Week 6

Question 1

RFs for bladder CA?

Answer 1

smoking, 2nd hand smoke exposure
chemical/carcinogen exposure
infrequent urination/dec water intake
diet: high beef, pork, fat, coffee
(+) FHx
radiation exposure
low nutrient intake (B6, antioxidants)
advancing age >60 yo
schistosomiasis infxn leading to SCC
cytoxin and opium addiction
artificial sweeteners
chlorinated water
genetics - mutation of p53
high beer consumption 
physical trauma to bladder epithelium
colon CA mets
endometriosis
chemotherapy
chronic cystitis
HPV

Question 2

MC type of bladder CA?

Answer 2

TCC

Question 3

other types of bladder CA?

Answer 3

adenocarcinoma
SCC
undifferentiated carcinomas
mixed carcinomas 
secondary bladder CA (mets to bladder from melanoma, lymphoma, stomach, breast, KD, and lung)

Question 4

presentation of bladder CA?

Answer 4

85-90% present with gross microhematuria, usu painless
potentially nocturia, dysuria, urge incontinence
if advanced will see frequency, urgency, dysuria, flank pn, abd pn, bone pain (if mets), anorexia

Question 5

dx of bladder CA?

Answer 5

labs will show hematuria, possibly pyuria, possibly azotemia when obstruction
anemia of chronic dz on CBC
cytology will show exfoliated cells from neoplastic epithelium, bx will show dysplastic changes
can also do IVP for tumor detection, pelvic CT will show extent of bladder invasion and enlarged nodes
CXR, bone scans, PET for mets

Question 6

ddx bladder CA?

Answer 6

IC
UTI
urolithiasis
neurogenic bladder
endometriosis

Question 7

naturopathic management and treatment of bladder CA?

Answer 7

eliminate toxins
general multivit
seacure - fish protein
glutamine for gut healing from chemo
B6, Vit C
immunomodulating herbs: rhodiola, mushrooms
hoxsey tea or essiac tea, allium sativa
lactobaccilus casei - increases urinary mutagen excretion

Question 8

MC causes of neurogenic bladder?

Answer 8

MS
spinal cord injury
DM
ALS
parkinson's 
spinal or pelvic surgery
degeneration from aging or inflammation

Question 9

two types of bladder sphincters?

Answer 9

internal involuntary smooth muscle sphincter at the bladder neck (sympathetic innervation)
external voluntary striated-muscle sphincter

Question 10

what is the fxn of the uretovesical jxn?

Answer 10

prevents backflow of urine from bladder to upper tract

Question 11

ANS innervation of ureterovesical jxn?

Answer 11

parasympathetics (S2-4) - cholinergic, enervates bladder base and internal sphincter, allows emptying
sympathetics (T10-12), noradrenergic, enervates bladder base and internal sphincter, maintains sphincter tone

Question 12

CNS innervation of ureterovesical junction?

Answer 12

somatic (S2-3) control of voluntary sphincter

Question 13

spastic bladder is dt lesion where? too much what type of activity? common causes?

Answer 13

spastic bladder dt lesion above sacral micturition center (above S2-4)
too much parasympathetic activity: detrusor hyperreflexia leads to loss of bladder capacity
common lesions above brainstem affecting voiding include dementia, vascular accidents, MS, tumors, inflammation (encephalitis, meningitis)

Question 14

ssxs of spastic bladder?

Answer 14

voluntary urination, frequent, spontaneous, triggered by spasm, decreased volume, residual urine, recurrent UTIs, increased pressure, bulbocavernosal, knee, ankle or toe reflexes increased
reduced bladder capacity

Question 15

diagnosis of spastic bladder?

Answer 15

periodic IVUs and retrograde cystograms will show low bladder volume, bladder wall hypertrophy
U/S or urethral catheterization to determine pos-void residual volume
cystoscopy to evaluate for strictures or stones

Question 16

where is the lesion with flaccid bladder? injury to what 4 potential areas?

Answer 16

lesions at or below the sacral micturation center
injury to detrusor motor nucleus (S2-4, anterior horn damage), afferent feedback pathways, injury causing poor detrusor distensibility (peripheral nerve injury), injury to external sphincter (pelvic fx, radical perineal surgery)

Question 17

ssxs of flaccid bladder?

Answer 17

increased volume, decreased P
retention w/overflow incontinence, lack of erections, loss of sensation in dermatomes
LMN changes: hypoactive reflexes, diminished sensation

Question 18

dx of flaccid bladder?

