BLADDER DISORDERS / UNARINY INCONTINENCE

Question 1

Does the hematuria represent glomerular or nonglomerular bleeding?

Answer 1

RBC casts = glomerular bleeding

Question 2

glomerular bleeding

Answer 2

⦁ RBC casts
⦁ dysmorphic RBCs
⦁ proteinuria with the hematuria, with a large percentage being albumin

Question 3

urine centrifuge

Answer 3

if sediment red = hematuria

if supernatant red = dipstick heme
⦁ dipstick heme negative = beets, phenazopyridine, porphyria, other
⦁ dipstick heme positive = myoglobin or hemoglobin
- if plasma color is clear = myoglobinuria
- if plasma color is red = hemoglobinuria

Question 4

risk factors for malignancy

Answer 4

Age > 35
Smoking history (extent of exposure correlates w/ risk)
Occupational exposure to chemicals/dyes—painter, printers
History of gross hematuria
History of chronic cystitis or irritative voiding symptoms
History of pelvic irradiation
Exposure to cyclophosphamide
H/O urologic disorder BPH, nephrolithiasis, etc.
History of chronic indwelling foreign body
History of non-narcotic analgesic abuse (also associated increased risk of kidney cancer)

Question 5

HEMATURIA WORKUP

Answer 5

Urine culture & UA in all pts with hematuria
Uriny cytology no longer needed

IMAGING = CT urography = preferred (contrast)
⦁ pregnant = US
⦁ can do US, CT without contrast, or MRI if dye from CT not tolerated

Cystoscopy

Question 6

what imaging is preferred for hematuria

Answer 6

CT UROGRAPHY*** (same as CT IVP)

if pregnant = US
if can’t have dye = US, CT w/o contrast, or MRI

Question 7

DO NOT SCREEN FOR HEMATURIA IN

Answer 7

ASYMPTOMATIC PATIENTS

Question 8

In young & middle age-patients; usually hematuria is

Answer 8

mild glomerular disease

monitor GFR, creatinine, and BP***

are predisposed to stones

Question 9

most common pathogen of UTI

Answer 9

E.coli

others
proteus & klebsiella

Question 10

UTI PRESENTATION

Answer 10

⦁	dysuria
⦁	frequency
⦁	urgency
⦁	suprapubic pain
⦁	hematuria

Question 11

pyelonephritis presentation

Answer 11

• symptoms of cystitis may or may not be present with pyelonephritis
• chills
• flank pain with costovertebral angle tenderness
• Nausea & Vomiting

Question 12

diagnostic tests for cystitis & pyelonephritis

Answer 12

CYSTITIS

• UA is a MUST! - look for positive leukocytes and/or positive nitrites
• if uncertain about diagnosis or resistance is possible = do urine culture
• ALL MALES with cystitis = need a culture

FOR PYELONEPHRITIS

• UA
• urine culture & sensitivity

Question 13

treatment for women with cystitis

Answer 13

⦁ Nitrofurantoin = 1st
⦁ Bactrim = 2nd
⦁ can give phenozopyridine (pyridium) - analgesic agent for dysuria- turns urine dark orange

-reserve fluoroquinolones for other uses in case resistance is built

Question 14

treatment for men with cystitis

Answer 14

⦁ Bactrim
⦁ Fluoroquinolone
- want to cover possible prostatitis (also treat with either bactrim or cipro for acute or chronic)
- men = usually have longer lengths of abx

Question 15

outpatient treatment of pyelonephritis

Answer 15

fluoroquinolones (cipro or levo) if resistance is low

others = Bactrim or augmentin

Question 16

inpatient treatment of pyelonephritis

Answer 16

oral fluoroqinolone + aminoglycoside

Question 17

non-infectious cystitis

Answer 17

• similar symptoms to cystitis + nocturia & pressure in pelvis
• in women of childbearing years

IRRITANTS = bubble baths, feminine hygiene sprays, tampons, spermicidal jellies, radiation, chemo, foods (tomatoes, artifical sweeteners, caffeine, chocolate)

WORK UP

• UA
• urine culture
• sometimes cystoscopy

TREATMENT

• avoid irritants
• voiding routine**
• kegel’s

Question 18

Most common cause of nongonococcal urethritis

Answer 18

chlamydia

tx = azithro

Question 19

overactive bladder

Answer 19

detrusor muscle contracts before bladder is filled

presentation =
Urgency
Frequency
Nocturia

Question 20

tx of overactive bladder

Answer 20

ANTIMUSCARINICS (anticholinergics)
MOA = Block basal release of acetyl choline during bladder filling & increases bladder capacity

Oxybutynin (Ditropan)
Tolterodine (Detrol)
Solifenacin (Vesicare)—once a day
(others = 2-3x/day)

SE = dry eyes, constipation, dry mouth

Question 21

pathophys of overactive bladder without incontinence

Answer 21

Detruser muscle contracts irregularly at smaller volumes of urine

Usually idiopathic

Can be secondary to DM, stroke, spinal disease

Question 22

new agent for overactive bladder

Answer 22

Mirabegron (Myrbetriq)
Beta 3-adrenoceptor agonist - relaxes detrusor muscle

SE
HTN**
Incomplete bladder emptying
Dry mouth

Question 23

do not give mirabegron to a pt with

Answer 23

uncontrolled HTN

Question 24

RISK FACTORS FOR INCONTINENCE

Answer 24

⦁	Obesity
⦁	Functional impairment
⦁	Parity
⦁	Family history
⦁	Smoking
⦁	Age
⦁	Others: diabetes, stroke, depression, estrogen depletion, genitourinary surgery, radiation
⦁	Non-Hispanic white women higher rates than non-Hispanic Black and Hispanic women

