Transcript Urinary Incontinence and Hematuria - Sara Accardi

Urinary
Incontinence
and Hematuria
Sara Accardi
April 19, 2016
Priority Topics: Menopause
Key Feature
1
In any woman of menopausal age, screen for key features of menopause (hot flashes, change in
libido, vaginal dryness, incontinence, psychological changes)
2
In a patient with typical symptoms suggestive of menopause, make the diagnosis without
ordering any tests (this diagnosis is clinical and tests are not required)
3
In a patient with atypical symptoms of menopause (e.g. weight loss, blood in stools), rule out
serious pathology through the history and selective use of tests, before diagnosing menopause
4
In a patient who presents with symptoms of menopause but whose test results may not support
the diagnosis, do not eliminate the possibility of menopause solely because of these results
5
When a patient has contraindications to hormone-replacement therapy, or chooses not to take
HRT: Explore other therapeutic options and recommend some appropriate choices
6
In a menopausal or peri-menopausal women: a) specifically inquire abut the use of natural or
herbal products; b) advise about potential effect and dangers (i.e. benefits and problems) of
natural or herbal products and interactions
7
In a menopausal or perimenopausal woman, provide counseling about preventative health
measures (osteoporosis, mammography)
8
Establish by history a patient’s HRT risk/benefit status
Priority Topics: Cancer
Key Feature
1
In all patients, be opportunistic in giving cancer prevention advice (e.g. stop smoking, reduce
unprotected sexual intercourse) even when it is not the primary reason for the encounter
2
In all patents, provide the indicated evidence-based screening (according to age group, risk
factors, etc.) to detect cancer at an early stage (Pap tests, mammography, colonoscopy, DRE,
PSA)
3
In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in
the treatment plan, in collaboration with the specialist cancer treatment system
4
In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the
personal and social consequences of the illness (family issues, loss of job), and the patient’s ability
to cope with these consequences
5
In a patient treated for cancer, actively inquire about side effects or expected complications of
treatment (e.g. diarrhea, feet paresthesias), as the patient may not volunteer this information
6
In patients with a distant history of cancer who present with new symptoms (e.g. SOB, neurologic
symptoms), include recurrence or metastatic disease in the differential diagnosis.
7
In a patient diagnosed with cancer, be realistic and honest when discussing prognosis (Say when
you don't know)
Priority Topics: UTI
Key Feature
1
Take an appropriate history and do the required testing to exclude serious complications of UTI
(e.g. sepsis, pyelonephritis, impacted infected stones)
2
Appropriately investigate all boys with UTI, and young girls with recurrences (e.g. ultrasound)
3
In diagnosing UTI, search for and/or recognize high-risk factors on history (e.g. pregnancy;
immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy)
4
In a patient with a diagnosed UTI, modify the choice and duration of treatment according to risk
factors (e.g., pregnancy, immunocompromised, male, extremes of age); and treat before
confirmation of culture results in some cases (e.g. pregnancy, sepsis, pyelonephritis)
5
Given an non-specific history (e.g., abdominal pain, fever, delirium) in elderly or very young
patients, suspect the diagnosis and do an appropriate work-up
6
In a patient with dysuria, exclude other causes (e.g. sexually transmitted disease, vaginitis, stone,
interstitial cystitis, prostatitis) through appropriate history, physical, examination, and investigation
before diagnosing a UTI
Case # 1: Hematuria in an
adult
 62
year old male presented to the ER with
hematuria
Differential Diagnosis
 Infection

UTI, Cystitis, Pyelonephritis
 Cancer

Bladder, Renal
 Renal
stones
 BPH
 AKI/
Nephritic syndromes
 IgA
nephropathy, SLE
Rare causes of hematuria
 Hereditary
hemorrhagic telangiectasis
 Radiation cystitis
 Schistosomiasis (which is not rare in
endemic areas)
 Arteriovenous malformations and fistulas
 Nutcracker syndrome (compression of L
renal vein between SMA and aorta)
 Loin pain-hematuria syndrome
Glomerular bleeding
 Red
cell casts
 Dysmorphic red cells
 Proteinuria > 500mg/day
Glomerular bleeding with no
proteinuria is most likely due to
 IgA
nephropathy
 Thin Basement Membrane Disease
(nebign familial hematuria)
 Mesangioproliferature glomerulonephritis
 Alport Syndrome
 Transient


Post-inectious glomerulonephritis
Exercise
Non-Glomerular bleeding
 Blood
clots
Epidemiology of Urinary tract
cancers
 2.5%
of patients with microscopic
hematuria had cancer


(about 90% of those were bladder Ca)
Of those over 50 with gross hematuria + one
other risk factor, 11% had Ca
Things to consider on history
 Has
been going on intermittently for
approximately 2 years every month or so
 No blood clots (indicate lower urinary
tract)
 No dysuria, frequency, nocturnal, pyuria,
hesitancy, dribbling
 No pain
 No fever, no recent illness/URTI
Things to consider on history
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No family history (polycystic kidney, sickle cell)
Smoking history- 60 pack years
No history of autoimmune disease
No history of abdominal surgery
No vigorous exercise, no trauma, no menses
No bleeding disorder, no use of
anticoagulants
No recent travel (Schistocoma haematobium,
Tb)
What tests would you order?

