more potent androgen than testosterone which binds to prostatic androgen receptors with higher affinity ****
- DHT stimulates prostate differentiation and growth
Know that DHT is MORE powerful than testosterone
Describe the pathology of BPH
Hyperplasia of glandular and stromal cells in transition zone and periurethral tissue
What causes BPH?
- Imbalance of cell proliferation and apoptosis
- Requires aging and androgens
What are the complications of BPH?
- Complications and morbidity of BPH due to bladder outlet obstruction (BOO) and associated LUTS
Describe the relationship of prostate size and symptoms
Severity of symptoms do NOT correlate with actual prostate size
What are the two different types of lower urinary tract symptoms?
- Irritative (storage) symptoms
- Obstructive (voiding) symptoms
What are the irritative (storage) symptoms?
What are the obstructive (voiding) symptoms?
- Weak stream
- Terminal dribbling
- Sensation of incomplete bladder emptying
Describe the AUA symptom index that you can ask a patient to see if they have BPH
- This is a 7-question survey that patients can often fill out in the waiting room.
- Items = Incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia
- Utilized to determine severity of symptoms (mild, mod, severe), monitor for progression of disease, and monitor response to treatment
How do you score the AUA symptoms index?
- Each item scored from 0 (not at all) to 5 (almost always)
Disease Severity Scores
- Mild: 0-7
- Moderate: 8-19
- Severe: 20-35
Describe the treatment possibilities for BPH
- BPH is primarily a quality of life condition
- Decision to treat is determined by patient’s level of bother and willingness/ability to comply with therapy or presence of complications
What are the complications of BPH?
- Acute urinary retention
- Renal insufficiency
- Chronic/recurrent UTIs
- Uncontrolled gross hematuria/clot retention
- Bladder calculi
What do you need to remember about placing a foli catheter in a patient with BPH?
Use a larger one, not a smaller one because you need the rigidity of the larger one to get through
What are the ways you can manage BPH?
- Watchful Waiting
- Minimally Invasive Thermal Therapy
- Surgical Options
Describe pharmacotherapy options for BPH
- alpha antagonists ******
- 5 alpha-reductase inhibitors
- Combination therapy
- Herbal supplements
Alpha antagonists are the FIRST LINE ***
Describe minimally invasive thermal therapies
- TUMT (transurethral microwave therapy)
- TUNA (transurethral needle ablation)
- IL (interstitial laser ablation)
Describe the surgical options for BPH
- Transurethral Surgery (TURP/ laser resection/TUIP)
- Open Prostatectomy
What is the most common solid organ cancer in men?
- Prostate cancer is the most common solid organ cancer in men
- Prostate cancer is the second leading cause of cancer-related deaths in US men (lung cancer is the most)
- Incidence peaked in 1992 approximately 5 years after the introduction of PSA as a screening test
- Prostate cancer specific mortality has declined since 1991
What are the risk factors for prostate cancer?
Age is strongest risk factor
- Prostate cancer is rarely diagnosed in men younger than 50
- Peak incidence occurs between the ages of 70 and 74
85% diagnosed after the age of 65 years
- African-Americans consistently have higher grade/stage at diagnosis and are 2x more likely to die of disease
- Lower incidence in Asian and Hispanic populations
- Accounts for 10-15% of prostate cancers
- Age of diagnosis of relative is important
What are the symptoms of prostate cancer?
There are no symptoms with early prostate cancer
Late in the course of disease symptoms occur due to metastasis
What are the sites of metastasis for prostate cancer?
1 - Pelvic Lymph Nodes: lower extremity edema, abdominal pain, ureteral obstruction
2 - Bone : bone pain, pathologic fractures
3 - Lung: pulmonary symptoms
Does NOT go to the liver or brain
DEFINITELY check lymph nodes, bones and brain for mets
What things can increase PSA?
All of the following diseases/condition increase PSA:
- Prostate disease (BPH, prostatic inflammation, acute and chronic prostatitis, prostate cancer)
- Prostate/urethral manipulation (e.g., catheterization, prostate biopsy, urinary retention, cystoscopy, transurethral resection),
ANYTHING associated with the prostate can increase PSA
It does NOT mean cancer
Describe the digital rectal exam (DRE)
- >50% of suspicious palpable lesions are proven to be cancer
- Imaging does not improve cancer detection over DRE alone and is not recommended for screening
- Transrectal ultrasound is utilized to guide biopsy and measure prostate size
Describe screening for prostate cancer
DRE and PSA
These are NOT diagnostic, just screening tools
GOLD STANDARD: biopsy ***
What are the treatment options for prostate cancer?
Watchful Waiting/Active Surveillance
- Surgery (Radical Prostatectomy)
- HIFU (High intensity focused ultrasound)
- Radiofrequency ablation
What is used to treat metastatic prostate cancer?
- Hormone therapy
- Hormone refractory prostate cancer
Describe the treatment of hormone therapy for metastatic prostate cancer
- Prostate cancer was the first malignancy found to be hormone dependent
- Hormonal manipulation used to decrease androgens circulating in blood stream to suppresses prostate cancer growth
- Hormone therapy is never curative