Urinary Frequency Tom Kincer, MD Program Director Clinical Professor of Medicine Montgomery Family Medicine Residency

11/30/2012

Urinary Frequency Tom Kincer, MD Program Director Clinical Professor of Medicine Montgomery Family Medicine Residency

 None

Disclosures

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 1:The learner should be able to identify the common causes of urinary frequency in a primary care practice.   2: The learner should be able to recognize the most appropriate treatments for the different causes of urinary frequency.   3: The learner should be able to recognize when a referral to a specialist is necessary.

Objectives

Male Bladder Anatomy

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Female Bladder Anatomy

 The urge to void is a spinobulbospinal reflex that is inhibited by higher brain centers, therefore being subject to voluntary control in a person with an intact neurological system.  Reflex contraction of the bladder is usually initiated from a urine volume of around 200- 400 ml but can be voluntarily overridden to a volume of around 800 ml.  Total bladder capacity is about 1500 ml.

Physiology of the Bladder

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 Sympathetic stimulation causes the internal urethral sphincter to contract and the detrusor muscle to relax for urine storage.  Alpha agonists such as pseudoephedrine have been used to improve leakage in Stress Incontinence.  Alpha antagonists, such as tamsulosin (Flomax), are used to improve urinary hesitancy from BPH.

Sympathetic Stimulation

 Parasympathetic stimulation causes the internal urethral sphincter to relax and the detrusor muscle to contract allowing you to Pee.  Bethanechol (Urecholine) is used to help void in atonic bladder.  Anticholinergics, such as oxybutynin (Ditropan), help the bladder to relax in Urinary Urge.  Diphenhydramine (Benadryl) and other antihistamines with anticholineric side effects may cause urinary retention especially in BPH.

Parasympathetic Stimulation

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 Number of urinations per day varies between four and twelve with an average of eight.  Normal nocturnal urination is zero to once.  Urinary Frequency can result from increased production of urine, overactivity of the bladder, small bladder capacity, urinary retention and irritation of the bladder.

Urinary Frequency

 Diabetes mellitus  Diuretic Therapy  Polydypsia  Diabetes Insipidus  Shifting volumes due to positioning such as nocturia from leg edema

Increased Urine Production

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 Urinary Urge  CNS disturbances: stroke, trauma to brain or spinal cord

Overactivity of the Bladder

 Detrusor hypertrophy from chronic outlet obstruction  Scarring post-bladder cancer  Scarring post-radiation  Chronic catheterization  Physiologically small  Pregnancy  Large Fibroid Tumors of the Uterus

Small Bladder Capacity

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 BPH  Neurogenic Bladder: DM, radiation, alcohol  Constipation  CNS lesions: MS, spinal trauma, Stroke  Medications: Anticholinergic side effects  Urethral Stricture  Bladder Stones

Urinary Retention

 Infection  Painful Bladder Syndrome/Interstitial Cystitis  Radiation  Bladder calculi

Irritation of the Bladder

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 Young Females: Infection, Painful Bladder Syndrome/Interstitial Cystitis  Older Females: Infection, Urge, DM, Medicines  Young Males: Infection (likely STD)  Older Males: BPH, Medicines  NH Population: not always infection. ◦ Female NH: Constipation, Infection, Stroke ◦ Male NH: BPH, Constipation, Stroke, Infection

Common Causes by Age/Sex

President: Allen Perkins, M.D. Chair: Tonya Bradley, M.D.

Executive Vice President: Jeffrey E. Arrington APR Membership Services: Lynn Woodruff

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 Urinary Urge  Special Considerations in BPH  Infections  Painful Bladder Syndrome/Interstitial Cystitis

Discussion of Specific Diseases

 Commonly called Overactive Bladder (OAB)  Urgency to urinate is the hallmark finding  Frequency and nocturia without signs or symptoms of infection or other causes  Caused by inappropriate contractions of the detrusor muscle.  More common in females, but don’t exclude males, and more common as we age.

Urinary Urge

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 Mainstay drugs are the anticholinergics: oxybutynin (Ditropan), tolterodine (Detrol), trospium (Sanctura), darifenacin (Enablex), solifenacin (Vesicare), fesoterodine (Toviaz)  Tricyclic antidepressants  Beta 3 adrenergic agonist: mirabegron (Myrbetriq) approved in July 2012  Estrogen

Treatment for Urge

 Benign Prostate Hypertrophy is a common finding in men as they age.  Symptoms include frequency, nocturia, urgency, difficulty starting a urine stream, weak stream and post-void dribbling.  As the prostatic obstruction worsens the detrusor muscle works harder and hypertrophies thus decreasing compliance and increasing involuntary contractions leading to a concomitant OAB and small bladder size.

