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Gu Exam 3 > Bladder and Urethral disorders > Flashcards

Bladder and Urethral disorders Flashcards

1
Q

Age is the single largest risk factor for _____

A

Urinary Incontinence

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2
Q

Urinary Incontinence

A

Involuntary leakage of urine – Stress – Urge – Mixed – Overflow

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3
Q

Urinary Incontinencen epidemiology

A

● 10-13 million people in the US
● Female incontinence is reported at 38%
○ 20–30% during young adult life
○ 50% in the elderly (peaks in the 5th decade)
● Stress incont more likely in caucasian women
● Age is the single largest risk factor
● Pregnancy/Childbirth
● Obesity

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4
Q

Patients often live with this condition for 6-9 years before seeking medical therapy

A

Urinary Incontinence

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5
Q

Transient/Reversible Causes of Incontinence – DIAPPERS

A

● D: Delirium or acute confusion
● I: Infection (symptomatic UTI)
● A: Atrophic vaginitis or urethritis
● P: Pharmaceutical agents
● P: Psychological disorders (depression, behavioral disturbances)
● E: Excess urine output (due to excess fluid intake, alcoholic or caffeinated
beverages, diuretics or hyperglycemia)
● R: Restricted mobility (limits ability to reach a bathroom in time)
● S: Stool impaction

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6
Q

Pathophysiology/Etiology of urinary incontinence

A

● Multifactorial – not completely understood
○ Can be transient or chronic
● Two-part system – the urinary bladder as a reservoir and the bladder outlet as a
sphincteric mechanism

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7
Q

Functional cause of urinary incontinence

A

Problem with the bladder’s ability to contract (neves or muscle)

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8
Q

Problem with sphincter, bladder (or other pelvic structure) positioning would be _____ causes of Urinary Incontinence

A

Anatomical

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9
Q

Stress Incontinence Etiology

A

○ Urethra hypermobility
■ Due to loss of structural support from the pelvic floor
○ Intrinsic sphincter deficiency
■ Sphincter unable produce enough closing pressure
■ Typically secondary to surgery

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10
Q

Stress Incontinence clinical presentation

A

● Urine leaks when pressure is exerted on the
bladder by coughing, sneezing, laughing,
exercising or lifting something heavy
○ Worse with high impact sports
● Typically small amounts of urine lost
● Absence of urinary frequency and urgency

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11
Q

Urge Incontinence

A

Involuntary loss of urine associated with LUTS
● LUTS – lower urinary tract symptoms (urgency, frequency, nocturia)

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12
Q

Etiology of Urge Incontinence

A

● Detrusor overactivity
● Low bladder compliance while attempting to inhibit micturition
● Bladder irritants, psychological

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13
Q

Urge Incontinence clinical presentation

A

● Uncontrolled urine loss associated with a strong desire to void
● Occurs without warning
● Cannot be prevented
● Not associated with physical activity

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14
Q

Syndrome of urinary urgency that Presents with frequency and nocturia and Occurs with or without urgency urinary incontinence

A

Overactive Bladder

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15
Q

Mixed Incontinence

A

Combination of stress and urge incontinence

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16
Q

Epidemiology of Mixed Incontinence

A

● 40-60% of females have this combination
● More common in older patients

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17
Q

Etiology of Mixed Incontinence

A

Detrusor overactivity and impaired urethral function

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18
Q

Clinical Presentation of Mixed Incontinence

A

● Mild-to-moderate urine loss with physical exertion (stress incontinence)
● Acute urine loss without warning (urge incontinence)
● LUTS

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19
Q

Overflow Incontinence

A

Involuntary loss of urine associated with bladder overdistension

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20
Q

Etiology

A

● Bladder outlet obstruction
● Inadequate bladder contractions
○ Neurogenic bladder
● Intravesical pressure exceeds the resting
urethral closure pressure and urine overflows
despite the absence of detrusor contraction
● With overdistension, the detrusor becomes
acontractile

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21
Q

Overflow Incontinence Clinical Presentation

A

● Frequent small voids
● Sensation of incomplete emptying
● Urine hesitancy and slow flow
● Dribble
● High PVR (>200 mL)

