1
Q
43YO smoker presents for annual exam - found to have microscopic hematuria - most likely dx?
A
- bladder cancer
2
Q
Signs of glomerular bleeding?
A
- red cell casts (pathognomonic for glomerulonephritis)
- dysmorphic RBCs
- proteinuria w/ hematuria w/ large percentage bing albumin
3
Q
Nonmalignant etiologies of hematuria?
A
- UTI: pyelo, acute cystitis - present w/ suprapubic pain, dysuria, and frequency
- trauma to kidneys
- stones
- menstruation or endometriosis
- BPH
- vigorous exercise
- PSGN or IgA nephropathy
- warfarin
- over 40: at high risk for cancer
4
Q
RFs for malignancy?
A
- age: over 35
- smoking hx (extent of exposure correlates with risk)
- occupational exposure to chemicals/dyes - painter, printers
- hx of gross hematuria
- hx of chronic cystitis or irritative voiding sxs
- hx of pelvic irradiation
- exposure to cyclophophamide
- hx of chronic indwelling fb
- hx of analgesic abuse (also assoc increased risk of kidney cancer) - NSAIDs
5
Q
Work up of hematuria?
A
- urine culture - if positive tx and repeat UA (all pts)
- urine cytology: all w/ gross hematuria and those w/ risk factors
- imaging: CT urography preferred - US in pregnant women
US CT w/o contrast or MRI may be used - cystoscopy: obtaining urine for cytology just b/f in high risk pts
(CT and cystoscopy done together)
6
Q
What should be done if you get a negative work-up for hematuria?
A
- in young and middle aged pts usually is:
mild glomerular disease (monitor PP, GFR, CrCl), have predisposition to stone disease - pts at high risk for malignancy:
need annual UA
may need another work-up q 3-5 yrs (esp if wt loss, night sweats)
7
Q
Should you screen for hematuria in asx pts?
A
- NO!
8
Q
Pathogenesis of cystitis?
A
- colonization of vaginal introitus from fecal flora
- acension to bladder via the urethra
- can ascend to kidneys causing pyelonephritis
- route much more difficult in males b/c longer and urethra not sitting right above anus - Much less common in men
9
Q
MC pathogens of cystitis?
A
- 75-90% E. coli
- others:
proteus
kelbsiella
10
Q
Clinical presentation of UTI?
A
- dysuria
- frequency
- urgency
- suprapubic pain
- hematuria
11
Q
Clinical presentation of Pyelonephritis?
A
- sxs of cystitis may or may not be present
- chills
- flank pain w/ CV angle tenderness
- N/V
12
Q
Dx tests for cystitis and pyelonephritis?
A
- UA is a must: looking for positive leukocyte esterase and/or positive nitrites
- in women who dx is uncertain or resistance is consideration a urine cuture w/ sensitivities should be done
- ALL males with cystitis should have a culture
- for pyelo:
UA
urine culture and sensitivities
13
Q
Women with cystitis - what should be ruled out? Tx?
A
- common, r/o vaginal source though
- tx:
Nitrofurantoin (100 mg BIDx5days)
bactrim (1 DS BID x 3 days)
fosfomycin 3 gmsx 1 dose
reserve fluoroquinolones for other uses
phenozyopyridine (pyridium)
14
Q
Diff for man presenting with cystitis sxs?
A
- prostatitis
- urethritis secondary to STI
- urinary tract abnormalitiy
- nephrolithiasis
15
Q
Tx for men w/ cystitis?
A
- Bactrim
- fluoroquinolone
- want to cover possible prostatitis
16
Q
Tx for outpt and inpt pyelonephritis?
A
outpt:
- mild to moderate illness: can keep meds down
- where fluoroquinolone resistance is low: cipro or levuoquin
- other: trimethoprim-sulphamethoxazole or augmentin
inpt:
oral fluroquinolone
plus aminoglycoside
or extended spectrum cephalosporin
17
Q
Sxs of noninfectious cystitis? Epidemiology? Irritants?
A
- sxs similar to cystitis w/ nocturia, pressure in pelvis
- epidemiology: women of childbearing yrs
- irritants:
bubble baths, feminine hygiene sprays, tampons, spermicidial jellies
radiation, chemo
foods: tomato, artificial sweetners, caffeine and chocolate
18
Q
W/u and tx of noninfectious cystitis?
A
- w/u:
UA
urine culture
sometimes cystoscopy
-tx:
avoiding irritants
voiding routine
kegels
19
Q
Chlamydia manifestations in a male? Dx? Tx?
A
- MC cause of nongonococcal urethritis
- manifestations:
urethritis: sx/asx
epididymitis
prostatitis - dx:
NAAT - some tests are expensive and don’t produce results quickly - xpert CT/NG assay is a NAAT provides testing in 90 minutes
- Tx: rocephin and Azithro
20
Q
Presentation of gonorrhea in males? Dx, Tx?