Answer 18

KUB to look for fx, calculi
IVU to look for hydronephrosis, obstruction
cystogram to assess detrusor, vesicoureteral reflux
cystoscopy will show lg capacity with some wall hypertrophy
urodynamic studies will show low bladder filling P, weak detrusor activity, lg vol of residual urine, dec tone of external sphincter

Question 19

ddx of neurogenic bladder?

Answer 19

cystitis, anterior vaginal wall prolapse, chronic urethritis, bladder outlet obstruction, IC

Question 20

goals of treatment of neurogenic bladder?

Answer 20

restore low P activity to the bladder, preserve renal fxn, continence, control infxn

Question 21

tx options for spastic bladder?

Answer 21

pharm agents such as parasympatholytics and anticholinergics, TCAs, C-fiber afferent neurotoxins

neurostim: bladder pacemaker
instrumentation: indwelling catheter, condom catheter and leg bag
surgical: sphincterotomy, rhizotomy, urinary diversion
naturopathic: tx underlying neuro condition if possible, prevent UTIs and stones, antispasmodics, anticholinergics, neurorestoratives, antioxs, HP remedies

Question 22

tx options for flaccid bladder?

Answer 22

suprapubic P (crede’s maneuver) to increase intra-abd P

pharm: acetylcholine derivatives
instrumentation: intermittent catetherization q 3-6 hrs
surgical: implant or TURP
naturopathic: above tx options, support nerve tone and re-growth, neurorestoratives, HP

Question 23

complications of neurogenic bladder?

Answer 23

infection
calculus dt low fluids, bed rest, immobilization
renal amyloidosis
sexual dysfxn

Question 24

RFs for urinary incontinence?

Answer 24

female
advancing age
abd or pelvic surgery
pelvic radiation
BPH

Question 25

types of urinary incontinence?

Answer 25

``` urge stress overflow mixed functional ```

Question 26

ssxs of urge incontinence?

Answer 26

abrupt, strong urge, delayed incontinence after cough or increased intra-abdominal P

Question 27

causes of urge incontinence?

Answer 27

BPH, stroke, MS, alzheimer's, parkinson's, supra sacral spinal cord lesion, neurogenic, aging

Question 28

sxs of stress urinary incontinence?

Answer 28

incontinence immediately after cough, sneeze, laugh or increase abd pressure

Question 29

causes of stress urinary incontinence?

Answer 29

urethral architecture, pelvic trauma, neurologic lesions, drugs (alpha adrenergic antatagonists)

Question 30

sxs of overflow incontinence?

Answer 30

feeling of fullness, frequent dribbling

Question 31

causes of overflow incontinence?

Answer 31

drugs (alpha adrenergic agonists, anticholinergics, CCBs, loop diuretics), fecal impaction, diabetic neuropathy, MS, organ prolapse, BPH, PCA, urethral stricture, neurogenic

Question 32

ssxs of functional incontinence?

Answer 32

feel urge ok just can't make it to the bathroom

Question 33

diagnosis of incontinence?

Answer 33

``` voiding diary PE: suprapubic tenderness, DRE, male genitalia, pelvic exam cystometrogram EMG stress cystourethrogram uroflowmetry urethral P profilometry urinary stress test ```

Question 34

treatment and management considerations of incontinence?

Answer 34

pharm: urge - anticholinergics, antimuscarinics; stress - alpha adrenergic agonists, estrogen surgical naturopathic: discont causative medications, bladder retraining, pelvic MS exercises, exercise-based behavioral therapy identify and eliminate food allergies avoid caffeine, tea, alcohol anti-inflams: flax, bromelain, vit C, vit E botanicals: soy, zea mays, gallium, anticholinergic/UR, ephedra, pygeum and serenoa (OR), st. john's wort (UR) biofeedback acupuncture hypnosis yoga

Question 35

changes you see in IC? what is seen on cystoscopy specifically? what is IC?

Answer 35

changes seen with IC include fibrosis of the bladder wall, loss of bladder capacity, chronic inflam with mucosal disruptions, cellular infiltrates and sub-urothelial hemorrhages Hunner's ulcers seen on cystoscopy hypersensitive bladder syndrome, leaky bladder

Question 36

etiological theories of iC?

Answer 36

inflammation uroepithelial dysfunction food allergies deficiency of GAG coating in bladder epithelium chronic infxn, instrumentation, urinary calculi toxins from food additives pathological organisms dormant in bladder deficiency of NO trauma genetics: HLA-DR6, FZD8

Question 37

presentation of IC?

Answer 37

urinary frequency, urgency, progressively worsening bladder pn w/filling, better w/voiding possible non-specific pelvic pn, mb dyspareunia, usu normal PE but mb suprapubic tenderness

Question 38

diagnosis of IC?

