Bladder, Urethral, and Penile Disorder - MedPath

What does this refer to

• Storage and voiding phases

• Detrusor muscle and sphincter coordination

Normal Bladder Function

What does this refer to

• Chronic syndrome of detrusor overactivity

• Symptom syndrome of urgency, with or without urge incontinence; usually associated with urgency, frequency and nocturia

• Urodynamic evaluation: To confirm diagnosis

  • Detrusor overactivity on urodynamics

Overactive bladder syndrome (OAB)

What does this refer to

• Lifestyle modifications

• Behavioral therapy, neuromodulation

• Pharmacotherapy (antimuscarinic agents); botulinum toxin therapy; surgery

Treatment for Overactive Bladder Syndrome

What does this refer to

• Weak detrusor contraction or outlet obstruction

• Bladder contraction of reduced strength and/or duration

  • Prolonged bladder emptying or incomplete bladder emptying, or both

• Caused by spinal cord injury, stroke, multiple sclerosis, Parkinson disease, diabetic neuropathy, aging

• Symptoms of weak stream, intermittency, hesitancy, straining

• Treatment includes sacral neuromodulation, drugs.

Underactive bladder syndrome (UAB)

What does this refer to

• Bladder dysfunction caused by neurologic disorders (CNS or PNS); problems with urine storage or voiding

• Affects detrusor contractility and sphincter tone

• Upper motor neurons

  • Dyssynergia: Overactive or hyperreflexive bladder function

  • Detrusor hyperreflexia: Uninhibited or reflex bladder

  • Detrusor-sphincter dyssynergia

    • Detrusor hyperreflexia with vesicosphincter (detrusor sphincter) dyssynergia: Both the bladder and the sphincter are contracting at the same time, causing a functional obstruction of the bladder outlet

  • Spastic bladder, small capacity, frequent voids

Neurogenic bladder

What does this refer to

• Lower motor neurons

  • Detrusor areflexia: Underactive, hypotonic, or atonic bladder

  • Flaccid detrusor

    • Large capacity, urinary retention, overflow incontinence

Neurogenic Bladder

What does this refer to

• Frequent daytime voiding: More often than every 2 hours while awake

• Nocturia: Night-time voiding

• Urgency: Often combined with hesitancy

• Dysuria

• Poor force of stream; intermittency of urinary stream

• Feelings of incomplete bladder emptying, despite micturition

Clinical manifestations of Neurogenic Bladder

What does this refer to

• Detrusor sphincter dyssynergia

  • α-adrenergic blocking (antimuscarinic) medications or botulinum toxin

  • Intermittent catheterization in combination with higher dose antimuscarinic drugs

  • Condom catheter containment, supplemented by anα-adrenergic blocking drug or transurethral sphincterotomy (surgical incision of the striated sphincter)

• Obstruction

  • Medication

  • Bladder neck incision

• Low bladder wall compliance

  • Antimuscarinic drugs and intermittent catheterization

  • Severe cases: Augmentation enterocystoplasty (enlargement of bladder wall using a detubularized piece of small bowel), urinary diversion, or long-term indwelling catheterization

Treatment of Neurogenic Bladder

What does this refer to

• Acute or chronic

• Causes: obstruction, meds, neurogenic

Urinary retention

What does this refer to

• Stress, urge, overflow, functional

• Mixed patterns common

Urinary Incontinence Types

What does this refer to

• Pessary: Rubber or silicone device designed to compensate for vaginal wall prolapse

• Intravaginal hormone replacement therapy and regular follow-up

• Surgery

Pelvic organ prolapse

What does this refer to

• Prostatic enlargement, strictures

• Impaired flow, incomplete emptying

Bladder Outlet Obstruction

What does this refer to

• Chronic pain syndrome

• Bladder hypersensitivity, urgency

  • Exact etiology unknown, probably multifactorial including inflammation, hypersensitivity, pelvic floor tension

  • Symptoms of cystitis for longer than 6 weeks’ duration, but with negative urine cultures and no other known cause

  • Treatment

    • Oral and intravesical therapies, sacral nerve stimulation, onabotulinumtoxinA; surgery

Painful bladder syndrome/interstitial cystitis

What does this refer to

• Inflammation of the bladder

• Acute or chronic

• Clinical manifestations

  • Asymptomatic

  • Frequency, dysuria, urgency, and low back and/or suprapubic pain

• Evaluation

  • Urine culture of specific microorganisms with counts of 10,000/mL or more

• Treatment

  • Antimicrobial therapy

Cystitis

What does this refer to

• Most common pathogens

  • Escherichia coli

  • Staphylococcus saprophyticus

• Virulence of uropathogens

  • Ability to evade or overwhelm the host defense mechanisms and cause disease in a host

