4. What is
UrinaryTract
Infection?
– In healthy people, urine in the bladder is sterile
– No bacteria or other infectious organisms are present
– The tube that carries urine from the bladder out of the body
(urethra) contains no bacteria or too few to cause an infection.
– Any part of the urinary tract can become infected; this is called a urinary
tract infection (UTI)
– UTIs are usually classified as upper or lower according to where they
occur along the urinary tract
– Sometimes difficult or impossible for doctors to determine
– Lower UTIs: Infections of the bladder (cystitis)
– Upper UTIs: Infections of the kidneys (pyelonephritis)
– Infections of the urethra (urethritis) and prostate (prostatitis) are
sometimes considered lower UTIs
– In kidneys, infection can occur in one or both organs
– UTIs can occur in children as well as in adults
5. Causes
– Organisms that cause infection usually enter the urinary tract by
one of two routes:
– Most common route is through the lower end of the urinary
tract
– Opening of urethra à infection ascends the urethra to the
bladder, kidneys, or both.
– Other possible route is through the bloodstream, usually to the
kidneys
– Urinary tract infections (UTIs) are almost always caused by
bacteria, although some viruses, fungi, and parasites can infect the
urinary tract as well
– More than 85% of UTIs are caused by bacteria from the intestine or
vagina
– Usually, bacteria that enter the urinary tract are washed out by the
flushing action of the bladder as it empties
6. Causes -
Bacteria
– Bacterial infections of the lower urinary tract (usually bladder) are
very common
– Especially among young, sexually active women
– Young women also often get bacterial kidney infections, less
commonly than bladder infection
– Escherichia coli is the most common bacteria to cause a UTI
– For people between the ages of 20 and 50, bacterial UTIs are 50x
more common among women than men
– In men, the urethra is longer, so it is more difficult for bacteria to
ascend far enough to cause an infection
– In men between the ages of about 20 to 50, most UTIs are
urethritis or prostatitis
– In people older than 50, UTIs become more common among
both men and women, with less difference between the sexes
7. Causes –
Viruses &
Fungi
– Herpes simplex virus may infect the urethra, making urination
painful and emptying of the bladder difficult
– Other viral UTIs, such as bladder and kidney infections, do not
usually develop unless a person's immune system is impaired (by
cancer, HIV/AIDS, drug that suppresses the immune system)
– Certain fungi or yeasts can infect the urinary tract
– This type of infection is often called a yeast infection
– Yeasts can also cause inflammation of the vagina (vaginitis)
– The fungus Candida is the organism most likely to cause urinary
tract yeast infections (candidiasis)
– Candida frequently infects people who have an impaired immune
system or a bladder catheter in place
– Fungi and bacteria may infect the kidneys at the same time
8. Causes -
Parasites
– A number of parasites, including certain types of worms, can infect the
urinary tract
– Trichomoniasis
– Caused by a type of microscopic parasite
– Sexually transmitted disease that can cause greenish yellow, frothy
discharge from the vagina in women
– Occasionally, the bladder or urethra becomes infected
– Trichomoniasis can infect the urethra in men but usually causes no
symptoms in men
– Schistosomiasis
– Caused by a type of worm called a fluke
– Can affect the kidneys, ureters, and bladder
– Common cause of severe kidney failure among people who live in
Africa, South America, and Asia
– Persistent bladder schistosomiasis often causes blood in the urine or
blockage of the ureters and may eventually result in bladder cancer
9. Causes -
Parasites
– Filariasis
– A threadworm infection
– Obstructs lymphatic vessels, causing lymph fluid to enter the
urine (chyluria).
