Genitourinary Problems in Males and Females: Dysuria, Hematuria, Proteinuria, & Urinary Incontinence

1. NR601-Genitourinary Problems in Males and Females

2. Dysuria • Is the subjective experience of pain or burning on urination? • Association with a bladder problem and frequent voiding • Common causes • Inflammatory lesions • Bladder/urethral infections • Less common causes • Tumors, renal failure, STD’s

3. Hematuria Define as blood in the urine and can be gross or occult More than 3 RBC per high power field There is a direct relationship to quantity of blood and the probability of pathology

4. Hematuria Two types -Transient: Occurs on one occasion -Persistent: Occurs on two or more consecutive occasions Both can be a sign of serious disease

5. Hematuria • Differentials • -Dietary substances • Caffeine, spices, tomatoes, chocolate, alcohol, citrus, soy sauce, some herbal meds • -Medications • Beta-lactam antibiotics, sulfonamides, NSAIDS, Cipro, allopurinol, Tagamet, dilantin • -Anticoagulation and papillary necrosis • Warfarin, heparin, aspirin, NSAIDS • -Glomerulonephritis • Hydrocarbons (glue, paint), NSAIDS • Urolithiasis • Menses

6. Hematuria Pathophysiology- depends on the cause Diagnostic test and findings UA +blood Urine culture with ID and sensitivities Microscopic urine exam-more than 3 RBC per high power field If not more than 3- explore hemoglobinuria If more than 3-test for cause ANA, immunoglobulins, CMP, CBC,

7. ASO, anti-DNASE B, VDRL, PT, PTT, ESR PPD Intravenous pyelogram (IPV) to assess structure CT Cystoscopy to evaluate the Upper tract

8. Hematuria Causes grouped according to anatomic site of source and other findings -Isolated with no other abnormal findings -Along with cast in the urine -Along with bacteria in the urine -Along with protein in the urine -Along with flank pain -Along with HTN, sore throat -Gross hematuria is associated with malignancy

9. Proteinuria Indicative of renal pathology, most often glomerular in origin Can be functional and appears as intermittent -Illness, stress, exercise, or benign Can develop from overproduction of filterable plasma proteins, may be associated with multiple myeloma Continuous is associated with renal pathology -Best test for this is a 24 hour urine *More than 165 mg of protein is abnormal *More than 3.5 grams is indicative of nephrotic disease

10. Proteinuria • Differentials • Benign or functional causes • Orthostatic proteinuria, exercise, environmental conditions, fever, illness, CHF, injury • Bence Jones protein suggest multiple myeloma • Nephrotic syndrome

11. Proteinuria • Pathophysiology-depends on the cause • Diagnostic tests for non-functional proteinuria • 24 hour urine • Measure protein and creatinine • If excretion rate is above 3.0-3.5 g/day the patient has nephrotic syndrome • Full chemistry panel- FBS • Lipid profile • UN/UC with ID and Sensitivity

12. Proteinuria • CBC with Diff • Test for Bence Jones = characterized as a free monoclonal light chain of protein, if this test is positive it suggests multiple myeloma • Only used for low-risk patients- non-diabetic or non-pregnant • If this test is positive do a serum protein electrophoresis

13. Proteinuria • Management is complicated! • With positive nephrotic syndrome per 24 hour urine • REFER • With 2 grams of protein in 24 hour urine • Test renal function • With normal renal function test urine on awakening before upright for one minute and after standing for 2 hours • If first test is normal and second shows protein- refer • With abnormal renal function refer for biopsy • Maybe managed with an ACE- by nephrology and primary care • With co-existing HTN and hyperlipidemia aggressive treatment is warranted for all conditions to prevent renal failure

14. Urinary Incontinence • Definition-Is the involuntary loss of urine from the bladder • Is so common in women that many consider it normal • Common in older men with enlarging prostate • Can affect quality of life

15. Urinary Incontinence • Pathophysiology-three major components are involved in urine storage and release; the central nervous system, the bladder, and the bladder outlet (urethral sphincters)

16. Pathophysiology Summary • Bladder smooth muscle (the detrusor) contracts via parasympathetic nerves from spinal cord levels S2 to S4. urethral sphincter mechanisms include proximal urethral smooth muscle (which contracts with sympathetic stimulation from spinal levels T11 to L2), distal urethral striated muscle (which contracts via cholinergic somatic stimulation from cord levels S2 to S4), and musculofascial urethral supports. In women, these supports form a two-layered “hammock” that supports and compresses the urethra when abdominal pressure increases.

