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Flashcards in Incontinence And Malignancy Deck (78):
1

Which nerve controls the detrusor muscle?

PNS pelvic nerves
S2-4
Involuntary

2

Which nerve controls the external urethral sphincter?

Somatic pudendal nerve
S2-4

3

Describe the positions of the external sphincter

Usually contracted
Relaxes when voiding

4

How does a lower motor neurone lesion affect the bladder and anus?

Low detrusor pressure
No action
Large volume of residual urine -> overflow incontinence
Can't feel the bladder filling
Reduced perianal sensation
Lax anal tone

5

How does an upper motor lesion affect the bladder?

Constantly contracting the detrusor muscle
Poor coordination with sphincters
(Detrusor-sphincter dyssynergia)
Urine can go up, dilate the ureters and cause damage to the kidneys

6

How do we classify lower urinary tract symptoms?

By phase:
Storage
Voiding
Post-micturition

7

Describe some LUT symptoms of the storage phase

Frequency
Urgency
Nocturia
Incontinence

8

Describe some LUT symptoms of the voiding phase

Slow stream
Spitting/spraying
Intermittency
Hesitancy
Straining
Terminal dribble

9

Describe some LUT symptoms of post-micturition

Dribble
Feeling of incomplete emptying

10

Define urinary incontinence

The complaint of any involuntary leakage of urine

11

How does incontinence affect quality of life?

Depression
Social exclusion - don't want to go out
Sense of shame

12

What are the different types of incontinence?

Stress
Urge
Mixed
Overflow

13

Describe stress urinary incontinence

Involuntary leakage on effort/exertion or on sneezing/coughing

14

Describe urge incontinence

Involuntary leakage accompanied by or immediately proceeded by urgency

15

Describe mixed urinary incontinence

Associated with urgency and also afford/exertion/coughing/sneezing

16

Describe overflow incontinence

Bladder accepts more and more urine without any action
Eventually it dribbles out due to the large volume

17

Describe the symptoms associated with overactive bladder syndrome

Urgency
Frequency
Nocturia

18

What is more common, overactive bladder or urge incontinence?

Overactive bladder syndrome

19

Why does the prevalence of urinary incontinence increase with age?

Bladder more sensitive
Smaller
Less able to hold urine

20

Describe how BPH affects urinary incontinence

Enlarged prostate blocks urine flow
Bladder gets larger and larger until cannot distend anymore
Starts to leak
Overflow incontinence

21

What is the most common type of urinary incontinence?

Stress
(Due to weak pelvic floor muscles)

22

Give some risk factors for urinary incontinence

Family predisposition
Anatomical abnormalities
Neurological abnormalities
Co-morbidities
Increased intraabdominal pressure
UTI
Menopause
Pregnancy/childbirth
Pelvic surgery
Pelvic prolapse
Obesity
Age
Cognitive impairment
Drugs
Race

23

What examinations would you do for someone with incontinence?

BMI
Abdominal exam (palpable bladder?)
DRE - check prostate
Females - external genitalia and vaginal exam

24

What is the mandatory investigation for urinary incontinence?

Urine dipstick
Check for UTI, haematuria, proteinuria, glycosuria etc

25

After a urine dipstick, what other investigations could you do for incontinence?

Urodynamics: frequency-volume chart, bladder diary, post-micturition residual volume (USS)
Pressure flow studies
Pad tests
Cystoscopy

26

What different factors does the management of incontinence depend on?

Symptoms
Degree of nuisance
Effects of treatment
Previous/current treatments

27

What is the general advice for someone experiencing urinary incontinence?

Lose weight
Decreased caffeine intake
Stop smoking
Try to regulate bowel movements

28

What is contained incontinence?

For patients unsuitable for surgery who have failed conservative/medical management
Condom catheters
Urethral/suprapubic catheter
Incontinence pads

29

Describe pelvic floor muscle training

8 contractions
3 times a day
For at least 3 months
Patients are not usually very compliant with this

30

Describe how duloxetine works to treat stress incontinence

Combined adrenaline and serotonin uptake inhibitor
Increased activity in external sphincter during filling so more likely to remain closed
Has many side effects

31

Describe the surgical options for women with incontinence

Low tension vaginal tapes
Suspension procedures
Classical sling procedure

32

What are the surgical options for men with incontinence?

Artificial (hydraulic) urinary sphincter
Male sling

33

How does an intramural bulking agent work for incontinence?

Decrease the lumen of the urethra to help retain urine
Eg. Collage/silicone

34

What is the short hand for prostate cancer?

CaP

35

What is the commonest cancer of men in the UK?

Prostate

36

What is the usual presentation of prostate cancer?