– Filariasis can cause enormous swelling of tissues (elephantiasis),
which may involve the scrotum in men
10. Risk Factors
– Urinary tract infections are common in women, and many women
experience more than one infection during their lifetimes
– Risk factors specific to women for UTIs include:
– Female anatomy: women have shorter urethras than men, which
shortens the distance that bacteria must travel to reach the bladder
– Sexual activity: sexually active women tend to have more UTIs than
those who are not; having new sexual partners also increases risk
– Certain types of birth control: women who use diaphragms for birth
control may be at higher risk, as well as women who use spermicidal
agents
– Menopause: after menopause, decline in circulating estrogen causes
changes in the urinary tract that make you more vulnerable to infection
11. Risk Factors –
Other Risk
Factors
– Urinary tract abnormalities: babies born with urinary tract
abnormalities that don't allow urine to leave the body normally or
cause urine to back up in the urethra
– Blockages in the urinary tract: kidney stones or an enlarged
prostate can trap urine in the bladder
– A suppressed immune system: diabetes and other diseases that
impair the immune system
– Catheter use: people who can't urinate on their own and use a tube
(catheter) to urinate have an increased risk of UTIs
– Includes people who are hospitalized, people with neurological
problems that make it difficult to control their ability to urinate
and people who are paralyzed
– A recent urinary procedure: urinary surgery or an exam of your
urinary tract that involves medical instruments
12. Symptoms
andSigns
– Urinary tract infections don't always cause signs and symptoms,
but when they do they may include:
– A strong, persistent urge to urinate
– A burning sensation when urinating
– Passing frequent, small amounts of urine
– Urine that appears cloudy
– Urine that appears red, bright pink or cola-colored (sign of
blood in the urine)
– Strong-smelling urine
– Pelvic pain, in women
– Center of the pelvis and around the area of the pubic
bone
13. Types ofUTIs
Part of UrinaryTract Infected Signs and Symptoms
Kidneys (acute pyelonephritis) • Upper back and side (flank)
pain
• High fever
• Shaking and chills
• Nausea
• Vomiting
Bladder (cystitis) • Pelvic pressure
• Lower abdomen discomfort
• Frequent, painful urination
• Blood in urine
Urethra (urethritis) • Burning with urination
• Discharge
14. Complications
– Recurrent infections, especially in women who experience
two or more UTIs in a six-month period or four or more
within a year
– Permanent kidney damage from an acute or chronic kidney
infection (pyelonephritis) due to an untreated UTI
– Increased risk in pregnant women of delivering low birth
weight or premature infants
– Urethral narrowing (stricture) in men from recurrent
urethritis, previously seen with gonococcal urethritis
– Sepsis (potentially life-threatening complication of an
infection)
– Especially if the infection works its way up your urinary
tract to your kidneys
15. Diagnosis
– Analyzing a urine sample
– Urine sample for lab analysis to look for white blood
cells, red blood cells or bacteria
– Growing urinary tract bacteria in a lab
– Lab analysis of the urine is sometimes followed by a
urine culture
– Tells your doctor what bacteria are causing your
infection and which medications will be most effective
16. Diagnosis
– Creating images of your urinary tract
– If you are having frequent infections that your doctor thinks
may be caused by an abnormality in your urinary tract, you
may have an ultrasound, a computerized tomography (CT)
scan or magnetic resonance imaging (MRI)
– Using a scope to see inside your bladder
– If you have recurrent UTIs, your doctor may perform a
cystoscopy
– Use a long, thin tube with a lens (cystoscope) to see inside
your urethra and bladder
– Cystoscope is inserted in your urethra and passed through to
your bladder
17. Treatment
– Antibiotics usually are the first line treatment for urinary tract
infections
– Specific drugs prescribed and duration depend on health
condition and the type of bacteria found in your urine
Simple infection
– Trimethoprim/sulfamethoxazole (Bactrim, Septra, others)
– Fosfomycin (Monurol)
– Nitrofurantoin (Macrodantin, Macrobid)
– Cephalexin (Keflex)
– Ceftriaxone
18. Treatment
– Group of antibiotics called fluoroquinolones (e.g. ciprofloxacin
(Cipro), levofloxacin) isn't commonly recommended for simple
UTIs
– Risks of these medicines generally outweigh the benefits for
treating uncomplicated UTIs
– Often, symptoms clear up within a few days of treatment
– May need to continue antibiotics for a week or more; take the
entire course of antibiotics as prescribed
– For an uncomplicated UTI in an otherwise healthy patient, the
doctor may recommend a shorter course of treatment, such as
taking an antibiotic for 1-3 days
– Doctor may also prescribe a pain medication (analgesic) that
numbs your bladder and urethra to relieve burning while urinating
19. Treatment
Frequent infections
– For frequent UTIs, treatment may include:
– Low-dose antibiotics, initially for six months but
sometimes longer
– Self-diagnosis and treatment
– A single dose of antibiotic after sexual intercourse if
infections are related to sexual activity
– Vaginal estrogen therapy if postmenopausal
Severe infection
– For a severe UTI, may need treatment with intravenous
antibiotics in a hospital
21. What is
Urinary
Incontinence?
