Genitourinary

Question 1

Issues Common to Pelvic malignancy

Answer 1

1. Pain
   - Often has a neuropathic component
   - Important to prevent constipation (limited pelvic capacity)
2. Skin irritation
   - Fistula formation if the tumour invades into bowel or bladder
   - Chronic discharge of stool or urine from the vagina can be an issue - skin hygiene and barrier creams, also consider use of a colostomy proximal to the fistula
3. Infection
   - Pelvic tumours may become colonized with anaerobes - if foul smelling discharge, consider metronidazole topical or oral
4. Bleeding
   - Low-dose palliative rads
   - Cauterization
   - Tranexamic acid (PO or vaginal) - not useful for slow bleeding, but may be helpful for slow oozing
   - Arterial embolization for severe bleeding
5. Ureteric obstruction
   - May cause hydronephrosis - could be asymptomatic if only one kidney obstructed
   - Loss of a solitary kidney or bilateral hydronephrosis can result in rapidly progressive renal failure
   - Ureteric stents have higher failure rates (inability to traverse site of blockage or malignant compression), requires change q3-4 months. Associated with colicky pain, pressure, dysuria, frequency.
   - Nephrostomy tubes don’t require general anesthetic, still require change q3-4 months
6. Lower limp lymphedema
   - Occurs if pelvic lymphatic drainage can be obstructed
   - May require subcutaneous lymphatic drainage (reverse dermoclysis)
7. DVT
   - May be difficult to treat in the case of concomitant vaginal bleeding - consider IVC filter in this case
8. Bowel obstruction
   - Difficult to manage surgically given peritoneal carcinomatosis
   - If slow-growing, could consider parenteral nutrition

Question 2

Pelvic Malignancy: Skin irritation

Answer 2

Skin irritation

• Fistula formation if the tumour invades into bowel or bladder
• Chronic discharge of stool or urine from the vagina can be an issue - skin hygiene and barrier creams, also consider use of a colostomy proximal to the fistula

Question 3

Pelvic Malignancy: Infection

Answer 3

Infection
- Pelvic tumours may become colonized with anaerobes - if foul smelling discharge, consider metronidazole topical or oral

Question 4

Pelvic Malignancy: Bleeding

Answer 4

Bleeding

• Low-dose palliative rads
• Cauterization
• Tranexamic acid (PO or vaginal) - not useful for slow bleeding, but may be helpful for slow oozing
• Arterial embolization for severe bleeding

Question 5

Pelvic Malignancy: Ureteric Obstruction

Answer 5

Ureteric obstruction

• May cause hydronephrosis - could be asymptomatic if only one kidney obstructed
• Loss of a solitary kidney or bilateral hydronephrosis can result in rapidly progressive renal failure

Management:

• Ensure patient is aware of consequences of ureteric obstruction
• Consider decompression via ureteric stents or percutaneous nephrostomy (may be complicated by leaking and infection)
• Ureteric stents have higher failure rates (inability to traverse site of blockage or malignant compression), requires change q3-4 months. Associated with colicky pain, pressure, dysuria, frequency.
• Nephrostomy tubes don’t require general anesthetic, still require change q3-4 months
• Some patients may opt for death by renal failure

Question 6

Pelvic Malignancy: Lower limb lymphedema

Answer 6

Lower limb lymphedema

• Occurs if pelvic lymphatic drainage can be obstructed
• May require subcutaneous lymphatic drainage (reverse dermoclysis)

Question 7

Pelvic Malignancy: DVT

Answer 7

DVT

- May be difficult to treat in the case of concomitant vaginal bleeding - consider IVC filter in this case

Question 8

Pelvic Malignancy: Bowel Obstruction

Answer 8

Bowel obstruction

• Difficult to manage surgically given peritoneal carcinomatosis
• If slow-growing, could consider parenteral nutrition

Question 9

Management of prostate cancer

Answer 9

Staging and Prognostication

• TNM staging
• Microscopic appearance (Gleason score)
• PSA (some prostate cancers do not secrete PSA, but many do and can be used as a tumour marker for disease progression/treatment response

Management

• Surgery or radiotherapy, depending upon patient age
• Androgen deprivation therapy (orchiectomy or drugs that suppress testosterone production)
• Chemotherapy (particularly in cases of disease progression despite androgen deprivation)