A
- urethritis: sx
- epididymitis: younger than 35
- dx: NAAT
- tx: Azithro and rocephin
21
Q
Presentation and PP of overactive bladder w/o incontinence?
A
- urgency, frequency, nocturia
- PP:
detrusor muscle contracts irregularly at smaller volumes of urine, usually idiopathic, can be secondary to DM, stroke, spinal disease
22
Q
Tx of OAB? Mechanism, agents used?
A
- antimuscarinics
- MOA: increase bladder capacity, block basal release of acetyl choline during bladder filling
- agents:
oxybutynin (Ditropan)
tolterodine (Detrol)
solifenacin (vesicare) - once a day
SE: anticholinergic - constipation, dry mouth, blurred vision - new agent:
Mirabegron (Myrbetriq) - beta 3-adrenoceptor agonist, can use alone or w/ other agents
SE:
HTN, incomplete bladder emptying (relaxes detrusor so much), dry mouth
23
Q
Epidemiology of urinary incontinence?
A
- prevalence in women: 25-45%
- prevalence increases with age (both men and women)
- 6-10% nursing home admissions in US due to urinary incontinence
24
Q
Medical morbidity - from incontinence?
A
- perineal candida infection
- cellulitis and pressure ulcers
- UTIs and urosepsis
- falls and fractures from slipping on urine
- sleep interruption and deprivation
- psychologically: poor self esteem, social withdrawl, depression and sexual dysfxn
25
Continence depends on?
- intact micturition physiology
| - intact fxnl ability to toilet onself
26
RFs for incontinence?
- obesity
- fxnl impairment
- parity
- family hx
- smoking
- age
- others: diabetes, stroke, depression, estrogen depletion, genitourinary surgery, radiation
- non-hispanic white women higher rates than non-hispanic black and hispanic women
27
Transient causes of incontinence? DIAPERS?
```
D: delirium
I: infection
A: atrophic vaginitis
P: pharm - sedatives, diuretics, anticholinergics
P: psychological: depression
E: excessive urine production (DI, hypercalcemia, psychogenic polydipsia)
R: restricted mobility
S: stool impaction
```
28
Incontinence questions for screening?
- in past 3 months: have you leaked urine?
- which precipitants led to leakage?
- which precipitant caused leakage most often?
- do you ever wears pads, tissues or cloth in your underwear to catch urine?
29
Hx questions to ask pt about incontience?
- questions about incontinence
- precipitants
- bowel and sexual fxn
- status of other medical conditions, parity, meds
- any prior continence therapy, particularly surgical tx
30
Etiology and presentation of urge incontinence?
etiology:
- uninhibited bladder contractions
- detrusor over activity
- may be due to bladder abnormalities or idiopathic
presentation:
- sudden urge to void
- preceded or accompanied by leakage of urine
- more common in older women
- also seen in men
31
What is stress incontinence? Who does this occur in? What is this due to?
- leakage of urine w/ increased intra-abdominal presure in absence of bladder contraction:
it is impt to determine if leakage occurs coincident or several seconds after a cough
- occurs in young women
- due to:
urethral hypermobility
intrinsic sphincter deficiency
- prostate surgery MC cause in men
32
Mixed incontinence MC in what pop?
- MC type in women
| - pts vary in predominance and/or bother of urge or stress leakage
33
What is incomplete emptying? Due to?
- incomplete bladder empyting preferred term
- continuous leakage or dribbling of urine
due to:
- detrusor underactivity: low estrogen, aging, peripheral neuropathy, damage to spinal detrusor efferents (MS)
- bladder outlet obstruction (BPH)
34
Possible etiologies of nocturia?
- CHF: fluid redistribution from pedal edema
- late evening beverages
- sleep apnea
- sleep disturbances: chronic pain, depression
- detrusor overactivity
35
Dx tool to use for incontinence - for pt?
- bladder diary:
record time and volume of every continent and incontinent void over 42-78 hrs
- other pertinents include: activity, caffeine intake, hours of sleep, episodes of nocturia
36
PE for incontinence?
- don't forget above waistline: respiratory, CV, neuro
- in women thorough genital exam:
check for cystocele/rectocele, atrophy, have pt cough looking for leakage of urine while standing
- in males: exam of prostate
- older persons: cognitive and fxnl status - including mobility, manual dexterity, depression screening looking for fxnl incontinence (ambulatory?)
37
What is a post-void residual?
- have pt void until they feel they have emptied their bladder completely
- then do bladder US or clean cath
- PVR less than 1/3 the total voided volume is considered adequate emptying
38
Labs for incontinence?