– Incontinence can occur in both men and women at any age, but it
is more common among women and older people
– 30% of older women and 15% of older men
– Although incontinence is more common among older people, it is
not a normal part of aging
– Incontinence may be sudden and temporary (e.g. person taking a
drug that has a diuretic effect) or it may be long lasting/chronic
– Even chronic incontinence may sometimes be relieved
22. Causes
– Several mechanisms can lead to urinary incontinence; more than
one mechanism may be present:
– Weakness of the urinary sphincter or pelvic muscles (called
bladder outlet incompetence)
– Something blocking the exit path of urine from the bladder
(called bladder outlet obstruction)
– Spasm or overactivity of the bladder wall muscles (sometimes
called overactive bladder)
– Weakness or underactivity of the bladder wall muscles
– Poor coordination of the bladder wall muscles with the urinary
sphincter
– An increase in the volume of urine
– Functional problems
23. Causes
– Weakness or underactivity of the bladder wall muscles, bladder outlet
obstruction, or particularly both can lead to inability to urinate (urinary
retention)
– Urinary retention can lead to overflow incontinence because of leaking
from an overly full bladder
– An increase in the volume of urine (e.g. caused by diabetes, use of diuretics,
or excessive intake of alcohol or caffeinated drinks) can:
– Increase the amount of urine lost to incontinence
– Trigger an episode of incontinence
– Cause temporary incontinence to develop
– Should NOT cause chronic incontinence
– Overall, the most common causes of incontinence are
– Overactive bladder in children and young adults
– Pelvic muscle weakness in women as a result of childbirth
– Bladder outlet obstruction in middle-aged men
– Functional disorders such as stroke and dementia in older people
24. Summary of
Causes
Temporary urinary incontinence
– Certain drinks, foods and medications may act as diuretics,
stimulating the bladder and increasing urine volume:
– Alcohol
– Caffeine
– Carbonated drinks and sparkling water
– Artificial sweeteners
– Chocolate
– Chili peppers
– Foods that are high in spice, sugar or acid, especially citrus
fruits
– Heart and blood pressure medications, sedatives, and muscle
relaxants
– Large doses of vitamin C
– Urinary incontinence may also be caused by an easily treatable
medical condition, such as:
25. Summary of
Causes
– Urinary tract infection: infections can irritate the bladder à
strong urges to urinate and incontinence
– Constipation: rectum is located near the bladder and shares
many of the same nerves
– Hard, compacted stool in your rectum causes these nerves
to be overactive and increase urinary frequency
26. Summary of
Causes
Persistent urinary incontinence
– Urinary incontinence can also be a persistent condition caused by
underlying conditions such as:
– Pregnancy: hormonal changes and the increased weight of the fetus à
stress incontinence
– Childbirth: vaginal delivery can weaken muscles needed for bladder control
and damage bladder nerves and supportive tissue à dropped (prolapsed)
pelvic floor
– With prolapse, the bladder, uterus, rectum or small intestine get
pushed down from the usual position and protrude into the vagina à
incontinence.
– Changes with age: aging of the bladder muscle can decrease the bladder's
capacity to store urine
– Involuntary bladder contractions become more frequent as you get
older
– Menopause: women produce less estrogen, a hormone that helps keep the
lining of the bladder and urethra healthy
– Deterioration of these tissues can aggravate incontinence
27. Summary of
Causes
Persistent urinary incontinence
– Enlarged prostate: older men, incontinence stems from
enlargement of the prostate gland (benign prostatic hyperplasia)
– Prostate cancer: stress incontinence or urge incontinence can be
associated with untreated prostate cancer
– More often, incontinence is a side effect of treatments for prostate
cancer
– Obstruction: tumor anywhere along your urinary tract can block
the normal flow of urine, leading to overflow incontinence
– Urinary stones (hard, stonelike masses that form in the bladder)
sometimes cause urine leakage
– Neurological disorders: multiple sclerosis, Parkinson's disease, a
stroke, a brain tumor or a spinal injury can interfere with nerve
signals involved in bladder control à urinary incontinence
28. Risk Factors
– Gender: women are more likely to have stress incontinence
– Pregnancy, childbirth, menopause and normal female anatomy
account for this difference
– Men who have prostate gland problems are at increased risk of
urge and overflow incontinence
– Age: older age à muscles in your bladder and urethra lose some of
their strength
– Changes with age reduce how much your bladder can hold and
increase the chances of involuntary urine release
– Being overweight: extra weight increases pressure on your bladder
and surrounding muscles, which weakens them and allows urine to leak
out when you cough or sneeze
– Smoking: tobacco use may increase your risk of urinary incontinence
– Family history: close family member has urinary incontinence,
especially urge incontinence
– Some diseases: neurological disease or diabetes
29. Types of
Incontinence/Signs
andSymptoms
– Urge incontinence is uncontrolled urine leakage (of moderate to large
volume) that occurs immediately after an urgent, irrepressible need to
urinate
– Needing to urinate during the night (nocturia) and nocturnal
incontinence are common
– Stress incontinence is urine leakage due to abrupt increases in intra-
abdominal pressure (e.g. occur with coughing, sneezing, laughing,