Question 10

Sexual impact of prostate cancer

Answer 10

• Erectile dysfunction and urinary difficulties are common
• Risk of impotence determined by tumour size and extent of local invasion, with prostatectomy commonly causing impotence
• Brachytherapy has lower risk of nerve damage resulting in impotence
• Androgen deprivation therapy commonly reduces libido and erectile function (and is first line for metastatic disease)
• After prostatectomy, orgasm will be ‘dry’ due to absence of seminal fluid

Question 11

Model to counsel regarding sexuality and sexual function

Answer 11

PLISSIT

P - Permission

• Give permission for the patient to discuss concerns
• Direct questioning may help men to overcome embarrassment
• Reassure that they are ‘normal’
• Make no assumptions about sexual function, interest, or orientation

LI - Limited Information

• Amount of information desired may vary from patient to patient
• Provide information in a sensitive manner
• Offer to refer the patient to a colleague of a different sex if requested by the patient

SS - Specific Suggestions

• Alternatives to vaginal or anal intercourse for sexual satisfaction
• Non-sexual ways to demonstrate affection
• Lubricants, sexual aids, different positions to alleviate discomfort may be helpful

IT - Intensive Therapy

• Consider sildenafil, urethral alprostadil pellet insertion, external vacuum device, intracorporeal injections
• Penile implants can be considered for patients cured of cancer
• In case of loss of libido, therapies above may not be helpful
• Despite prostatectomy and androgen deprivation, approx 20% of men can maintain a degree of erectile function
• Consider referral to sexual therapist or counsellor

Question 12

Normal urinary function

Answer 12

Urethral sphincter: Three levels

1. Internal sphincter
   - Layers of the detrusor muscle around entrance to the urethra from bladder
   - Autonomic control
2. Upper urethral sphincter
   - Circumferential layer of smooth muscle in the wall of the urethra
   - Autonomic control
3. Lower urethral sphincter
   - Striated muscle of the pelvic floor
   - Voluntary control

Neurologic control - controlled by T11-L2, S1-S4

• Spinal cord lesions from L1 down can cause micturition difficulty (atonic bladder - retention)
  1. Sympathetic activity
• Internal urethral sphincter contracts, detrusor (bladder wall) muscle relaxes - prevents urine from exiting

2. Parasympathetic
   - Relaxation of the internal urethral sphincter, detrusor contraction - allows urination

Question 13

Neurologic control of urination

Answer 13

Neurologic control - controlled by T11-L2, S1-S4

• Spinal cord lesions from L1 down can cause micturition difficulty (atonic bladder - retention)
  1. Sympathetic activity
• Internal urethral sphincter contracts, detrusor (bladder wall) muscle relaxes - prevents urine from exiting

2. Parasympathetic
   - Relaxation of the internal urethral sphincter, detrusor contraction - allows urination

Question 14

Sphincters involved in urination

Answer 14

Urethral sphincter: Three levels

1. Internal sphincter
   - Layers of the detrusor muscle around entrance to the urethra from bladder
   - Autonomic control
2. Upper urethral sphincter
   - Circumferential layer of smooth muscle in the wall of the urethra
   - Autonomic control
3. Lower urethral sphincter
   - Striated muscle of the pelvic floor
   - Voluntary control

Question 15

Four Types of Urinary Incontinence

Answer 15

1. Stress Incontinence
   - Urethral sphincter unable to prevent flow of urine in the setting of increased intra-abdo pressure
   - Can be damaged during pelvic surgery or rads
   - In women, often due to external (lower urethral) sphincter damage to the pelvic floor
   - Modest incontinence
   - Treat with antimuscarinics (Tolterodine 2-4mg PO qDaily)
2. Urge incontinence
   - Inability to control urine flow when detrusor contracts
   - Often without warning
   - Often caused by bladder wall inflammation (infection, tumour invasion, drugs, radiation)
   - Often large volume as bladder may completely empty
   - Catheters very uncomfortable
   - Treat with TCAs (Imipramine 10-25mg PO qHS, anticholinergic to increase sphincter tone and decrease detrusor contractility) or Oxybutynin 2.5 - 5mg TID-QID (smooth muscle relaxant, decreases detrusor instability)
3. Overflow incontinence
   - Occurs when bladder fills to capacity but cannot contract properly (neuro damage, drugs, outflow obstruction)
   - Causes of outflow obstruction include constipation, prostatic hypertrophy, stricture, or tumour
   - Small, frequent volumes of urine without control
   - High risk of infection with retained urine
   - Treat with alpha adrenergic blockers (Terazosin or doxazosin, 1mg qDaily, increase to up to 10mg qDaily)
4. Total incontinence
   - Complete loss of sphincter function due to tumour invasion or spinal cord injury
   - Consider self-catheterization or indwelling catheter

