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Flashcards in Bladder Disorders Deck (53)
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1

43YO smoker presents for annual exam - found to have microscopic hematuria - most likely dx?

- bladder cancer

2

Signs of glomerular bleeding?

- red cell casts (pathognomonic for glomerulonephritis)
- dysmorphic RBCs
- proteinuria w/ hematuria w/ large percentage bing albumin

3

Nonmalignant etiologies of hematuria?

- UTI: pyelo, acute cystitis - present w/ suprapubic pain, dysuria, and frequency
- trauma to kidneys
- stones
- menstruation or endometriosis
- BPH
- vigorous exercise
- PSGN or IgA nephropathy
- warfarin
- over 40: at high risk for cancer

4

RFs for malignancy?

- age: over 35
- smoking hx (extent of exposure correlates with risk)
- occupational exposure to chemicals/dyes - painter, printers
- hx of gross hematuria
- hx of chronic cystitis or irritative voiding sxs
- hx of pelvic irradiation
- exposure to cyclophophamide
- hx of chronic indwelling fb
- hx of analgesic abuse (also assoc increased risk of kidney cancer) - NSAIDs

5

Work up of hematuria?

- urine culture - if positive tx and repeat UA (all pts)
- urine cytology: all w/ gross hematuria and those w/ risk factors
- imaging: CT urography preferred - US in pregnant women
US CT w/o contrast or MRI may be used
- cystoscopy: obtaining urine for cytology just b/f in high risk pts

(CT and cystoscopy done together)

6

What should be done if you get a negative work-up for hematuria?

- in young and middle aged pts usually is:
mild glomerular disease (monitor PP, GFR, CrCl), have predisposition to stone disease
- pts at high risk for malignancy:
need annual UA
may need another work-up q 3-5 yrs (esp if wt loss, night sweats)

7

Should you screen for hematuria in asx pts?

- NO!

8

Pathogenesis of cystitis?

- colonization of vaginal introitus from fecal flora
- acension to bladder via the urethra
- can ascend to kidneys causing pyelonephritis
- route much more difficult in males b/c longer and urethra not sitting right above anus - Much less common in men

9

MC pathogens of cystitis?

- 75-90% E. coli
- others:
proteus
kelbsiella

10

Clinical presentation of UTI?

- dysuria
- frequency
- urgency
- suprapubic pain
- hematuria

11

Clinical presentation of Pyelonephritis?

- sxs of cystitis may or may not be present
- chills
- flank pain w/ CV angle tenderness
- N/V

12

Dx tests for cystitis and pyelonephritis?

- UA is a must: looking for positive leukocyte esterase and/or positive nitrites
- in women who dx is uncertain or resistance is consideration a urine cuture w/ sensitivities should be done
- ALL males with cystitis should have a culture

- for pyelo:
UA
urine culture and sensitivities

13

Women with cystitis - what should be ruled out? Tx?

- common, r/o vaginal source though
- tx:
Nitrofurantoin (100 mg BIDx5days)
bactrim (1 DS BID x 3 days)
fosfomycin 3 gmsx 1 dose
reserve fluoroquinolones for other uses
phenozyopyridine (pyridium)

14

Diff for man presenting with cystitis sxs?

- prostatitis
- urethritis secondary to STI
- urinary tract abnormalitiy
- nephrolithiasis

15

Tx for men w/ cystitis?

- Bactrim
- fluoroquinolone
- want to cover possible prostatitis

16

Tx for outpt and inpt pyelonephritis?

outpt:
-mild to moderate illness: can keep meds down
-where fluoroquinolone resistance is low: cipro or levuoquin
- other: trimethoprim-sulphamethoxazole or augmentin

inpt:
oral fluroquinolone
plus aminoglycoside
or extended spectrum cephalosporin

17

Sxs of noninfectious cystitis? Epidemiology? Irritants?

- sxs similar to cystitis w/ nocturia, pressure in pelvis
- epidemiology: women of childbearing yrs
- irritants:
bubble baths, feminine hygiene sprays, tampons, spermicidial jellies
radiation, chemo
foods: tomato, artificial sweetners, caffeine and chocolate

18

W/u and tx of noninfectious cystitis?

- w/u:
UA
urine culture
sometimes cystoscopy

-tx:
avoiding irritants
voiding routine
kegels

19

Chlamydia manifestations in a male? Dx? Tx?

- MC cause of nongonococcal urethritis
- manifestations:
urethritis: sx/asx
epididymitis
prostatitis
- dx:
NAAT - some tests are expensive and don't produce results quickly
- xpert CT/NG assay is a NAAT provides testing in 90 minutes
- Tx: rocephin and Azithro

20

Presentation of gonorrhea in males? Dx, Tx?

- urethritis: sx
- epididymitis: younger than 35
- dx: NAAT
- tx: Azithro and rocephin

21

Presentation and PP of overactive bladder w/o incontinence?

- urgency, frequency, nocturia
- PP:
detrusor muscle contracts irregularly at smaller volumes of urine, usually idiopathic, can be secondary to DM, stroke, spinal disease

22

Tx of OAB? Mechanism, agents used?

- antimuscarinics
- MOA: increase bladder capacity, block basal release of acetyl choline during bladder filling
- agents:
oxybutynin (Ditropan)
tolterodine (Detrol)
solifenacin (vesicare) - once a day
SE: anticholinergic - constipation, dry mouth, blurred vision

- new agent:
Mirabegron (Myrbetriq) - beta 3-adrenoceptor agonist, can use alone or w/ other agents
SE:
HTN, incomplete bladder emptying (relaxes detrusor so much), dry mouth

23

Epidemiology of urinary incontinence?

- prevalence in women: 25-45%
- prevalence increases with age (both men and women)
- 6-10% nursing home admissions in US due to urinary incontinence

24

Medical morbidity - from incontinence?

- perineal candida infection
- cellulitis and pressure ulcers
- UTIs and urosepsis
- falls and fractures from slipping on urine
- sleep interruption and deprivation
- psychologically: poor self esteem, social withdrawl, depression and sexual dysfxn

25

Continence depends on?

- intact micturition physiology
- intact fxnl ability to toilet onself

26

RFs for incontinence?

- obesity
- fxnl impairment
- parity
- family hx
- smoking
- age
- others: diabetes, stroke, depression, estrogen depletion, genitourinary surgery, radiation
- non-hispanic white women higher rates than non-hispanic black and hispanic women

27

Transient causes of incontinence? DIAPERS?

D: delirium
I: infection
A: atrophic vaginitis
P: pharm - sedatives, diuretics, anticholinergics
P: psychological: depression
E: excessive urine production (DI, hypercalcemia, psychogenic polydipsia)
R: restricted mobility
S: stool impaction

28

Incontinence questions for screening?

- in past 3 months: have you leaked urine?
- which precipitants led to leakage?
- which precipitant caused leakage most often?
- do you ever wears pads, tissues or cloth in your underwear to catch urine?

29

Hx questions to ask pt about incontience?

- questions about incontinence
- precipitants
- bowel and sexual fxn
- status of other medical conditions, parity, meds
- any prior continence therapy, particularly surgical tx

30

Etiology and presentation of urge incontinence?

etiology:
-uninhibited bladder contractions
-detrusor over activity
-may be due to bladder abnormalities or idiopathic

presentation:
- sudden urge to void
- preceded or accompanied by leakage of urine
- more common in older women
- also seen in men