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22
Q

Diagnosis of Incontinence

A

● Voiding Log: “How often, how much, how many pads…”
● UA: Urine culture
● Blood work: BUN and Creatinine, A1c
● PVR/ultrasound: High PVR (>200 mL)
● Pelvic Exam
● Neurologic Exam
● Stress Incontinence Testing
● Cystoscopy
● Urodynamic Testing

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23
Q

Pelvic exam for urinary incontinence

A

○ Inspection of the external genitalia and
urethral meatus
○ The vaginal mucosa should be inspected
for pallor, thinning, loss of rugae, fistula
○ Evaluate for cystocele, rectocele, uterine
or vaginal prolapse, and enterocele
○ Evaluate for pelvic organ prolapse
○ Inspect the perineal floor of tone
○ Anal sphincter tone
Male Exam
○ Prostate exam
■ Enlargement, tenderness, nodules
○ Rectal tone

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24
Q

Whats included in a neurologic exam for urinary incontinence?

A

○ Sensation of the perineum and perianal areas
○ Anal Wink reflex
○ Bulbocavernosus Reflex

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25
Q

What is included in a Stress Incontinence Testing for urinary incontinence?

A

○ Q-Tip Test
○ Stress Test

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26
Q

When to perform a Cystoscopy for diagnosing incontinence?

A

○ Irritative voiding symptoms/OAB
■ Cystitis, stones, tumors
○ Postoperative incontinence
○ Voiding dysfunction

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27
Q

What is Stress Incontinence Testing?

A

○ Stress Test
■ The bladder is filled with sterile fluid at least halfway (eg, 200-250 ml)
■ Visualizing the urethra, instruct the patient to bear-down or cough
■ Observation of leakage during valsalva or cough denotes a positive test
● Display immediate loss of a few drops to a brief squirt of urine

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28
Q

Urodynamic Testing in Urinary incontinence

A

○ Evaluate the pressure-flow relationship between the bladder and the urethra
■ Electromyography (EMG), Uroflow, voiding
cytometrography (CMG)

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29
Q

Stress Incontinence Management

A

● Absorbent products – pads
● Weight loss
● Timed voids – “Bladder Training”
● Pelvic floor muscle training – Kegels
● Acupuncture
● Radio-frequency
● Mechanical devices

30
Q

Mechanical Devices for Stress Incontinence

A

● Pessary
○ May be useful severe pelvic organ prolapse

31
Q

Kegels

A

● Stress and mixed incontinence
● Pelvic prolapse
● Sexual function
● Benefits men who develop urinary
incontinence following prostate surgery
● Success rate of 75-80%

32
Q

Surgical management of stress incontinence

A

● Bladder neck suspension
○ Mid-urethral sling surgery
● Periurethral bulking therapy
● Artificial urinary sphincter placement

33
Q

Urge Incontinence Management

A

● Absorbent products – pads
● Weight loss
● Timed voids – “Bladder Training”
● Pelvic floor muscle training – Kegels
● Medication Modification
○ Diuretics, sedatives, muscle relaxers,
antidepressants
● Dietary Modification – Avoid the irritants
● Pharmacotherapy (Antimuscarinics, Beta-3 adrenergic agonists, etc.)

34
Q

Antimuscarinics for Urge incontinence

A

○ Oxybutynin (Ditropan), solifenacin (Vesicare), fesoterodine (Toviaz), tolterodine (Detrol)
○ MOA – binding the muscarinic receptor on the detrusor decreasing the contractility of the
detrusor muscle
○ S/E (ABCD’s) - Anorexia, Blurry vision, Constipation/confusion, Dry mouth, Stasis urine
○ Contraindications – Narrow or closed-angle glaucoma, caution in patients with history of
impaired gastric emptying or history of urinary retention
○ High discontinuation rate due to intolerable side effects