17. Pathophysiology-Summary Micturition is coordinated by the central nervous system: Parietal lobes and thalamus receive and coordinate detrusor afferent stimuli; frontal lobes and basal ganglia provide signals to inhibit voiding; and the pontine micturition center integrates theses inputs into socially appropriate voiding with coordinated urethral relaxation and detrusor contraction until the bladder is empty. Urine storage is under sympathetic control (inhibiting detrusor contraction and increasing sphincter tone), and voiding is parasympathetic (detrusor contractor and relaxation of sphincter tone)

18. Urinary Incontinence • Subjective Presentation • History • Medical (DM, CA, illness) • Medications such as sedatives, hypnotics, diuretics, narcotics, alpha-blockers, antispasmodics, antihistamines, calcium channel blockers, decongestants, alcohol, anticholinergics • Surgical • Date of Onset • Number of voids each day • Fluid intake • Types of fluid • Characteristics of the incontinence • Sneezing, nocturina, urgency or dysuria

19. Urinary Incontinence • Objective • Physical exam • ID underlying pathophysiologic causes • Maybe more than one • Neuro assessment • CVA, Parkinson’s • Cognitive ability and mobility • Abdominal exam • Rule out constipation (common cause) • Masses • Distended bladder

20. Urinary Incontinence Physical exam continued Pelvic exam Check muscle strength Uterine prolapse Perineal structures Skin around this area -atrophic vaginitis -Skin breakdown -In men, check for foreskin, penis or perineum abnormalities Rectal -Check sphincter tone -Prostate size in men

21. Urinary Incontinence • Heart and Lungs • Assess for CHF • Cough stress test-observe for leaking

22. Urinary Incontinence • Tests/Findings • UI or pad test • Patient takes pyridium wears a pad and checks for staining at determined intervals • UA/UC • Serum electrolytes • Blood urea nitrogen (BUN), creatinine, calcium, glucose • Post void catheterization

23. Urinary Incontinence • Further testing depends on test results so far and if the onset is acute • Urine show no infection but is positive for sugar • Urine shows infection may need further work-up • Urine shows increased RBC’s work up for tumor or infection • Other tests that may be indicated • Cystometry, cystometrogram, video-urodynamics, ultrasound

24. Urinary Incontinence • Differentials • Four major types of incontinence • Stress • Urge • Overflow • functional • Other types • Overactive bladder • A type of Overflow UI • Compensated incontinence • Elderly • Transient • Other major illness

25. Urinary Incontinence • Stress UI-is the involuntary loss of urine caused by increased pressure- coughing, laughing, sneezing, etc caused by hypermobility of the bladder neck, intrinsic sphincter deficiency, neurogenic sphincter deficiency, or medications. • Typically have a history of vaginal deliveries • Work-up includes: history, pelvic exam, the pad test, cough stress test, UA, UC, video-urodynamics, and maybe a cystometrogram

26. Urinary Incontinence • Stress UI continued • Management includes- pelvic floor exercises, weight loss, electrical stimulation, HRT, medications such as a alpha-adrenergic agonist, surgical correction, periurethral bulking injections • Feel free to refer these patients who are easily managed!

27. Urinary Incontinence Urge UI- also known as detrusor instability with leakage of urine resulting from the inability to delay voiding. It is the failure to delay voiding. It is the failure to store urine due to urinary tract infection, vaginitis, bladder stones and tumors, may also be caused by brain lesion, CVA, dementia, MS, or medications.