- renal fxn
- serum Ca, glucose
- UA
- those with increased PVR: B12
- PSA for men if indicated
- urine cytology if there is hematuria or pelvic pain
39
Tx of incontinence other than pharm?
lifestyle:
- wt loss
- adequate but not excessive fluid intake (2 L)
- avoid caffeinated beverages and alcohol
- minimize evening fluid intake for nocturia
- smoking cessation
behavioral therapy: urge, stress, mixed:
- bladder training - frequent voluntary voiding, relaxation techniques for urge incontinence
- pelvic muscle exercises: kegels (have to do a lot)
- biofeedback
- pessiaries for organ prolapse for stress incontinence
40
Pharm tx for incontinence?
used for urge and mixed if behavioral alone isn't successful:
- anticholinergic w/ antimuscarinic activity:
increase bladder capacity - Detrol LA, Vesicle, SE: dry mouth, blurred vision, constipation, drowsiness, decreased cog. fxn
CI: narrow angle glaucoma
- Oxybutynin (Ditropan): IR, ER, patch - direct antispasmodic effect on detrusor muscle, less SE although dry mouth still prominent
- new agent:
miragebron (Myratriq) -
causes bladder relaxation, help urge and mixed incontinence
SE: HTN, tachycardia, urinary retention (Infection), inflammation of nasal passages, dry mouth, constipation, abdominal pain, and memory problems
- not recommended for pts with uncontrolled HTN
41
Surgical therapy for incontinence?
- used for stress incontinence
- high rate of success
- abdominal or vaginal approaches
- vaginal includes:
midurethral sling
bladder neck sling
submucosal injection of urethral bulking agents
42
Mesh kit complications?
```
- these were previously used for repair of stress incontinence and pelvic floor prolapse
complications:
- mesh exposure (erosion)
- dyspareunia
- infection
- urinary problems
- bleeding
- organ perf
- deaths assoc w/ bowel perf or hemorrhage
```
43
Surgery for incontinence used today?
- stricter guidelines
- mesh kits no longer used
- more stringent training is reqd to do surgeries
- selected procedure for SUI is mesh midurethral sling
44
When would you refer a pt with incontience immediately?
- incontinence w/ abdominal and or pelvic pain
- hematuria in absence of UTI
- suspected fistula
- complex neuro conditions
- abnormal findings
45
When would you electively refer on a pt with incontinence?
- persistent sxs after adequate therapeutic trial
- uncertainty in dx
- significantly elevated PVR that doesn't resolve after tx of possible precipitants
- prior pelvic surgery or pelvic irradiation
- desiring surgical therapy for stress incontinence
46
a 56YO hispanic woman presents to clinic complaining of wetting herself - says she feels urgent need to urinate and can't get to BR soon enough, doesn't occur when she sneezes or coughs. This occurs 1-2x a week. BMI 36, drinks 2-3 cups of coffee in morning. Dx? Labs? Tx?
labs:
UA and CMP
- urge incontinence
- wt loss, stop caffeine intake, relaxation (biofeedback), meds - hold off on (only have episodes 1-2x a week)
47
49 yo female presents to clinic for annual exam. G5P5, no specific complaints, what do you want to ask her?
- if she ever leaks urine, does she use a pad?
| - check for stress incontinence - coughing
48
What is interstitial cystitis AKA? Epidemiolgy? Definition?
- bladder pain syndrome (BPS)
- epidemiolgy: usually dx in 4th decade or later, female to male ratio: 5:1
- an unpleasant sensation (pain, pressure, discomfort) - perceived to be related to urinary blladder, assoc with lower urinary tract sxs of more than 6 wks duration, in absence of infection or other ID causes
49
Presentation of IC/BPS?
- persistent feature: pain or unpleasant sensatio w/ filling of bladder - relieved by voiding
- gradual onset w/ worsening sxs
- may have other urinary sxs:
urinary frequency
urgency
nocturia
50
Dx of IC/BPS?
throrough PE:
pt usually has tender suprapubic area, may have other pain conditions such as dyspareunia, irritable bowel, vulvodynia
- UA and culture to r/o cancer and infection
51
1st line management of IC/BPS?
- pt education noting reasonable expectations about pain relief and chonicity of condition
- psychosocial support
- self-care and behavior modification
52
2nd line management of IC/BPS?
- PT: for pts with pelvic muscle pain
- Meds: amitriptyline (chronic pain)
pentosan polysulfate sodium (PPS - Elmiron) - concentrates in the ballder, proposed mechanism is reconstitutes deficient protective glycosaminoglycan layer over urothelium
- hydroxyzine: antihistamine inhibits histamine release
- referral
53
What should you always rule out if pt presents with painless hematuria?
- CANCER
