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GU > Lecture 10: Bladder and Urinary Incontinence COPY > Flashcards

Lecture 10: Bladder and Urinary Incontinence COPY Flashcards

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1
Q

What is the 2nd MC urologic cancer?

A

Bladder cancer.

MC in men and older pts.

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2
Q

What are the risk factors for bladder cancer?

A
  • Cigarettes
  • Industrial solvents
  • Chronic inflammation
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3
Q

What is the most common form of bladder cancer?

A
  • Epithelial cell malignancies
  • Specifically: Urothelial cell carcinoma
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4
Q

What is the #1 presenting s/s in bladder cancer?

A

Hematuria

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5
Q

What would appear on urine cytology for bladder cancer?

A

Abnormal shed epithelial cells

Highly sensitive in high grade cancers

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6
Q

What is the gold standard for diagnosing bladder cancer?

A

Cystoscopy with biopsy

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7
Q

What imaging finding is commonly seen in bladder cancer?

A

Filling defect

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8
Q

What is the treatment for superficial bladder cancer?

A
  • Transurethral tumor resection
  • BCG weekly for 6-12 weeks

TIS, Ta, T1

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9
Q

What is the treatment for invasive bladder cancer?

A
  • Radical cystectomy
  • Urinary diversion
  • Chemo, immunotherapy, radiation

T2+

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10
Q

What is the prognosis for superficial bladder cancer?

A

81%

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11
Q

What is nocturnal enuresis?

A

Repeated urination into clothing or bedding during the night.

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12
Q

What is monosymptomatic enuresis?

A
  • No LUTS
  • No hx of bladder disorders
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13
Q

Define primary nocturnal enuresis.

A
  • Young children 5-6yo
  • Never achieved urinary continence.
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14
Q

Define secondary nocturnal enuresis.

A
  • Previous continent for 6 months prior.
  • Often associated with a stressful time in a child’s life.
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15
Q

Who is nocturnal enuresis MC in and what does increased duration of it suggest?

A
  • MC in males
  • The longer it goes, the less likely it will spontaneously resolve.
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16
Q

What is the classic presentation of nocturnal enuresis?

A
  • Involuntary urination during sleep in a person who NORMALLY has voluntary urinary control.
  • Occurs 3-4 hours past bedtime.

Voiding diaries may help track it.

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17
Q

What is the main purpose of diagnostics in regards to nocturnal enuresis?

A

UA and UC are generally used to r/o other possible causes.

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18
Q

What are the behavioral and pharmacological treatments for nocturnal enuresis?

A
  • Enuresis alarm
  • Desmopression (1st line)
  • Imipramine, oxybutynin (2nd line)
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19
Q

What is the primary etiology of interstitial cystitis?

A

Unknown

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20
Q

What is the typical onset of interstitial cystitis?

A
  • Women in their 40s
  • Fibromylagia or IBS
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21
Q

What is the classic presentation of interstitial cystitis?

A
  • Pain/discomfort with bladder filling
  • Pain relieved with urination
  • +/- irritative voiding symptoms
  • Suprapubic tenderness
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22
Q

How do labs typically present for interstitial cystitis?

A

Normal

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23
Q

What imaging modalities may be useful in interstitial cystitis?

A
  • Postvoid residual bladder US to r/o retention.
  • Cystoscopy to r/o bladder cancer
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24
Q

What is the diagnostic criteria for interstitial cystitis?

A

Unpleasant sensation related to the bladder, with other LUTS, for > 6 weeks without any identifiable cause.