35
Q

Beta-3 adrenergic agonist for Urge Incontinence

A

○ Mirabegron (Mybetriq)
○ MOA – binding the β-3 adrenergic receptor on the bladder signaling relaxation of the detrusor muscle
○ S/E – hypertension (7-25%) increase systolic by 4 mm/Hg and diastolic of 1.6 mm/Hg, headaches, UTI
○ Contraindications – Uncontrolled hypertension, Hx of or current low-risk papillary thyroid cancer, beta-blockers and antiarrhythmics (CYP-2D6)

36
Q

Other interventions for Urge Incontinence

A

● Posterior Tibial Nerve Stimulation
(PTNS)
● Botox

37
Q

What is Posterior Tibial Nerve Stimulation
(PTNS)?

A

Neuromodulation — aims to
change the abnormal pattern
of stimulation of the nerves
that supply the bladder and
pelvic floor
-Used for urge incontinence

38
Q

Overflow Incontinence management

A

Pharmacotherapy
● Alpha-adrenergic antagonist
● 5-alpha reductase inhibitors
● Self catheterization

39
Q

Alpha-adrenergic antagonist

A

(Overflow Incontinence)
Tamsulosin (Flomax), Doxazosin (Cardura), Prazosin (Minipress), others
■ Smooth muscle relaxer
■ S/E – Orthostatic hypotension

40
Q

5-alpha reductase inhibitors

A

(Overflow incontinence)
Finasteride (Proscar), Dutasteride (Avodart)
■ Shrink the prostate (may take several months)
■ S/E – ED, breast enlargement/tenderness

41
Q

Urethral catheter is contraindicated in the treatment of _____

A

urge incontinence

42
Q

When can catheters be used for incontinence?

A

● Healing of a perineal wound
● Overflow incontinence
○ Intermittent self catheterization

43
Q

Nocturnal Enuresis (NE)

A

Involuntary voiding of urine at night – “Bed-wetting”
● Twice as common in boys as in girls

44
Q

Nocturnal Enuresis etiology

A

● Small bladder, inability to recognize a full bladder, low ADH, UTI, diabetes, constipation, structural or neurological abnormality
● Genetics - 77% of children when both mom and dad had history of NE

45
Q

Impact of Nocturnal Enuresis on children

A

● Children with NE are commonly punished and are at risk for emotional and physical abuse
● Children with NE report feelings of embarrassment and anxiety, loss of self-esteem, and
effects on self-perception, interpersonal relationships, quality of life, and school
performance even with only one episode a month

46
Q

Nocturnal Enuresis Clinical presentation

A

Primary – bladder control never attained
Secondary – has had control for at least 6 months before return of NE
DDx – See the list in “Etiology”

47
Q

Nocturnal Enuresis Diagnosis

A

● History
○ Hydration history
○ Daytime voiding history (urine and stool)
○ Number (how many/night) and timing (interval between episodes)
○ Sleep history
○ Nutrition history
○ Behavior, personality, and emotional status
● Physical
○ Inspection of external genitalia
○ Thorough neurologic exam
● UA – glucose, inflammation
● Urine culture
● Bladder ultrasound – Full and PVR
● X-ray (if indicated by exam)

48
Q

Nocturnal Enuresis Management

A

● Reassurance – especially with family Hx
● Timed voids – just before bed
● Avoid sugary and caffeinated drinks
● Majority of fluid intake should occur in the
morning and early afternoon (nothing after 7 pm)
● Consistency with fluid, voiding, and bedtime
routine
● Alarms
● Desmopressin (DDAVP) – synthetic ADH
● Imipramine – TCA
● Referral if no improvement despite appropriate treatments

49
Q

Desmopressin (DDAVP) – synthetic ADH use in nocturnal enuresis

A

○ Use for 5 years old or older
○ Dose tritrat from 0.2 mg up to 0.6
mg/night
■ Take 1 hour before bedtime
○ Monitor electrolytes (hyponatremia)

50
Q

Imipramine – TCA use in nocturnal enuresis

A

○ Decreases smooth muscle
contractility
■ Using the S/E of TCA’s to
“dry” thing out
■ Take 1-2 hours before bed
○ Overdose can be fatal