  • Adherence to the uroepithelium

    • Have pili or fimbriae or both

  • Ability to resist the host’s defense mechanisms

    • Biofilms

Urinary Tract Infection

What does this refer to

• Sulfamethoxazole/Trimethoprim (Bactrim) DS po BID

• Nitrofurantoin (Macrobid) 100mg po BID

• Fosfomycin (Monurol) 3 gram as a single dose

First line for UTI

What does this refer to

• Ciprofloxacin (Cipro) 250mg po BID

• Levofloxacin (Levaquin) 250mg po daily

Second line Fluoroquinolones for UTI

What does this refer to

• Amoxicillin/Clavulanate (Augmentin) 500/125mg po BID

• Cefdinir (Omnicef) 300mg po BID

Second Line– Beta-lactams for UTI

What does this refer to

• Form in setting of urinary stasis

• May cause hematuria, infection

Bladder Stones

What does this refer to

• Urothelial (transitional cell) carcinoma: Most common

• Risk factors

  • Smoking

  • Aromatic amines, e.g. aniline dyes

  • Arsenic in drinking water

  • Phenacetin

  • Cyclophosphamide

  • Pioglitazone

• Oncogenes of the ras gene family and tumor-suppressor genes including TP53 mutations

• Inactivation of retinoblastoma gene (pRb)

• Loss of heterozygosity at Chromosome 9

Bladder tumors

What does this refer to

• Painless microscopic hematuria

• Papillary vs. flat lesions

Clinical manifestations of bladder tumors

What does this refer to

• Transurethral resection or laser ablation, combined with intravesical chemotherapy or immunotherapy

• Radical cystectomy with urinary diversion

• Adjuvant chemotherapy

• Radiation therapy

• Cisplatin-based combination chemotherapy

Treatment of bladder tumors

What does this refer to

• Male vs. female length and segments

• Important for infection/spread

Urethral Anatomy

What does this refer to

• Inflammation of the urethra usually but not always caused by a STD

  • Nonsexual origins can be due to urologic procedures, anatomic abnormalities, or trauma

• Pain, discharge, dysuria

Urethritis Pathophysiology

What does this refer to

• GC: abrupt, purulent

• NGU: chlamydia, mycoplasma

Gonococcal vs. Nongonococcal Urethritis

What does this refer to

• Fibrotic narrowing of urethra caused by scarring

• Commonly due to

  • Trauma

  • Untreated or severe urethral infections

  • Urinary catheters

Urethral strictures

What does this refer to

• Collagen deposition, fibrosis

• Reduced urinary flow, retention

Stricture Pathophysiology

What does this refer to

• Rare, often squamous

• Risk: chronic inflammation, STIs

Urethral Carcinoma

What does this refer to

• Female dysuria-frequency syndrome

• No proven infection, linked to irritation

Urethral Syndrome

What does this refer to

• Corpora cavernosa, corpus spongiosum

• Tunica albuginea, glans, urethra

Penile Anatomy Overview

What does this refer to

• Penile foreskin (prepuce) is “too tight”

• Phimosis

  • Inability to retract foreskin from the glans of the penis (distal to proximal)

• Paraphimosis

  • Inability to replace or cover the glans with the foreskin (proximal to distal)

• Frequently caused by poor hygiene or chronic infections

Disorders of the penis

What does this refer to

Balanitis

What does this refer to

• Prolonged erection (>4h)

• Ischemic vs. non-ischemic types

Priapism Pathophysiology

What does this refer to

• Low flow, painful, emergency

• Risk: sickle cell, medications

Ischemic Priapism

What does this refer to

• High flow, less painful

• Often post-trauma

Non-Ischemic Priapism

What does this refer to

• Tearing of tunica during trauma

• Audible pop, swelling, detumescence

Penile Fracture

What does this refer to

• Slow development of fibrous plaques (thickening) in the tunica albuginea, causing lateral curvature of penis during erection

• Occurs in middle-aged men and causes painful erections and intercourse

Peyronie disease

What does this refer to

• STI-related (HSV, syphilis) vs. non-infectious

• Evaluate based on pain and appearance

Penile Ulcers

What does this refer to

• Carcinoma of the penis is rare

• Mostly squamous cell carcinomas

• HPV, smoking

• Often diagnosed in men older than age 55

Penile cancer (Malignancy)

What does this refer to

• HPV 16/18, chronic inflammation

• Commonly begins as lesion on glans

Penile Cancer Pathophysiology

What does this refer to

• Neurogenic, vascular, psychogenic causes

• May signal cardiovascular disease

Penile Disorders: Erectile Dysfunction Overview

What does this refer to

• Nitric oxide-cGMP pathway impaired

• Vascular insufficiency, nerve damage

Penile Disorders: Erectile Dysfunction Pathophysiology