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Flashcards in Bladder Disorders & Urinary Incontinence Deck (60)
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1

Hematuria: Are there any clues in the H & P to suggest etiology?

1. Gross vs. microscopic

2. Glomerular [???] vs. nonglomerular

3. Microscopic: transient vs. persistent

2

Hematuria—nonglomerular
1. Etiologies? 6
2. Etiology if older than 40?

1.
-Fever,
-vigorous exercise,
-trauma,
-nephrolithiasis,
-infection,
-prostatitis,
-IgA nephropathy
-Strep glomerulonephritis

2. Bladder cancer

3

Risk Factors for Malignancy
9

1. Age > 35
2. Smoking history (extent of exposure correlates w/ risk)
3. Occupational exposure to chemicals/dyes—painter, printers
4. History of gross hematuria
5. History of chronic cystitis or irritative voiding symptoms
6. History of pelvic irradiation
7. Exposure to cyclophophamide
8. History of chronic indwelling foreign body
9. History of analgesic abuse (also associated increased risk of kidney cancer)

4

Hematuria—Work-up
6

1. Urine culture—if positive treat and repeat UA

2. Urine cytology: all w/ gross hematuria & those w/ risk factors


3. Imaging—CT urography preferred**:
4. US in pregnant women
5. US, CT without contrast or MRI may be used

6. Cystoscopy: obtaining urine for cytology just before in high risk patients

5

Hematuria—Negative Work-up
1. In young and middle-age patients usually is? 2

2. Patients at high risk for malignancy may need what? 2


3. Signs of glomerular bleeding? 3

1.
-Mild glomerular disease (Monitor--???)
-Predisposition to stone disease

2.
-Need annual UA
-May need another work-up in 1-3 years

3.
-Red cell casts
-Dysmorphic RBCs
-Proteinuria with the hematuria with a large percentage being albumin

6

Pathogenesis of cystitis?
3

1. Colonization of the vaginal introitus from fecal flora

2. Ascension to the bladder via the urethra

3. Can ascend to the kidneys causing pyelonephritis


7

This route much more difficult in males—why?

Because of the length of the urethra

8

1. What is the most common pathogen in cystitis?

2. Others? 2

1. E. coli

2. Others:
-Proteus
-Klebsiella

9

Clinical Presentation—UTI
5

1. Dysuria
2. Frequency
3. Urgency
4. Suprapubic pain
5. Hematuria

10

1. Diagnostic tests for cystitis? 1

2. What are we looking for?

3. In women who the diagnosis is uncertain or resistance is a consideration what should be done?

4. ALL males with cystitis should have what?

1. UA is a must!

2. Looking for positive leukocyte esterase and/or positive nitrites

3.urine culture with sensitivities should be done

4. ALL males with cystitis should have a culture

11

Dx tests for pyleonephritis? 2

1. UA
2. Urine culture and sensitivities

12

Women with Cystitis: This is Common!
1. What do we have to Rule out?

2. Treatment? 5

1. R/O vaginal source

2. Treatment:
-Nitrofurantoin (100 mg BID x 5 days)
-Bactrim [Trimethoprim-Sulphamethoxazole] (1 DS BID x 3 days)
-Fosfomycin 3 gms. X 1 dose
-Reserve fluoroquinolones for other uses
-Phenozopyridine (pyridium)**

13

Men with Cystitis
1. Differential? 4

2. Treatment? 3

1. Differential:
-Prostatitis
-Urethritis secondary to STI
-Urinary tract abnormality
-Nephrolithiasis

2. Treatment:
-Trimethoprim-sulphamethoxazole (Bactrim)
-Fluoroquinolone
-Want to cover possible prostatitis

14

Treatment for Pyelonephritis
1. OUtpatient? 3

2. Inpatient? 3

1. Outpatient:
-Where fluoroquinolone resistance low use Cipro or levuoquin
-Other: trimethoprim-sulphamethoxazole or
-Augmentin

2. Inpatient:
-Oral fluoroquinolone
-Plus aminoglycoside
-Or extended spectrum cephalasporin

15

Noninfectious Cystitis
1. How does it present?
2. Most common in what population?