Asymptomatic
Have localised disease
Unlikely to die of it
Urinary symptoms of BPH, bladder overactivity
Bone pain
Unusual to have haematuria

37

Give some CaP risk factors

Increasing age
Family Hx
BRCA2 gene mutation
Ethnicity (black>white>asian)

38

What are the issues with PSA screening?

Overdiagnosis
Overtreatment
Quality of life
Cost effectiveness
There are other causes of increased PSA

39

Other than cancer, what causes a raised PSA?

Infection
Inflammation
Large prostate

40

How do we make a diagnosis of CaP?

Digital rectal examination
And
Serum PSA

41

What investigations do we do for CaP?

Serum PSA
Transrectal ultrasound-guided biopsy of prostate for histology
MRI/bone scan to look for mets

42

If the PSA is greater than which number do we rarely consider removal?

> 20

43

What do we assess looking for cancer with a biopsy of the prostate?

Gleason grade (low magnification)
Extent (how involved the core is)

44

What are the established treatments for localised CaP?

Surveillance (PSA)
Radical prostatectomy
Radiotherapy

45

Name some developmental treatments for localised CaP treatment

HIFU
Primary cryotherapy
High dose rate brachytherapy

46

Give some treatments for metastatic prostate cancer treatment

Surgical castration
Medical castration - given LHRH agonists
(LH and testosterone start to decrease)

47

Give some treatments that can help with palliative care of CaP

Single dose radiotherapy
Bisphosphonates
Chemotherapy

48

What type of bone metastases does CaP make?

Sclerotic
'Hot spots' on bone scans

49

Under which PSA are bone mets unlikely?

< 10

50

What are the treatments for locally advanced CaP?

Surveillance
Hormones
Hormones and radiotherapy

51

Give a differential diagnosis for haematuria

Renal cell carcinoma
Upper tract transitional cell carcinoma
Bladder cancer
Advanced prostate carcinoma
Stones
Infection
Inflammation
BPH
Nephrological (glomerular)

52

What do we need to ask about in a Hx with haematuria?

Smoking
Occupation
Pain
Other lower urinary tract symptoms
Family Hx

53

What do we examine if someone presents with haematuria?

BP
Abdominal masses
Varicocele
Leg swelling (lymphoedema)
DRE

54

What investigations would we carry out for someone with haematuria?

Blood - FBC, U+E
Ultrasound - any tumours or stretching
Flexible cystoscopy
Urine - culture and cytology

55

Is bladder cancer commoner in males or females?

Males

56

Is the incidence of bladder cancer increasing or decreasing?

Decreasing

57

What is the commonest type of bladder cancer?

Transitional cell carcinoma

58

Give some risk factors for bladder cancer

Smoking
Occupational exposure - rubber, plastics, carbon, paint, dyes
Schistosomiasis

59

Which type of bladder cancer is schistosomiasis linked to?

Squamous cell carcinoma

60

What is the treatment for bladder cancer?

Resect the tumour
Chemotherapy into the bladder

61

What percentage of bladder cancers are superficial on diagnosis?

75%

62

How do we grade bladder cancer?

Traditional high magnification grading system
Mitotic bodies, nuclei size and ratio etc

63

What is the potentially curative treatment for muscle-invasive bladder cancer?

Radical cystectomy or radiotherapy
(+/- chemotherapy)

64

What is a radical cystectomy?

Removal of the bladder
(In women also remove the womb and ovaries)
Redirect urine to come out of the abdominal wall

65

95% of all upper urinary tract tumours are which type?

Renal cell carcinoma

66

Is the incidence of renal cell carcinoma increasing or decreasing?

Increasing

67

Is renal cell carcinoma more common in males or females?

Males

68

What percentage of renal cell carcinomas have mets on presentation?

30%

69

What are the risk factors for renal cell carcinoma?

Smoking
Obesity
Dialysis

70

Describe the different ways renal cell carcinomas can spread

Perinephric
Lymph nodes
IVC spread to right atrium - forms a thrombus

71

What imaging can we use to diagnose renal cell carcinoma?

Ultrasound
CT

72

What are the treatments for RCC?

Surveillance
Radical nephrectomy
Partial nephrectomy
Ablation (developmental)

73

Describe the treatment for metastatic RCC

Palliative
Molecular therapies

74

What are the causes of upper tract transitional cell carcinoma?

Smoking
Phenacetin abuse
Balkan's nephropathy

75

What percentage of upper urinary tract tumours are transitional cell carcinomas?

5%

76

What percentage of people who develop upper urinary tract cancer develop bladder cancer?

40%

77

What investigations would we do for upper tract transitional cell carcinoma?

Ultrasound for hydronephrosis
CT urogram
Retrograde pyelogram
Ureteroscopy - biopsy

78

What is the standard treatment for upper tract transitional cell carcinoma?

Nephro-ureterectomy