Obstructive voiding: -Weak stream -Incomplete bladder emptying and urinary retention -Dysuria -Ejaculatory dysfunction UTI, bladder stones. Urinary spraying. Urethral Stricture Clinical Manifestations Urethral Prolapse Clinical Manifestations Urge Incontinence (Overactive Bladder) Urethral Mass Differential Diagnosis

Urethral Stricture Clinical Manifestations

To establish Dx, location, and length of stricture: Retrograde urethrogram*** PLUS Voiding cystourethrogram (VCUG) *** And/or Cystourethroscopy +/- biopsy. US or MRI urethrography Urethral Strictures Diagnostic Studies Urge Incontinence Treatment Urethral Prolapse Pelvic Organ Prolapse Pelvic Exam

Urethral Strictures Diagnostic Studies

Prepubertal girls; Menopausal women Urethral prolapse is most common in ____ and ____ BPH Surgical Treatment Mixed Incontinence Urethral Stricture Treatment

Urethral prolapse is most common in ____ and ____

Incidental finding Vaginal spotting or bleeding Donut-shaped protrusion around urethral opening --> confirmed w/ visualization of urine from meatus or into catheter Pelvic Organ Prolapse Symptoms Brain initiates urination sending signals to....... Urethral Prolapse Clinical Manifestations Pelvic Organ Prolapse Treatment

Urethral Prolapse Clinical Manifestations

Consider sexual trauma in children. Urethral or vaginal malignancy . Urethral caruncle. Ectopic ureterocele. Condyloma. Rhabdomyosarcoma. Stress Incontinence Treatment Urethral Mass Differential Diagnosis Urethral Prolapse Treatment Stress Incontinence

Urethral Mass Differential Diagnosis

UA w/ micro, urine C&S. NAAT testing for STD. +/- biopsy (sarcoma). +/- voiding cystourethrogram. Urethral Prolapse Diagnostic Studies Stress Incontinence Surgical Treatment Urethral Strictures Diagnostic Studies Urethral Stricture Clinical Manifestations

Urethral Prolapse Diagnostic Studies

Gen Med - Urethral and Bladder Disorders

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Medicine - Urology

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Narrowing of the urethra by scar tissue.

Iatrogenic Procedures (TURP, cystoscopy, catheter) Trauma Urethritis Malignancy. Radiation therapy Lichen sclerosus.

Obstructive voiding: -Weak stream -Incomplete bladder emptying and urinary retention -Dysuria -Ejaculatory dysfunction UTI, bladder stones. Urinary spraying.

To establish Dx, location, and length of stricture: Retrograde urethrogram*** PLUS Voiding cystourethrogram (VCUG) *** And/or Cystourethroscopy +/- biopsy. US or MRI urethrography

Emergent bladder decompression --> suprapubic or urethral catheter Endoscopic dilation w/ balloons or dilators Permanent urethral stents Incision urethrotome cold knife, electrocautery, or laser. Urethral reconstruction. Urinary diversion.

Circumferential protrusion of the distal urethra through the external urethral meatus

Prepubertal girls; Menopausal women

Incidental finding Vaginal spotting or bleeding Donut-shaped protrusion around urethral opening --> confirmed w/ visualization of urine from meatus or into catheter

Consider sexual trauma in children. Urethral or vaginal malignancy . Urethral caruncle. Ectopic ureterocele. Condyloma. Rhabdomyosarcoma.

UA w/ micro, urine C&S. NAAT testing for STD. +/- biopsy (sarcoma). +/- voiding cystourethrogram.

Topical estrogen cream 0.01% BID x 2 weeks. Prevent constipation. Refer to pediatric urologist. Hygiene Sitz baths +/- topical antibiotics and steroids if indicated Surgical reduction

Strangulated or necrotic tissue. Stenosis. Stricture. Urinary retention.

Abnormal descent or herniation of the pelvic organs to/beyond the pelvic wall: -Bladder. -Vagina. -Uterus. -Rectum. -Intestine.

Parity Vaginal delivery. Menopause/age.

Loss of connective tissue or muscular support of the pelvic floor secondary to tearing/stretching Anterior vaginal wall MC --> bladder/cystocele

Asymptomatic Sensation or visible bulge/protrusion Pelvic pressure, heaviness Urinary dysfunction Bowel dysfunction

Bulging tissue upon valsalva. Bimanual to r/o mass. Pelvic floor squeeze strength with 2 fingers.

Urinary tract evaluation -UA, BMP, post-void residual volume Bowel function --> make sure its not compressing anything

Symptomatic urinary, bowel, or sexual dysfunction.

Reduce risk factors Pelvic floor muscle exercises Pessary -Silicone or latex device inserted into the vagina; provides support +/- estrogen therapy. Surgery

Conditions affecting the brain or spinal cord Pregnancies, vaginal deliveries Prostate surgery DM, CKD, obesity, UTIs Increased alcohol or caffeine intake

Detrusor muscles to contract via the parasympathetics. Internal/external sphincters to relax via the sympathetics

Normal: < 50 mL Elderly: < 50-150 acceptable > 150-250 abnormal

Urge. Stress. Overflow. Mixed. Functional.

Sudden and unexpected need to void urine due to detrusor muscle overactivity MC > 65 y/o "Gotta go!"

Cystitis. MS. CVA. Parkinson's. BPH.

Leakage due to abrupt increase in IAP, urethral sphincter insufficiency, and weak pelvic floor muscles MC < 65 y/o

Pregnancy. Childbirth. Constipation. Obesity.

Bladder overdistention due to detrusor inactivity (neuro) or bladder outlet obstruction (prostate) Continuous leakage w/o urge to urinate or sensation of fullness Dribbling MC type in men.

Enlarged prostate MC.

Involuntary urine loss due to cognitive, functional, or mobility impairments.

Urge + stress OR Urge, stress, and functional.

UA, C&S Bladder stress test Post-void residual by bladder US or catheterization As indicated: -Glucose if polyuria -Electrolytes if pt. confused -PSA -Refer for urodynamic testing

Diuretics. CCBs. Morphine. Pseudoephedrine. Dyphenhydramine. Haldol. Risperidone.

Limit fluid before going out or 3-4 hr before bed Avoid bladder irritants -caffeine, ETOH, soda Incontinence bed pads Incontinence pads/undergarments Treat specific cause: -Obesity -Infection -BPH -Menopause/Vaginal atrophy -Constipation -Smoking cessation

Avoid exacerbating activity Ex. Jumping Pelvic Floor Exercises/Strengthening Pessary Vaginal estrogens Urethral bulking agents --> makes the seal stronger +/- Duloxetine

Surgery allows urethral sphincter muscles to close properly: Mid-urethral sling Prolapse repair

Bladder training --> ignore urge, timed urination Pelvic floor exercises Beta-3-receptor agonists and/or antimuscarinic drugs

Mirabegron (Myrbetriq). Vibegron (Gemtesa).

Oxybutynin (Ditropan, Oxytrol) Tolterodine (Detrol) Trospium (Sanctura) Solifenacin (VESIcare) Darifenacin (Enablex) Fesoterodine (Toviaz)

Treat underlying condition D/C meds that impair detrusor activity Ex. Anticholinergics, antihistamines, decongestants, analgesics, opioids

Sacral nerve stimulation. Indwelling or intermittent catheter. Condom catheter. Suprapubic catheter. Urinary diversion.

Alpha-1-receptor agonists. 5-alpha-reductase inhibitors. PDE-5 inhibitors. Beta-3-adrenergic agonists. Anticholinergics/antimuscarinics

TURP. Prostatectomy. Robotic resection.

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