It is a diagnosis of exclusion

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25
What procedure involving a cystoscope can help improve symptoms of interstitial cystitis?
Hydrodistension
26
What are the cystoscopy findings associated with interstitial cystitis?
* Hunner's lesions/ulcers * Glomerulations (non-specific) * Increased mast cells on biopsy
27
How do you treat interstitial cystitis?
* Lifestyle modifications * Self Care
28
What medications may be used for interstitial cystitis?
* TCAs (amitriptyline first line among TCAs) * Antihistamines - hydroxyzine * CCBs - nifedipine * Pentosan polysulfate sodium
29
What is the only FDA-approved drug for interstitial cystitis and what does it do?
* Pentosan polysulfate sodium * Improvement of glycosaminoglycan layer over the urothelium
30
What are the SEs of pentosan polysulfate sodium?
* GI upset, hair loss, LFT elevations * Minor sedation * **Retinal toxicity**
31
What allergy contraindicates pentosan polysulfate sodium?
Heparin
32
What is third-line treatment for interstitial cystitis?
* Hydrodistension * Electrocauterization of hunner's lesions * Intravesical lido, heparin, or DMSO
33
What is the last resort treatment for interstitial cystitis?
Cystectomy with urinary diversion
34
What two urinary drugs can be used as adjuncts in interstitial cystitis?
* Azo-short term * Methenamine
35
What is the usual cause of urethral strictures in developed countries?
Iatrogenic
36
What are the risk factors for urethral strictures?
* Hx of GU surgery or instrumentation * Hx of pelvic trauma or irradiation * Hx of GU infection or cancer
37
What are the typical S/S of urethral strictures?
* Obstructive voiding s/s are the MC * Spraying of the urinary stream * Recurrent UTIs/prostatitis * 10% are asymptomatic
38
How do labs for urethral strictures typically present?
Normal unless infection present.
39
What imaging modalities are useful in diagnosing urethral strictures?
* Uroflometry * US * Cystourethrogram * Cystourethroscopy
40
When should urethral strictures be treated?
* Recurrent UTIs * Problematic symptoms * Urinary retention * High PVR * Bladder stones
41
How are urethral strictures treated?
* Urethral dilation * Urethrotomy * Reconstruction (urethroplasty +/- replacement graft) * Urinary diversion
42
What are the two etiologies that generally predispose someone to urethral prolapse?
* Malformation of the urethra * Weak pelvic floor structures
43
What is urethral prolapse?
Protrusion of the distal urethra through the external urethral meatus
44
What demographics is urethral prolapse MC in?
* Prepubertal * Postmenopausal
45
What are the risk factors for urethral prolapse?
* Chronically increased intra-abdominal pressure * Post-menopausal status * Traumatic vaginal delivery
46
How does prepubertal urethral prolapse typically present?
* Asymptomatic * Vaginal bleeding * Bloody spotting on underwear * Donut shaped protrusion
47
How does postmenopausal urethral prolapse typically present?
* Often symptomatic * Vaginal bleeding * Irritative voiding symptoms * Large can involve venous obstruction, thrombosis, or necrosis * Donut shaped protrusion
48
When is imaging suggested for urethral prolapse?
Concerns over complications. Perform cystourethroscopy.
49
What medical therapy is suggested for urethral prolapse?
* Prepubertal: sitz baths, topical ABX, topical estrogen * Post-menopausal: sitz baths, topical estrogen cream, ABX * Not recommended if significant necrosis, thrombosis, or bleeding.
50
What are the surgical therapies for urethral prolapse?
* Manual reduction and urethral cath for 1-2 days * Ablative therapy (not commonly used) * MC: excision of mucosa with short-term catheterization
51
What is the function of the Pons in regards to the bladder?
* Sympathetic, which relaxes the detrusor muscle and closes the internal urethral sphincter. * Somatic nerves, which contract the external urethral sphincter
52
What triggers inhibition of the sympathetic and somatic systems of the pons in the bladder?
Stretching of the detrusor/trigone stretch
53
What nerve is used to voluntarily stop urination?
Pudendal nerve.
54
What are the risk factors for urinary incontinence?
* Female * Advanced age * Obesity * Parity * Prostate disease * Neurologic disease * Immobility
55
What are the transient causes of urinary incontinence?
* Delirium * Infection * Atrophic urethritis/vaginitis * Pharmaceuticals * Psychological disorders * Endocrine disorders * Restricted mobility * Stool impaction | DIAPPERS
56
Name all the causes of each type of urinary incontinence.
* Urge incontinence: detrusor overactivity * Stress incontinence: Urethral sphincter incompetence * Overflow incontinence: detrusor underactivity * Mixed: multiple * Functional: problems thinking/moving
57
How does urge incontinence present?
Strong urge to urinate before or after involuntarily passing urine.
58
What are the two underlying etiologies for stress incontinence?
* Hypermobility of the urethra (prostatectomy/hysterectomy) * Intrinsic sphincter deficiency
59
How does stress incontinence present?
Involuntary leakage with increases in pressure. | Often seen in young women. ## Footnote Sneezing, laughing , coughing
60
How does overflow incontinence typically present?
Frequent, involuntary leakage of urine. | Need to r/o bladder obstruction first.
61
Who is mixed incontinence MC in?
Women
62
What is functional incontinence?
Inability to recognize need for urination or inability to get to the restroom in a timely fashion.
63
What are the 3 Ps of urinary incontinence history taking?
* Position * Protection * Problem
64
What simple physical test can be used to test for stress incontinence?
Bladder stress test | Stand and cough. ## Footnote Instant = stress Delayed = bladder contraction due to coughing
65
What is considered an abnormal postvoid residual and the management suggested?
* > 200 cc = refer to urology * > > 400 cc = overflow highly likely.
66
What would be a good initial lab test for someone with suspected urinary incontinence?
UA to screen for UTI and hematuria
67
What are good exercises for urinary incontinence?
Kegel exercises (6 weeks to benefit)
68
What are the suggested treatments for stress incontinence?
* Pessaries for women if bladder prolapse * Urethral bulking agents * Duloxetine (off-label) * Surgery (last resort but most effective)
69
What medications work for urge incontinence?
* Anticholinergics * B3 agonists * TCAs * Alpha blockers for men
70
What are the SEs of anticholinergics?
* Dry mouth * Constipation * Urinary retention * Dizziness/drowsiness * **Caution in elderly** | Can't pee, can't see, can't shit
71
What conditions contraindicate the use of anticholinergics?
* Gastric retention * Glaucoma
72
What is the MC anticholinergic?
Oxybutynin
73
When do we use B3 agonists for urinary incontinence and what should we be wary of?
* Cant tolerate anticholinergics * Add-on in overactive bladder * SE: HTN, tachy, dry mouth, UTI | Mirabegron and vibegron
74
What injection can help with urge incontinence?
Botox
75
What is the treatment for overflow urinary incontinence?
* Treat underlying cause * Neuromodulation via sacral nerve * Indwelling catheter (last resort)
76
What incontinence types do kegels help with?
* Stress * Urge * Mixed

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