28. Urinary Incontinence • Urge incontinence subtype of UI • Overactive Bladder or OAB- is a syndrome of symptoms that include urgency, frequency, and nocturia all of which are associated with involuntary contractions of the detrusor muscle. These patients may or may not be a feature of this syndrome • 1/3 have urge incontinence, such as stress incontinence • This is often mistaken for Urge UI

29. Urinary Incontinence • Overactive Bladder continued: • The cause is multifactorial- it can include disorders of the lower urinary tract, alcohol and caffeine use, may be associated with certain medications, or with neurologic conditions • Is most common in women • Often results in anxiety and depression due to restriction of daily living • Sexual dysfunction can occur due to fear of urine leakage

30. Urinary Incontinence • Overflow incontinence is the involuntary leakage of small amounts of urine. It is caused by an over-distended bladder in a patient who does not feel the need to void due to an antonic detrusor muscle, outlet obstruction, BPH or medications • The history and PE may indicate hesitancy, dribbling, nocturia, decreased stream, feeling of not emptying the bladder, and/or constipation • The PE should include a neurologic exam and prostate exam

31. Urinary Incontinence • Overflow UI continued • Testing should include UA, UC, serum creatinine, biding cystometrogram and maybe a video-urodynamics • Treatment consists of treating the underlying disease-m ay include scheduled toileting, Crede’s maneuver, medications such as alpha-blockers

32. Urinary Incontinence • Functional urinary Incontinence- is the incontinence that occurs in a normal functioning urinary system. The leakage is caused by factors outside the lower urinary tract and can be transient in nature • Causes vary and include delirium, impaction, immobility problems, medications such as diuretics, decongestants, alcohol

33. Urinary Incontinence • Functional UI continued • History and PE should include assessment for fecal impaction, sleep pattern problems, mental status, hearing and vision, functional ability, fluid intake, accessibility, infection, and neuro deficits

34. Urinary Incontinence • Functional UI • Treatment consists of removing barriers, education regarding a scheduled bowel and bladder program, PT, OT, habit training. Patient may need caregiver assistance. Patients may need catheters. Medications should be used in conjunction with other treatments such as Kegal exercises, vaginal rings, surgical interventions for prolapsed uterus, obstructions, enlarged prostate, or tumors may be indicated

35. Interstitial Cystitis • Definition- chronic bladder inflammation syndrome characterized by pelvic pain and irritative voiding symptoms • Unknown pathophysiology, related to autoimmune, allergic, infection etiologies • Is a diagnosis of exclusion

36. Interstitial Cystitis • Occurs mostly in women • 10% are men • Onset between 30-70 years of age • Does occur in children and is under diagnosed

37. Interstitial Cystitis • Symptoms • Pain, relieved by voiding small amounts • Uncomfortable constant urge to void • May worsen the week before menstruation • Differential Diagnosis • UTI, prostatitis, cystitis • GYN conditions such as vaginitis and endometriosis • Neuropathic bladder dysfunction • Neoplasm • Overactive bladder

38. Interstitial Cystitis • Diagnostic Test • UA, UC, and may be potassium sensitivity test-slow instillation of 40 ml of sterile water into the bladder, the patient grades the pain 0-5. This is the baseline, then empty bladder and repeat with potassium chloride solution. IC is suggested when there is a 2 point increase in pain or urgency • Cystoscopy and hydro distention under anesthesia confirms the diagnosis

39. Interstitial Cystitis • Plan • Education • IC is not a malignancy, has an organic basis, no specific cure, is chronic, will treat symptoms, avoid acidic food, caffeine, alcohol, artificial sweeteners, chocolate, cigarette smoking, drink plenty of water, bladder retraining may help

40. Interstitial Cystitis • Medication treatments • Tricyclic antidepressants • Antihistamines • Nonsteroidals • Pyridium, Ditropan, Procardia may help?? • May require long acting opioids • Refer-for further treatments