3. Irritants? 6

1. Symptoms similar to cystitis along with nocturia, Pressure in pelvis
2. Epidemiology: women of childbearing years

3. Irritants:
-Bubble baths,
-feminine hygiene sprays,
-tampons,
-spermicidal jellies
-Radiation, chemo
-Foods—tomatoes, artificial sweeteners, caffeine and chocolate

16

Noninfectious Cystitis
1. Work up? 3

2. Treatment? 3

1. Work-up:
-UA
-Urine culture
-Sometimes cystoscopy

2. Treatment:
-Avoiding irritants
-Voiding routine**
-Kegel’s

17

Chlamydia—Male
1. It is the most common cause of what?

2. Manifestations? 3

3. Main symptoms? 2

1. Most common cause of nongonococcal urethritis

2. Manifestations:
-Urethritis: symptomatic*/asymptomatic
-Epididymitis
-Prostatitis

3. Symptoms—
-dysuria,
-thin watery sometimes scant discharge

18

Chlamydia in Males
1. Dx?

2. Tx?

1. NAAT testing:
-Some tests are expensive and don’t produce results quickly
Xpert CT/NG assay is a NAAT provides testing in 90 minutes

2. Treatment--1000mg of Azithromycin in one pill

19

Gonorrhea in males:
1. Presents how? 2
2. Dx? 2
3. Tx?

1.
-Urethritis—symptomatic
-Epididymitis—age less than 35years

2.
-NAAT testing of urine or swab
-GS showing PMNs with gram neg diplococci


3. ceftriaxone 250 mg intramuscularly in a single dose

20

Gonorrhea most common symptoms?
2

1. Dysuria and
2. copious amounts of purulent discharge

21

What is the difference between a normal bladder and an overactive bladder?

1. Normal- detrusor muscle contracts with a full bladder

2. Overactive- Detrusors muscle contacts before bladder is filled

22

Overactive bladder Without Incontinence
1. Presentation? 3

2. PP? 1

3. Causes? 4

1. Presentation:
-Urgency
-Frequency
-Nocturia

2. Pathophysiology:
-Detruser muscle contracts irregularly at smaller volumes of urine


3.
-Usually idiopathic
Can be secondary to
-DM,
-stroke,
-spinal disease

23

Treatment of OAB
1. Antimuscarinics SE? 5
2. MOA? 2
3. Agents? 3

1. SE:
-Dry mouth,
-constipation,
-blurry vision,
-confusion,
-drowsiness

2. Mechanism:
-Increase bladder capacity
-Block basal release of acetyl choline during bladder filling

3. Agents:
-Oxbutynin (Ditropan)
-Tolterodine (Detrol)
-Solifenacin (Vesicare)—once a day

24

Treatment of OA- New Agent?

Mirabegron (Myrbetriq)

25

Mirabegron (Myrbetriq)
1. MOA?
2. SE? 3

1. Beta 3-adrenoceptor agonist
-Can use alone or with other agents

2. SE:
-HTN**
-Incomplete bladder emptying
-Dry mouth

26

Urinary Incontinence: types? 3

1. Stress
2. Urge
3. Overflow

27

Medical Morbidity of urinary incontinece?
6

1. Perineal candida infection
2. Cellulitis and pressure ulcers
3. UTIs and urosepsis
4. Falls & fractures from slipping on urine
5. Sleep interruption and deprivation
6. Psychologically: poor self esteem, social withdrawal, depression and sexual dysfunction

28

Pathophysiology: Continence depends on what? 2

1. Intact micturition physiology
2. Intact functional ability to toilet oneself

29

Risk factors for urinary incontinece?
12

1. Obesity
2. Functional impairment
3. Parity
4. Family history
5. Smoking
6. Age
7. diabetes,
8. stroke,
9. depression,
10. estrogen depletion,
11. genitourinary surgery,
12. radiation


Non-Hispanic white women higher rates than non-Hispanic Black and Hispanic women

30

Transient causes
of Urinary incontinence?
DIAPPERS

Delirium

Infection

Atrophic vaginitis

Pharmacoloic: sedatives, diuretics, anticholinergics

Psychological: depression

Excessive urine production (?)

Restricted mobility

Stool impaction