bending, or lifting)
– Leakage volume is usually low to moderate
– Overflow incontinence is dribbling of urine from an overly full bladder
– Volume is usually small, but leaks may be constant, resulting in large
total losses
– Functional incontinence is loss of urine because of a problem with
thinking or a physical impairment unrelated to the control of urination
– Example: a person with dementia due to Alzheimer disease may not
recognize the need to urinate or not know where the toilet is
– Mixed incontinence: people who have more than one type of incontinence
30. Complications
– Skin problems: rashes, skin infections and sores can
develop from constantly wet skin
– Urinary tract infections: incontinence increases risk of
repeated urinary tract infections
– Impacts on your personal life: urinary incontinence
can affect social, work and personal relationships
31. Diagnosis
– Urinary incontinence usually does not indicate a disorder
that is life threatening
– Incontinence may cause embarrassment or lead people
to restrict their activities unnecessarily à decline in
quality of life
– Rarely, sudden incontinence can be a symptom of a
spinal cord disorder
Warning signs
– In people with urinary incontinence, certain symptoms and
characteristics are cause for concern
– Symptoms of spinal cord damage
– Weakness in the legs
– Loss of sensation in the legs or around the genitals or
anus
32. Diagnosis
– Doctors first ask questions about the person's symptoms and
medical history, then do a physical examination
– Results suggests a cause of the incontinence and the tests that
may need to be done
– Doctors may ask:
– Circumstances of urine loss, including amount, time of day, and
any precipitating factors (such as coughing, sneezing, or
straining)
– Whether they can sense the need to urinate and, if so, whether
the sensation is normal or comes with sudden urgency
– Estimate the amount of urine leakage
– Whether the person has any additional problems with urination,
such as pain or burning during urination, a frequent need to
urinate, difficulty starting urination, or a weak urine stream
33. Diagnosis
– Sometimes patients keep a record of their urination habits over a day
or two (voiding diary)
– Each time the person urinates, the volume and time are recorded
– After an episode of incontinence, the person also records any
related activities, especially eating, drinking, drug use, or sleep
– Doctors ask about:
– Whether the person has other disorders that are known to cause
incontinence, such as dementia, stroke, urinary tract stones,
spinal cord or other neurologic disorders, and prostate disorders
– Drugs that a person is taking because (some drugs cause or
contribute to incontinence)
– For women, the number and types of deliveries and any
complications
– For all, previous pelvic and abdominal surgery, particularly
prostate surgery in men
34. Diagnosis
– Physical examination can help doctors narrow possible causes
– Doctors test strength, sensation and reflexes in the legs, and sensation
around the genitals and anus to detect nerve and muscle problems that
may make it difficult for the person to remain continent
– In women, doctors do a pelvic examination to detect abnormalities that could
cause incontinence, such as vaginal atrophy (menopausal change, lining of the
vagina becomes thinner, drier, and less elastic) or weakness of pelvic muscles
– In men and women, doctors do a rectal examination to look for signs of
constipation or damage to the nerves supplying the rectum
– In men, the rectal examination allows doctors to check the prostate because an
enlarged prostate or occasionally prostate cancer can contribute to incontinence
– Patient may be asked to cough with a full bladder to detect whether stress
incontinence is present
– Women may be asked to repeat this procedure during a pelvic examination, to
see whether supporting some pelvic structures (with the doctor's fingers)
eliminates the leak of urine
35. Diagnosis -
Tests
– Findings during the physical examination can help doctors
determine the cause or identify factors that contribute to
incontinence
– Some tests are often needed so doctors can make a firm diagnosis
– Routinely obtained tests include
– Urinalysis and urine culture
– Blood tests of kidney function and sometimes others
– Postvoid residual volume
– Catheter or ultrasonography probe is used to determine
how much urine is left in the bladder after a person
urinates
– Sometimes urodynamic testing
36. Diagnosis
Urodynamic testing includes cystometry, urinary flow rate testing, and
cystometrography and is done when clinical evaluation and the above tests
do not reveal the cause of incontinence
– Cystometry: confirm urge incontinence and to determine whether the
cause is overactive bladder
– Bladder catheter is placed through the urethra; measures how much water
can be injected into the bladder until the person develops a sense of
urgency or bladder contractions
– Peak urinary flow rate is measured in men to determine whether
incontinence is caused by bladder outlet obstruction (prostate disease)
– Men urinate into a special device (uroflowmeter) that measures the speed
of urine flow and how much urine is released
– Cystometrography: if all other evaluation fails to reveal the cause of
incontinence
– Test that measures bladder pressures when the bladder is filled with
various volumes of water
– Often done with electromyography, a test that can assess sphincter
function
37. Treatment –
General
Measures
– Regardless of the type and cause of incontinence, some general measures are
usually helpful.