Urine
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
Blood
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CBC, Cr, Urea, Lytes
Abdo US


C&S, R&M, Consider Cytology
Note: semen, myoglobin, and alkaline urine can
give false + for heme
Include Renal and bladder
Referral to urology/gynecology

cystoscopy (if age > 40 years, persistent,
unexplained (not infectious of glomerular), clots,
any risk factor for malignancy, gross hematuria)
Risk Factors For Malignancy

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Age > 35
Smoking history
Occupational exposure to chemicals or dyes
Gross hematiruia
Chronic cystitis / irritative voiding symptoms
Pelvic irradiation
Cyclophosphamide exposure
Chronic cathetor
Analgesic abuse
What would you tell your
patient?
 Treat



What medication?
What duration?
What side effects?
 Will

for UTI
be sending for other tests
Possibility of cancer, but we cannot be sure
until the other tests are complete
 If
UTI, recheck in 6 weeks for resolution of
hematuria
 Imaging study options: CT urography,
radiography, IV pyelogram, retrograde
pyelogram, MRU, US
Case # 2: Urinary incontinence
in a menopausal woman
 56
year old woman comes to your office
complaining of not being able to control
her voiding
Epidemiology of Urinary
Incontinence
 In
the community 26-61% of women seek
help
 25 to 84 year old women; 10-15%
prevalence
 More common if multigravida
 In nursing homes 43-77% prevalence
Why do we care?
 Associated
with anxiety and depression
 Major cause of social isolation
 Major cause of caregiver burnout
 Morbidity- increased perineal infections
 Major cause of sexual dysfunction
 No increased mortality
Risk Factors
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Advanced age
Obesity (RR 3); improves with weight loss
Parity
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Mode of delivery only has an effect on stress
incontinence
Family History (RR 1.3-1.6)
Smoking
Vaginal atrophy
DM
Stroke
Caffeine intake
GU surgery
Radiation
Types of Urinary Incontinence

Stress

Increased intra-abdominal stress causes
leakage
Urethral hypermobility
 Sphincteric deficiency (neuromuscular)

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Urgency
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
Overflow
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Detrusor over-activity
Detrusor under-activity
BOO
Decreased cognitive/functional ability
Differential
 UTI
 Cancer
 Stones
 Inflammatory
causes
What do you want to know?
 In
the past 3 months, have you leaked
urine?
 What were you doing when you leaked?
 Was there an urge to void?
 What activity made you leak most often?
What do you want to know?
 “When
I have to go, I have to go”
 Frequency, urgency, nocturia
 Small volume of urine each time
 Some urine leakage when coughing
What do you want to know?
 Patient
has had 4 children
 No fever, dysuria, pelvic pain, hematuria
 Gait is normal, no neurological symptoms
 Normal BM
 Normal cognition and functional status
 Not on any medications
Medication Review
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Antihistamines (decrease contractility)
Decongestants (increase sphincter tone)
Benzos (muslce relaxant)
Opiods (decrease sensation of fullness, increased sphincter tone)
Antimuscarinics (decreased contractility)
Spasmolytics (decreased contractility)
Anticholinergics (decreased contractility)
Cardiac (ACE inhibitor, Alpha agonist, alpha blocker,
antiarrhythmic, diuretics)
Psych (antidepressants, antipsychotics)
Muscle relaxants
Estrogens
Alcohol/ Caffiene
Exam findings
 Vaginal
atrophy
 Pelvic masses
 Pelvic prolapse
Exam findings
 If
sudden onset- do a full neurological
exam
 Include LE strength, reflexes and perineal
sensation, DRE for sphincter tone
What lab tests do you want to
order?
 Urinalysis
 C&S?
– only if UA is suggestive of infection
 Cytology? – only if no UTI + hematuria/
concern for malignancy
 Creatinine/ Uric acid? – only if concern for
severe urinary retention
What clinical tests do you
want to order?
 Bladder
stress test
 Post void residual (catheter or bladder
scan) is not necessary; may help with
diagnosing overflow incontinence
 Urodynamic testing (not necessary)

Invasive and OK to initiate therapy based
on history
How might you manage this
patient?
 Voiding
Diary (N = < 8 times in 24 hrs and
<1.8 L)
 Consider Pelvic flood distress inventory or
similar grading tool
 Pads for incontinence (not menstruation)
Treatment: Lifestyle
modifications