Special Considerations in BPH

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 Treat early to avoid detrusor hypertrophy, OAB and decreased compliance.  Alpha 1 receptor antagonists: doxazosin (Cardura), prazosin (Minipress), and terazosin (Hytrin)  Prostate Specific Alpha 1A receptor antagonists: alfuzosin (Uroxatral), tamsulosin (Flomax)  5-Alpha Reductase Inhibitors: finasteride (Proscar) and dutasteride (Avodart)  PDE5 inhibitor: tadalafil (Cialis)

Treatment of BPH

 Common causes: E. coli, Staph saprophyticus, Proteus mirabilis, K. pneumonia, Enterococcus  Special Considerations ◦ STI’s: Chlamydia, GC, Trichomonas ◦ 80% of nosocomial UTI’s are related to catheters ◦ Yeast ◦ Opportunistic Bacteria: Pseudomonas, multidrug resistant gram negative bacteria  Asymptomatic Bacteriuria

Bladder Infections

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 Herpetic Cystitis  Adenovirus Cystitis  Schistosomiasis: ◦ More than 207 million people, 85% of who live in Africa, are infected, and an estimated 700 million people are at risk of infection in 76 countries where the disease is considered endemic ◦ 400,000 cases in U.S. annually.  Autoimmune cystitis ◦ SLE, RA, Sjogrens

Much less Common Infections and Autoimmune Cystitis

 Colonization of the urinary bladder with bacteria without clinical signs or symptoms of infection.  Common in patients with indwelling catheters, NH patients, neuromuscular diseases and older females.  USPSTF recommends not screening in the above groups.  Screening and treatment is recommended in pregnancy at 12 weeks due to increased incidence of pyelonephritis, IUGR and neonatal death.

Side Bar: Asymptomatic Bacteriuria

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 Symptoms of Painful Bladder Syndrome include urinary frequency, urgency, dysuria and suprapubic discomfort without demonstrable infection or other urological pathology for more than 6 weeks duration.  The diagnosis of IC is reserved for patients with characteristic cystoscopic and histologic features.

Painful Bladder Syndrome Interstitial Cystitis

 Likely separate pathological conditions  Most common in women 30-50 years of age, 94% are white, with a 10% occurrence in men  IC has ulcerations on the bladder epithelium (Ulcerative) or tiny raspberry-like lesions (Nonulcerative)  More likely in women who had gynecological surgery, childhood bladder problems, IBS, fibromyalgia, SLE and in patients with anxiety, depression and adjustment disorders

PBS/IC

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 Caffeine, alcohol, tomatoes, vinegar, spicy foods, chocolate  Sexual Intercourse  Stress  Exercise  Being seated for long periods of time

Exacerbation of Symptoms

 Suspicion based on history  UA with culture  Consider cervical swab for STI’s  Chemistries and CBC  Consider pelvic ultrasound  Cystoscopy

Workup for PBS/IC

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 Patient Education, ongoing reassurance and emotional support  Only rarely will patients have immediate and complete response to any form of treatment  Behavioral therapy and Biofeedback ◦ Some authors recommend 6 months of behavioral therapy prior to proceeding with medications.

Treatment of PBS/IC

 Pentosan polysulfate sodium (PPS; Elmiron®) ◦ Oral medication that takes up to 6 months to see effects. Not curative and rarely resolves all the pain.  Amitriptyline  Hydroxyzine  Dimethylsulfoxide (DMSO) ◦ Instilled directly into the bladder weekly.

Medications for PBS/IC

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 You are called because an 87 year old male patient with advanced dementia is noticed to have increased restlessness, decreased alertness and increased urinary frequency. The nurse checked a UA and it is reported as follows:  Spec Gr: 1.020, color-yellow, WBC-few, nitrite-negative, 2+ bacteria, no glucose or protein.  Thoughts and Concerns?

Patient Scenario 1

 Does the patient have a UTI? Unlikely since nitrite negative and few WBCs. Bacturiuria common in elderly.  Considerations for Symptoms: Urinary Retention due to constipation, BPH, medications.  Approach: bladder scan in available. If not, insert foley and check residual. Check for impaction. Review medication list.

Concerns-patient 1

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 A 24 year old female presents with 5 days of urinary frequency and dysuria. She has already taken 3 days of ciprofloxacin that she had left after a bladder infection a few weeks ago. She denies vaginal discharge or irritation.  Urinalysis: Spec. Grav. 1.012, Color- yellow, WBC’s 10-15, nitrate negative, bacteria-few, no protein or glucose  Thoughts and Considerations?

Patient Scenario 2

 Patient could have a partially treated common UTI.  Patient could have a resistant UTI due to having a previous, likely partially treated, UTI a few weeks ago.  Patient could have Chlamydia or Trichomonas Urethritis.  Approach: Obtain urine culture, finish 7 days of ciprofloxacin while awaiting culture. If culture shows resistant bacteria, change antibiotics. If culture is negative, consider testing for STIs.

Considerations Patient 2

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THE END

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