Question 16

Urinary Incontinence: Stress Incontinence

Answer 16

Stress Incontinence

• Urethral sphincter unable to prevent flow of urine in the setting of increased intra-abdo pressure
• Can be damaged during pelvic surgery or rads
• In women, often due to external (lower urethral) sphincter damage to the pelvic floor
• Modest incontinence
• Treat with antimuscarinics (Tolterodine 2-4mg PO qDaily)

Question 17

Urinary Incontinence: Urge

Answer 17

Urge incontinence

• Inability to control urine flow when detrusor contracts
• Often without warning
• Often caused by bladder wall inflammation (infection, tumour invasion, drugs, radiation)
• Often large volume as bladder may completely empty
• Catheters very uncomfortable
• Treat with TCAs (Imipramine 10-25mg PO qHS, anticholinergic to increase sphincter tone and decrease detrusor contractility) or Oxybutynin 2.5 - 5mg TID-QID (smooth muscle relaxant, decreases detrusor instability)

Question 18

Urinary Incontinence: Overflow

Answer 18

Overflow incontinence

• Occurs when bladder fills to capacity but cannot contract properly (neuro damage, drugs, outflow obstruction)
• Causes of outflow obstruction include constipation, prostatic hypertrophy, stricture, or tumour
• Small, frequent volumes of urine without control
• High risk of infection with retained urine
• Treat with alpha adrenergic blockers (Terazosin or doxazosin, 1mg qDaily, increase to up to 10mg qDaily)

Question 19

Urinary Incontinence: Total Incontinence

Answer 19

Total incontinence

• Complete loss of sphincter function due to tumour invasion or spinal cord injury
• Consider self-catheterization or indwelling catheter

Question 20

Bladder spasms: Manifestations, causes, management

Answer 20

Bladder spasm
- Intermittent, sharp, suprapubic pain with the sensation of needing to pass urine

Causes

• Catheter irritation
• Infection/UTI
• Bladder hemorrhage

Treatments

• If catheterised, consider change to size of catheter or reduction in size of balloon
• Ensure catheter not blocked (irritate with NS as necessary)
• Rule out UTI - do not treat asympthatic bacteruria, but new fever, pain, or evidence of infection should prompt rx. Be especially cautious with patient on steroids
• PO Tranexamic acid if bladder hemorrhage is an issue (note increased risk of DVT)
• Belladonna and opium suppositories
• Smooth muscle relaxant (e.g. oxybutynin 2.5-5mg TID to QID)

Question 21

Management of bowel to bladder fistula

Answer 21

• Divert bowel from fistula with a colostomy - however, major surgery with risks, though lower risk with laparoscopic approach
• May also divert urine with a foley, suprapubic catheter, bilateral nephrostomy tubes as ‘conservative management’
• Note that spontaneous closure is rare

Symptoms:

• Recurrent UTIs
• Fecal matter in urine
• Urine through the rectum
• Fecal odour in the urine
• Pneumaturia

Investigations

• Pelvic exam
• Urinalysis
• CT cystogram with contrast
• CT with rectal contrast
• CT urogram
• May also require cystoscopy

Question 22

Lower Urinary Tract Obstruction Causes and Diagnosis

Answer 22

• BPH
• Invasive bladder/prostate cancer
• Urethral stricture (especially if prior rads, TURB, urethral dilatation, bladder tumour)
• Bladder neck contracture (esp if prior prostatectomy)
• Invasive gyne or colorectal malignancy
• Neurogenic causes of urinary retention (e.g. pelvic trauma, surgeries, neuro disease)

Diagnosis:
- PVR > 90-100mL

Question 23

Choice of catheter for chronic bladder outlet obstruction

Answer 23

1. Clean intermittent catheterization
   - Intermittent catheterisation generally preferred, but requires patient compliance, capacity, and physical dexterity (or nursing care)
2. Indwelling urethral catheter
   - Increased risk of recurrent UTIs, irritative bladder symptoms, urethral erosion with chronic usage
   - Requires routine change q3 weeks
   - In case of recurrent, symptomatic UTIs, may consider prophylactic low dose antibiotics
   - Intermittent catheterisation generally preferred, but requires patient compliance, capacity, and physical dexterity (or nursing care)
3. Suprapubic catheter
   - Reduced risk of infection, urethral erosion, trauma, epididymitis
   - Requires surgical intervention