41. Urinary Tract Infection • Definition: Inflammation and infection of the urinary bladder; urethra may be involved • Etiology/incidence • Most common causative organisms • E coli-women • Proteus species-men

42. Urinary Tract Infection • Contributing factors in women • Sexual intercourse • Pregnancy • Diabetes • Catheterization • Instrumentation • Retaining urine in bladder despite urge to go • Constipation • Diaphragm use • Meatal stenosis • Bowel incontinence

43. Urinary Tract Infection FYI • Oral antibiotic treatment cures 85% of uncomplicated urinary tract infections, although the rate of recurrence remains high. There is some debate over whether to treat young sexually active women with high bacterial counts but no symptoms (asymptomatic bacteriuria). Given growing bacterial resistance to antibiotics and the benign nature of this condition, many experts do not recommend routine treatment.

44. Urinary Tract Infection • The most common antibiotics used for uncomplicated UTIs are either trimethoprim-sulfamethoxazole (TMP-SMX) or an antibiotic known as a fluoroquinolone. Pregnant women should not take fluoroquinolones. For uncomplicated UTIs, better options during pregnancy may be sulfisoxazole or a cephalosporin.

45. Duration of Treatment • Studies are now reporting that uncomplicated female UTIs can often be successfully diagnosed over the phone. In such cases, the provider provides the patient with a three-day antibiotic regimen without even requiring a urine test. A single oral dose of antibiotics, usually TMP-SMX (Bactrim, Cotrim, Septra) or a fluoroquinolone, is sometimes prescribed in mild cases, but cure rates are generally lower than with the three-day regimens. (Longer term therapy, given 7-10 days, is now mostly limited to men, children, the elderly, people with diabetes with any UTI, and women with pyelonephritis or who are pregnant) After a week of antibiotic treatment, most patients are free of infection. If the symptoms do not clear up within the first few days of therapy, physicians generally suggest that women submit a urine sample for culturing in order to identify the specific organism causing the condition.

46. Treatment of Relapsing UTI • A relapsing infection (caused by the same organism as the first episode) occurs within three weeks in about 10% of women. Relapse is treated similarly to a first infection but the antibiotics are continued for at least two weeks. (Relapsing infections may be due to structural abnormalities, abscesses, or other problems that may require surgery, and such conditions should be ruled out).

47. UTI: Bacterial Resistance to Antibiotics • Of major concern for physicians and the public is the emergence of strains of common bacteria, including E-coli, that are resistant to specific antibiotics. The prevalence of such bacteria has dramatically increased worldwide, in large part due to widespread use of antibiotics in people and animal feeds

48. UTI: Preventive Antibiotics (Prophylaxis) • Prophylaxis (preventive antibiotics) is an option for women who experience two or more symptomatic UTIs within six months or three or more over the course of a year. A woman’s own perception of discomfort should guide her decisions on whether to use preventive antibiotics or not. The increasing use of antibiotics for many common infections is causing concern because of emerging strains of common bacteria that have become resistant to standard antibiotics.

49. Antibiotics for Urethritis in Men • Urethritis in men has typically been treated with a 7 day regimen of doxycycline. Some research is showing that a single dose of azithromycin may be just as effective while cauasing fewer side effects. One-dose treatment also improves compliance, so cure rates may even be better than with a long-term regimen. Of concern, however, is an infection that spreads to the prostate gland, which is harder to treat, so most physicians still prefer the longer regimen. It should be noted that azithromycin and similar antibiotics do not cure the infection and may mask the symptoms of an accompanying sexually transmitted disease, such as gonorrhea. Tests for such diseases should be conducted if urethritis is diagnosed • So, men always need to be cultured and treated for all STD on the day of service as well as for urethritis.

50. UTI: Contributing Factors in Men • Contributing factors in men • Residual urine (prostatic enlargement) • Naturopathic bladder • Calculi • Prostatitis • Catheterization • Instrumentation • Meatal stenosis