Decrease caffeine and alcohol intake
Decrease fluid intake before bed time
Limit fluids to <2L per day
Change timing and dosing of diuretics
Weight loss
Treat constipation
Smoking cessation (no evidence for improvement)
Pelvic floor muscle exercises (Kegel)
Bladder training
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Treat conservatively for 6 - 12 weeks
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Kegel Exercises
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3 sets of 8 to 12 contractions sustained for 8 –
10 seconds; 3 times per day
15-20 weeks
Can check adequacy during pelvic exam
Place two fingers within the vagina, ask the
patient to contract her pelvic floor using the
same muscles she would use to stop urine flow
or gas
If pt has difficulty isolating muscles, consider
PT, supervised exercises, vaginal weighted
cones, biofeedback
Bladder Training
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Effective for urgency incontinence
Start with timed voiding
Start based on shortest voiding interval
identified on voiding diary
If urgency between voids- use distraction and
relaxation (mental math, deep breathing,
quick flicks)
Slowly increase interval until reaching 3-4
hours (increase by 1 hour after 2 days of no
urge between scheduled voids)
May take up to 6 weeks
Treatment: Medical
Management
 Vaginal
woman



estrogen in post-menopausal
Premarin (0.5 grams twice per week)
Vagifem (10 mcg tablet daily x 2 weeks,
then twice weekly)
Estring (once per 90 days)
 May
take 3 months to notice benefit
 Systemic estrogen therapy may worsen
incontinence
Types of vaginal estrogen
Treatment: Pessaries

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Indicated for stress incontinence and pelvic
organ prolapse
50% success rates
Contraindications
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Infection
Latex sensitivity (use silicone)
Exposed foreign body
Noncompliance
Sexual activity if pt uncomfortable removing
pessary
Treatment: Pessary- Types
Treatment: Pessary- fitting
 Average
size is 3-5 for ring pessary
 Make sure it fits in place without shifting or
falling out
 Make sure it is comfortable
 Have pt stand up and walk around
 Return to clinic in 2 weeks to check in
Medical Management of
urgency incontinence

Antimuscarinic/ anticholinergic
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Most Useful
Act at M2 and M3 receptors in detrusor, some
are non-selective and act on M1-M5
Can cause dry mouth, dizziness, blurred vision,
constipation, GI upset, GERD
Serious AE include decreased cognition leading
to MVA, confusion, convulsion, falls, arrhythmia,
allergy, urinary retention
Contraindicated in delirium, dementia,
glaucoma
Medical Management of
urgency incontinence

Oxybutynin
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 Doses:
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5 mg tablet, BIDQID
1, 10, 15mg ER,
30mg max dose
3% gel, 3 pumps
daily (fewer side
effects)
Patch, twice per
week
 Can
use PRN
Fesoterodine
(Toviaz)
 Doses:
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
4mg, 8gm ER
tablet, daily
Tolterodine
 Doses:
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
1-2mg BID IR
2-4 mg daily, LA
Medical Management of
urgency incontinence
 Tricyclic


antidepressants
Dual mechanism; both ACh at detrusor and
adrenergic at urethral sphincter
Imipramine- little evidence, but often used
for nocturia in children and adults
Medical Management of
urgency incontinence
 Follow
up in 4-6 weeks
 Improvement in 4-12 weeks
 Can try different med in same class or
different class if no improvement
Medical Management of
stress incontinence
 Duloxetine


(SNRI)
Not approved for use
Can use as antidepressant in pt with
incontinence
 Imipramine

Insufficient evidence for efficacy
Treatment: Surgical options
 Improved
outcomes for stress
incontinence (>80% success rate)
When to refer
 Pain
with no UTI
 Hematuria with no UTI
 Suspected fistula or dierticula
 Pelvic mass, pelvic prolapse (stage 3 or 4)
 Neurological symptoms
 Unclear diagnosis
 History of pelvic surgery or radiation
 Overflow incontinence or high PVR
SAMP style question
 Question
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
#1
A 45 year old man comes to your office
with gross hematuria for 1 day. UA is positive
for Hemoglobin and Leukocyte Esterase.
1) Name 3 differential diagnoses
2) Name 5 risk factors for bladder cancer
3) What blood tests and investigations
would you order?
SAMP style question

Question # 2




An 73 year old woman presents to your office
because she has had difficulty controlling her urine
for the past year. She says that she often has a
sudden urge to void and she cannot wait to get to
a bathroom. As a result, she has not been going
out as much as usual because she fears she will
have an accident.
1) What type of incontinence is most likely
bothering her?
2) Name 5 risk factors for incontinence
3) What are three management options for this
type of incontinence?
References
 Lukacz,
Emily S. Evaluation of women with
urinary incontinence. In: UpToDate, Post
TW (Ed), UpToDate, Waltham, MA
(Accessed on April 1, 2016)
 Feldman, Adam S. Etiology and
evaluation of hematuria in adults. In:
UpToDate, Post TW (Ed), UpToDate,
Waltham, MA (Accessed on April 1, 2016)