Question 24

Sexuality - definition

Answer 24

• Process of giving and receiving sexual pleasure and is closely connected to a sense of ‘being’
• Sexuality is a feeling of belonging, being accepted by another, and the conviction that we are worthy to live and enjoy life

Question 25

Intimacy - definition

Answer 25

- Sharing of identity, closeness, and reciprocal rapport | - Emphasis on emotional closeness and intimate communication rather than sexual function

Question 26

Health benefits of sexual and intimate expression

Answer 26

- Pain relieving effects of sexual expression - Distraction from day to day challenges - Heightened pain threshold, especially following orgasm - Lower anxiety and fewer depressive symptoms

Question 27

Impact of life-limiting diagnosis on sexuality

Answer 27

- Sexuality and intimacy remain an important part of patients' lives even until the last days and weeks of life - Cancer diagnosis may directly impact body parts traditionally associated with sexual expression - May be associated with high levels of distress - Partners generally experience a decrease in levels of sexual expression and frequency of intercourse - Chemo may result in infertility - Premature menopause may occur for treatment reasons (e.g. breast CA) - Reduced circulating androgens due to chemo can decrease sexual desire and arousability

Question 28

Normal ageing processes and sexuality in women

Answer 28

- Reduced natural lubrication - Shortening in the length and width of vagina - Altered sensitivity to clitoris - Potentially, loss of libido

Question 29

Normal ageing processes and sexuality in men

Answer 29

- Increased time required for erection - Erection being less rigid for extended periods without ejaculation - Amount of seminal fluid decreases - Orgasmic strength and pleasure may decrease - Increased rates of erectile dysfunction (may be related to medication use, EtOH, depression, etc.)

Question 30

Safe sex while undergoing chemo/rads

Answer 30

- Cytotoxic waste can be excreted through bodily fluid, especially in first 48 hours - Dental dams, condoms recommended during sex to protect partner from cytotoxic irritation - Note that with external beam radiation, the patient body does not become 'radioactive', though certain guidelines are in place for temporary internal radiation implants

Question 31

Sexuality and doctor patient relationship

Answer 31

- Patients feel it is the HCPs responsibility to bring up sexuality, but HCPs rarely do

Question 32

Barriers to conversations regarding patient intimacy and sexuality

Answer 32

- Lack of time - Belief that patient is too ill or not interested in sex - Belief that disfigured bodies are not attractive - Fear of opening 'Pandora's Box' - Transgressing medico-legal boundaries - Presence of third parties at the consult

Question 33

Ways to start a conversation regarding sexuality

Answer 33

"Many people who have undergone this kind of treatment tell me they experience sexual or intimate changes. How has this been for you?" "How has your sexual confidence changed since . . . ? "How do you think this treatment has affected the way you feel about yourself or your relationship with your partner?" "Sometimes a person's body image changes with this illness . . . "

Question 34

Management of sexual side effects: Dysparenua

Answer 34

- Vaginal moisturizer (Replens) | - Lubricating products (especially water-based or silicone based)

Question 35

Management of sexual side effects: Dyspnea

Answer 35

- Well ventilated room, fan - Encourage 'gentle' intimacy (hugging, hand holding, light massage) - Water bed may conserve energy - Pursed lip breathing during sex - Avoid long kisses on the mouth

Question 36

Management of sexual side effects: Fatigue

Answer 36

- Use time of day where the patient has the most energy and 'set the scene' - Different positions to conserve energy - Avoid extreme temperature, heavy meals, alcohol

Question 37

Management of sexual side effects: Xerostomia

Answer 37

- Education on regular oral hygiene - Artificial saliva (Moi-Stir) - Saliva stimulants (lozenges, pilocarpine tablets)

Question 38

Management of sexual side effects: Incontinence

Answer 38

- Encourage use of bath and shower for foreplay and post-coital relaxation - Shower chair, disabled baths, fluffy towel over an incontinent sheet

Question 39

Management of sexual side effects: Privacy on inpatient unit

Answer 39

- 'Do not disturb' signs for patients - Setting 'privacy time' daily - Designated sensuality areas (private rooms with double beds, access to music, etc.) - Double hospital beds