Bladder
·
Usually elderly patients
·
Urine sterile
·
If severe then intractable pain
with decreasing bladder capacity
·
Microscopy ®
ulcerative chronic cystitis
·
?Viral aetiology
·
Classic association with azo dyes
(clothing, plastics, batteries) and smoking
· Present with painless haematuria (ALWAYS investigate painless haematuria)
·
Develop as a flat
carcinoma-in-situ ® papillary tumour ® infiltrates
·
Management: regular scrapping it
out until pathology says its metastatic then cystectomy
·
Squamous cell carcinoma: common
in Egypt due to Schistosoma (parasite).
Early infiltration
·
Adenocarcinoma: Rare. Resembles large bowel adenocarcinoma. Derived from urachal remnant
·
Rhabdomyosarcoma: In
childhood. Aggressive but responds to chemo
·
Bladder pressure > urethral
pressure = flow of urine
·
8- 34% of community dwelling
older people. Women 1.5 to 2 times rate of men
·
Only 25 – 50% with urinary
incontinence seek medical help
·
Physiology:
o Bladder fills at 25 – 125 ml/hr. Low pressure maintained by reflex arc ®
detrussor muscle inhibition
o Conscious sensation to void at 250 – 350 ml, normal capacity 400 – 600
ml
o Micturition co-ordinated by pontine micturition centre ®
parasympathetic nerves ® S2 to S4 ® relaxation of urethral sphincter muscles + contraction of detrussor
until < 30 ml left in bladder. Inhibition of pontine centre ® voiding.
·
Age related changes:
o Uninhibited
detrusor contractions
o Benign prostatic hypertrophy in men ® urinary outflow obstruction ® urinary
retention
o ¯Oestrogen
in women ® ¯ urethral sphincter function
o Miscellaneous: ¯bladder capacity, residual urine, nocturnal urine production
·
Impact of age related diseases:
o D: Drugs (diuretics, anticholinergic side effects ® ¯detrusor
contraction, sedatives) and Dementia (¯executive function)
o R: Retention of urine (eg prostate hypertrophy ®
retention ® bladder pressure sphincter pressure)
o I: Immobility (arthritis, etc), inflammation of bladder (asymptomatic
bacteruria), impaction of faeces
o P: Polyuria (Diabetes, heart failure)
·
Established urinary incontinence:
o Overactive detrussor: Detrussor Instability. Spontaneous contraction
when attempting to inhibit voiding (eg stroke, prostate disease) ®
frequency, nocturia, urgency, urge incontinence. = Blabber instability –
common. = Urge incontinence. Usually
no pathology found
o Under-active sphincter: If normal bladder then Genuine Stress
Incontinence (GSI). In small portion of men with prostate surgery, in women
more complex (childbirth trauma, ¯oestrogen, prolapse etc) ® momentary loss of small volume of urine with intra-abdominal pressure (eg
cough). Occurs in the absence of detrusor activity. Upper urethra slips through
the pelvic floor.
o Caused by childbirth, surgery, menopause (®atrophy
of urethral epithelium), masses, prolapse, pregnancy, etc
o Overactive sphincter: anticholinergics, neural damage or prostate
problems ® retention ® overflow incontinence
o Overflow incontinence: due to over-distended bladder (without detrusor
activity)
o Reflex Incontinence: involuntary loss due to abnormal spinal reflex
activity without the desire to void
·
Assessment:
o History: Screen all elderly people. „Have you ever lost control/wet
yourself „? Impact on function, proximity to toilets, fluid intake,
medications, etc
o Exam: neurological, esp. sacral nerve lesions, signs of stroke. Rectal
exam (eg sphincter tone, faecal impaction, prostate - although large prostate
size does not correlate to urethral obstruction), in women cough induced urine
leakage, mobility, eyesight, cognition
o Investigations: urinalysis to exclude infection, exclude polyuria due to
diabetes, urodynamic investigations (measuring micturition pressure and volume)
·
Management:
o Genuine stress incontinence: pelvic floor exercises, a
agonists, oestrogen, surgery
o Detrusor instability: bladder retraining, bladder relaxants, remove
obstruction
o Overflow: surgery to remove obstruction, intermittent/permanent catheter
o Other: schedule toileting, pads, etc
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