51
Q

Interstitial Cystitis

A

Chronic Bladder Pain Syndrome
Urinary frequency, urgency, and bladder pain with unknown etiology

52
Q

Interstitial Cystitis Presentation

A

● Not uniform
● Irritative voiding symptoms
○ Dysuria, urgency, frequency, nocturia
● Bladder pain worsened with certain foods
● Dyspareunia
● “Feeling of chronic pelvic pressure”
Men
● Chronic scrotal, testicular, or prostatic pain

53
Q

Interstitial Cystitis Diagnosis

A

● Diagnosis of exclusion
○ Physical exam – typically noncontributory
○ Labs
■ Microscopic hematuria
■ Negative (no growth on C&S)
○ Imaging
■ No stones, hydro, reflux, normal bladder capacity
● Cystoscopy - critical part of diagnosis
○ Still may be completely negative

54
Q

Findings on cystoscopy for Interstitial Cystitis

A

Hunner’s lesions
○ Distinctive areas of scarring and cracking of the
mucosa after hydrodistention
○ 5-10% of interstitial cystitis patients
Glomerulations
○ Pinpoint-sized areas of bleeding in the bladder wall
■ Not specific to interstitial cystitis

55
Q

Interstitial Cystitis Management

A

● Stress reduction (anxiety and depression control)
● Avoidance of triggers – 3-6 months trial
● Analgesics
● Antihistamines
○ Cimetidine (H2 receptor antagonist)
○ Hydroxyzine (1st Gen Antihistamine)
● Others
○ Amitriptyline (TCA)
○ Gabapentin

56
Q

Interstitial Cystitis Surgical management

A

● Bladder Hydrodistention
○ Under anesthesia, the bladder is filled, and then some, with water and kept full for several minutes (this process may be repeated in the same visit)

57
Q

Urethral Stricture

A

Scarring or narrowing of the urethra

58
Q

Urethral Stricture Pathophysiology/Epidemiology

A

● Congenital (rare)
● Acquired
○ Trauma
○ Infection
■ Catheters
■ Post G&C

59
Q

Urethral Stricture Clinical presentation

A

● Decreased urine stream
● Urinary frequency
● Dysuria
● Spray or double stream
● Post void dribbling
● Possible cystitis

60
Q

Urethral Stricture Diagnosis

A

● Urinary flow rates/Peak flow
● Urine culture
● Imaging
○ Voiding cystourethrogram
● Ureteroscopy

61
Q

Urethral Stricture Management

A

● Dilatation – temporary fix, but relieves Sx
● Urethrotomy – endoscope → several cuts (blade or laser) → catheter for days.
30-80% recurrence rates
● Ureteroplasty – surgically removing stricture → anastomosis or graft to repair

62
Q

Urethral Stricture Complications

A

● Prostatitis
● Urinary retention
● Bladder hypertrophy
● Ureteral reflux → renal failure
● Recurrence after surgery

63
Q

Urethral Stricture referral

A

● Decreased or spray in urine stream
● Urinary frequency and/or dysuria with negative
infection work-up

64
Q

Urethral Prolapse

A

Outward eversion of the urethra

65
Q

Urethral Prolapse epidemiology

A

Prepubertal girls (2-10 years old) and
in postmenopausal women

66
Q

Urethral Prolapse Clinical Presentation

A

● Bleeding/spotting
● Uncomfortable voiding symptoms
● “Beefy red” doughnut-shaped lesion with the urethral meatus at the center

67
Q

Urethral Prolapse DDx

A

● Urethral caruncle – postmenopausal
● Ureterocele

68
Q

Urethral Prolapse Diagnosis

A

● Visual inspection
● Cystoscopy (after reduction to rule out
ureterocele)

69
Q

Urethral Prolapse Management

A

● Topical estrogen cream (BID)
● Sitz baths (BID)
● Surgical cauterization/ligation or excision

70
Q

Urethral Prolapse complications

A

● Urethral mucosa may become gangrenous if it is not reduced promptly
● Recurrence

Gu Exam 3 (5 decks)

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