Answer 38

diagnosis of exclusion hx, pelvic pain/urgency/frequency variable tenderness of abd wall, buttocks, pelvic floor, urethra labs show no sxs of infxn, possibly hematuria, normal renal function unless obstruction or reflux run cytology if high risk for bladder CA imaging shows normal urogram cystoscopy w/hydrodistention under anesthesia to visualize bladder - shows chronic wall inflammation, edema, small mucosal disruptions, cellular infiltrates, glomerulations, punctate hemorrhages

Question 39

special test to run for IC?

Answer 39

potassium sensitivity test or Parson's test - infiltration of KCl solution causes pain from epithelial leakage

Question 40

NIH diagnostic criteria for IC?

Answer 40

pts must have either glomerulations on cystoscopic exam OR hunner's ulcers AND either pain assoc w/the bladder or urinary urgency

Question 41

when do you start to consider IC?

Answer 41

pts tx for overactive bladder who continues to experience persistent urge w/ associated suprapubic/pelvic discomfort or pn pt who does not respond to empirical abx therapy for "recurrent UTI" female pt who cont to have pelvic pn after endometriosis therapy male pt who has been tx for prostatitis w/multitude of therapies but cont to have pelvic pn perceived to be associated with the bladder and possibly irritative voiding sxs

Question 42

DDX of IC?

Answer 42

TB of bladder, schistosomiasis, cystitis, urethritis, spastic urogenic bladder, anxiety d/o, colorectal CA, bladder CA drug effects F: vaginal wall prolapse, endometriosis, uterine fibroids M: prostate CA, prostatitis, pelvic floor hypertonicity

Question 43

tx options for IC?

Answer 43

pharm: prednisone, anti-histamines, general or vesical sedatives, abx, CCBs, TCAs, gabapentin, LDN procedures to increase bladder size, irrigation, intravesical tx options surgery: to augment bladder capacity naturopathic: psychosocial support, avoid activities that flare, guided imagery, avoid allergens, decrease EtOH, coffee, soda, tomato, citrus, MSG, chocolate, bananas, beer, cheese, GACs, quercetin, cystoprotek, melatonin, EFAs, buffered vit C, estriol suppositories, arginine, anti-inflam diet, anxiolytics, immuno-modulators, antispasmodics, vitanica supplement, physical therapy, sitz baths, HP

Question 44

in both men and women, inquisitive, self-exploration, contraception --> cystitis, often hematuria dx via plain fill or cystoscopy, stone may form rapidly in alkaline pH tx: cystoscopic or suprapubic removal

Answer 44

foreign bodies introduced into the bladder and urethra

Question 45

secondary to either obs distal to the vesical neck or UMN neurogenic bladder inc intravesical P cz vesical mucosa to push between hypertrophied muscle bundles leading to vesicoureteral reflux and urine retention, risk of CA tx: may need surgical removal

Answer 45

diverticula

Question 46

from diverticulitis, Colon CA, Crohn dz, vesical irritability, passage of feces adn gas through urethra, change in bowel habits, sxs of intestinal obstruction and abd tenderness dx via barium enema, cystoscopy and cystograms tx: proximal colostomy, defect closure

Answer 46

vesicointestinal fistula

Question 47

secondary to obstetric, surgical or radiation injury, or invasive CA of the cervix, constant urine leakage dx: pelvic exam w/cystoscops, radiopaque dye w/x-ray, bx may show carcinoma tx: electrocautery of the opening, direct surgical repair

Answer 47

vesicovaginal fistula

Question 48

primarily in 20-40 yo A.A. men, no pathognomonic sxs - soe dysuria, mild obstruction, enlarged pear-shaped bladder dx: excretory urograms and cystoscopy show dilation of both upper tracts and upward displacement and lateral displacement of the bladder tx: surgical removal of fat prognosis: progression to hydronephrosis in most cases; surgery for urinary diversion

Answer 48

perivesical lipomatosis

Question 49

complete ventral defect of the urogenital sinus and the overlying skeleton lower central abd occupied by the inner surface of the bladder, whose mucosal edges are fused with the skin urine spurts onto abd wall renal infxn and hydronephrosis common staged surgical reconstruction (may lead to incontinence)

Answer 49

exstrophy

Question 50

embryonic canal connecting bladder to allantois (umbilicus) persists, becomes a cyst leakage of urine through umbilicus adenocarcinoma may occur in the persistent urachal cyst tx: surgical excision

Answer 50

persistent urachus (cyst)