Question 25

CAUSES OF INCONTINENCE = DIAPPERS

Answer 25

``` ⦁ Delirium ⦁ Infection ⦁ Atrophic vaginitis ⦁ Pharm: sedatives, diuretics, anticholinergics ⦁ Psychological: depression ⦁ Excessive urine production ⦁ Restricted mobility ⦁ Stool impaction ```

Question 26

detrusor over-activity = __________ incontinence

Answer 26

urge

Question 27

URGE INCONTINENCE

Answer 27

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 ```

Question 28

Leakage of urine with increased intra-abdominal pressure in the absence of a bladder contraction:

Answer 28

STRESS INCONTINENCE It is important to determine if leakage occurs coincident or several seconds after a cough++ Occurs in younger women Due to: Urethral hypermobility Intrinsic sphincter deficiency

Question 29

due to Intrinsic sphincter deficiency

Answer 29

stress incontinence

Question 30

= MOST COMMON CAUSE OF STRESS INCONTINENCE IN MEN

Answer 30

PROSTATE SURGERY

Question 31

Most common type of incontinence in women

Answer 31

MIXED INCONTINENCE

Question 32

INCOMPLETE BLADDER EMPTYING = OVERFLOW INCONTINENCE

Answer 32

- continuous leakage/dribbling of urine due to detrusor underactivity (occurs with low estrogen, aging, peripheral neuropathy - DM, MS) or bladder outlet obstruction (BPH / stones)

Question 33

detrusor underactivity

Answer 33

incomplete bladder emptying = overflow incontinence

Question 34

possible etiologies of nocturia

Answer 34

- possible etiologies ⦁ CHF—fluid redistribution form pedal edema ⦁ Late evening beverages ⦁ Sleep apnea************ ⦁ Sleep disturbances—chronic pain, depression ⦁ Detrusor overactivity

Question 35

PVR for incontinence

Answer 35

Have patient void until they feel they have emptied their bladder completely Then do bladder ultrasound or clean cath PVR < 1/3 the total voided volume is considered adequate emptying

Question 36

labs for incontinence

Answer 36

Renal function Serum calcium, and glucose UA Those with increased post-void residual—B12, etc. PSA for men if indicated Urine cytology if there is hematuria or pelvic pain

Question 37

lifestyle & behavioral treatment

Answer 37

Lifestyle: Weight loss Adequate, but not excessive fluid intake (2 L) Avoid caffeinated beverages and alcohol Minimize evening fluid intake for nocturia Smoking cessation Behavioral therapy: for urge, stress and mixed: Bladder training: - Frequent voluntary voiding - Relaxation techniques for urge incontinence Pelvic muscle exercises: Kegels Biofeedback Pessaries for organ prolapse or stress incontinence

Question 38

rx therapy for incontinence = for urge & mixed

Answer 38

Anticholinergics w/ antimuscarinic activity Increase bladder capacity Tolterodine (Detrol LA), Solifenacin (Vesicare) SE: dry mouth, blurred vision, constipation, drowsiness, decreased cognitive function CI: Narrow angle glaucoma

Question 39

CI to anticholinergics with antimuscarinic activity = increase bladder capacity and relaxes the bladder

Answer 39

narrow angle glaucoma

Question 40

which anticholinergic med for incontinence has Less SE although dry mouth still prominent

Answer 40

oxybutynin (Ditropan) = ER & Patch Direct antispasmodic effect on detrusor muscle

Question 41

newer agent for incontinence

Answer 41

Miragebron (Myratriq) Causes bladder relaxation.....? works on alpha receptors, which are in the internal sphincter - Help urge and mixed incontinence SE: HTN, tachycardia, urinary retention (infection), inflammation of the nasal passages, dry mouth, constipation, abdominal pain, and memory problems NOT recommended for patients with uncontrolled HTN

Question 42

Mirabegron = NOT recommended for patients with uncontrolled

Answer 42

HTN

Question 43

surgery = used for ________ incontinence

Answer 43

stress

Question 44

The selected procedure for SUI (stress urinary incontinence)

Answer 44

mesh midurethral sling

Question 45

when to refer immediately for incontinence

Answer 45

``` Incontinence w/ abdominal and/or pelvic pain Hematuria in the absence of UTI Suspected fistula Complex neurological conditions Abnormal findings ```

Question 46

INTERSTITIAL CYSTITIS

Answer 46

also known as BPS = Bladder Pain Syndrome - usually presents in 4th decade or later - much more common in women

Question 47

Persistent feature: pain or “unpleasant” sensation with filling of the bladder—relieved with bladder voiding

Answer 47

interstitial cystitis Gradual onset w/ worsening symptoms May have other urinary symptoms: Urinary frequency Urgency Nocturia

Question 48

DIAGNOSIS OF INTERSTITIAL CYSTITIS

Answer 48

- thorough PE - pt usually has a tender suprapubic area - may have other pain conditions, such as dyspareunia, irritable bowel, vulvodynia - do UA & culture to r/o cancer and infection

Question 49

TREATMENT OF INTERSTITIAL CYSTITIS

Answer 49

1st line = Management; patient education about pain relief & chronicity of condition; psychosocial support. self-care & behavioral modification - very difficult to manage; basically a chronic pain condition 2nd line = PT - for those pts with pelvic muscle pain - Meds ⦁ Amitryptiline ⦁ PPS (Elmiron) = Pentosan polysulfate sodium = concentrates in the bladder and has a protective layer over urothelium ⦁ Hydroxyzine = antihistamine - makes you sleepy

Question 50

MEDS THERAPY FOR INTERSTITIAL CYSTITIS

Answer 50

amitryptiline PPS hydroxyzine