Incontinence And Malignancy Flashcards by Maya White

Which nerve controls the detrusor muscle?

PNS pelvic nerves
S2-4
Involuntary

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Which nerve controls the external urethral sphincter?

Somatic pudendal nerve

S2-4

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Describe the positions of the external sphincter

Usually contracted

Relaxes when voiding

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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

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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

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How do we classify lower urinary tract symptoms?

By phase:
Storage
Voiding
Post-micturition

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Describe some LUT symptoms of the storage phase

Frequency
Urgency
Nocturia
Incontinence

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Describe some LUT symptoms of the voiding phase

Slow stream 
Spitting/spraying
Intermittency 
Hesitancy 
Straining 
Terminal dribble

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Describe some LUT symptoms of post-micturition

Dribble

Feeling of incomplete emptying

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Define urinary incontinence

The complaint of any involuntary leakage of urine

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How does incontinence affect quality of life?

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

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What are the different types of incontinence?

Stress
Urge
Mixed
Overflow

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Describe stress urinary incontinence

Involuntary leakage on effort/exertion or on sneezing/coughing

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Describe urge incontinence

Involuntary leakage accompanied by or immediately proceeded by urgency

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Describe mixed urinary incontinence

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

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Describe overflow incontinence

Bladder accepts more and more urine without any action

Eventually it dribbles out due to the large volume

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Describe the symptoms associated with overactive bladder syndrome

Urgency
Frequency
Nocturia

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What is more common, overactive bladder or urge incontinence?

Overactive bladder syndrome

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Why does the prevalence of urinary incontinence increase with age?

Bladder more sensitive
Smaller
Less able to hold urine

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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

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What is the most common type of urinary incontinence?

Stress

Due to weak pelvic floor muscles

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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

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What examinations would you do for someone with incontinence?

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

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What is the mandatory investigation for urinary incontinence?

Urine dipstick

Check for UTI, haematuria, proteinuria, glycosuria etc

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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

What different factors does the management of incontinence depend on?

Symptoms Degree of nuisance Effects of treatment Previous/current treatments

What is the general advice for someone experiencing urinary incontinence?

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

What is contained incontinence?

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

Describe pelvic floor muscle training

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

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

Describe the surgical options for women with incontinence

Low tension vaginal tapes Suspension procedures Classical sling procedure

What are the surgical options for men with incontinence?

Artificial (hydraulic) urinary sphincter | Male sling

How does an intramural bulking agent work for incontinence?

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

What is the short hand for prostate cancer?

CaP

What is the commonest cancer of men in the UK?

Prostate

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 ```

Give some CaP risk factors

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

What are the issues with PSA screening?

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

Other than cancer, what causes a raised PSA?

Infection Inflammation Large prostate

How do we make a diagnosis of CaP?

Digital rectal examination And Serum PSA

What investigations do we do for CaP?

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

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

> 20

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

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

What are the established treatments for localised CaP?

Surveillance (PSA) Radical prostatectomy Radiotherapy

Name some developmental treatments for localised CaP treatment

HIFU Primary cryotherapy High dose rate brachytherapy

Give some treatments for metastatic prostate cancer treatment

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

Give some treatments that can help with palliative care of CaP

Single dose radiotherapy Bisphosphonates Chemotherapy

What type of bone metastases does CaP make?

Sclerotic | 'Hot spots' on bone scans

Under which PSA are bone mets unlikely?

< 10

What are the treatments for locally advanced CaP?

Surveillance Hormones Hormones and radiotherapy

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) ```

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

``` Smoking Occupation Pain Other lower urinary tract symptoms Family Hx ```

What do we examine if someone presents with haematuria?

``` BP Abdominal masses Varicocele Leg swelling (lymphoedema) DRE ```

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

Is bladder cancer commoner in males or females?

Males

Is the incidence of bladder cancer increasing or decreasing?

Decreasing

What is the commonest type of bladder cancer?

Transitional cell carcinoma

Give some risk factors for bladder cancer

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

Which type of bladder cancer is schistosomiasis linked to?

Squamous cell carcinoma

What is the treatment for bladder cancer?

Resect the tumour | Chemotherapy into the bladder

What percentage of bladder cancers are superficial on diagnosis?

75%

How do we grade bladder cancer?

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

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

Radical cystectomy or radiotherapy | +/- chemotherapy

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

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

Renal cell carcinoma

Is the incidence of renal cell carcinoma increasing or decreasing?

Increasing

Is renal cell carcinoma more common in males or females?

Males

What percentage of renal cell carcinomas have mets on presentation?

30%

What are the risk factors for renal cell carcinoma?

Smoking Obesity Dialysis

Describe the different ways renal cell carcinomas can spread

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

What imaging can we use to diagnose renal cell carcinoma?

Ultrasound | CT

What are the treatments for RCC?

Surveillance Radical nephrectomy Partial nephrectomy Ablation (developmental)

Describe the treatment for metastatic RCC

Palliative | Molecular therapies

What are the causes of upper tract transitional cell carcinoma?

Smoking Phenacetin abuse Balkan's nephropathy

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

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

40%

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

Ultrasound for hydronephrosis CT urogram Retrograde pyelogram Ureteroscopy - biopsy

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

Nephro-ureterectomy