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Chapter: Medicine Study Notes : Renal and Genitourinary


Interstitial Cystitis, Bladder Tumours, Urinary Incontinence.



Interstitial Cystitis


·        Usually elderly patients

·        Urine sterile

·        If severe then intractable pain with decreasing bladder capacity

·        Microscopy ® ulcerative chronic cystitis

·        ?Viral aetiology


Bladder Tumours


Transitional Cell Carcinoma


·        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


Other Bladder Tumours


·        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


Urinary Incontinence


·        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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Medicine Study Notes : Renal and Genitourinary : Bladder |

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