– Modifying fluid intake
– Bladder training
– Pelvic muscle exercises
– Fluid intake can be limited at certain times (e.g. 3 to 4 hours before bedtime
– Avoid fluids that irritate the bladder (such as caffeine-containing fluids)
– People should drink 1.5-2 L of fluid a day because concentrated urine
irritates the bladder
– Bladder training: technique that involves having the person follow a fixed
schedule for urination while awake
– Establish a schedule of urinating every 2 to 3 hours and suppressing the
urge to urinate at other times (for example, by relaxing and breathing
deeply)
– As the person becomes better able to suppress the urge to urinate, the
interval is gradually lengthened
– A similar technique, called prompted voiding, can be used by people who
care for a person with dementia or other cognitive problems
38. Treatment –
General
Measures
– Pelvic muscle exercises (Kegel exercises): effective, especially
for stress incontinence
– People exercise the muscles around the urethra and rectum
that stop the flow of urine
– Muscles are tightly squeezed for 1 to 2 seconds and then
relaxed for about 10 seconds; exercises are repeated about
10 times three times each day
– People are gradually able to increase the time the muscles
are tightly squeezed until the contraction is held for about 10
seconds each time
39. Treatment
Urge incontinence
– Goal is to relax the bladder wall muscles
– Bladder training, Kegel exercises, and relaxation techniques are
tried first
– With the urge to urinate, the person can try relaxing, standing in
place or sitting down, or tightening the pelvic muscles
– Most commonly used drugs are oxybutynin and tolterodine
– Newer drugs include mirabegron, fesoterodine, solifenacin,
darifenacin, and trospium
– If ineffective, further treatments can be tried:
– Gentle electrical stimulation of the sacral nerves by a device
similar to a pacemaker, instillation of chemicals into the
bladder or surgery
40. Treatment
Stress incontinence
– Treatment begins with bladder training and Kegel exercises
– Avoiding physical stresses that cause loss of urine (e.g. heavy lifting) and
losing weight may help control incontinence
– Pseudoephedrine may be useful in women with bladder outlet
incompetence
– Imipramine may be used for mixed stress and urge incontinence or for
either separately
– Duloxetine is also used for stress incontinence
– If stress incontinence is caused by atrophic urethritis or vaginitis, estrogen
cream is often effective
– Urinating frequently to avoid a full bladder is often helpful
41. Treatment
Stress incontinence
– For stress incontinence that is not relieved with drugs and
behavioral measures, surgery or devices such as pessaries may be
helpful
– Vaginal sling procedure creates a hammock of support to help
prevent the urethra from opening during coughing, sneezing, or
laughing
– Most commonly, a sling is created from synthetic mesh
– Mesh implants are effective, but a few people with mesh
implants have serious complications
– Alternatively, sling using tissue from the abdominal wall or leg
– In men with stress incontinence, a mesh sling or an artificial urinary
sphincter implant may be placed around the urethra to prevent
leakage of urine
42. Treatment
Overflow incontinence
– Treatment depends on whether the cause is bladder outlet
obstruction, weak bladder wall muscles, or both
– For overflow incontinence caused by bladder outlet
obstruction, specific treatments may help relieve
obstruction (e.g. surgery or drugs for prostate disease,
surgery for cystocele, and dilation or stenting for urethral
narrowing)
– For overflow incontinence caused by weak bladder wall
muscles, treatments can include:
– Reducing the amount of urine in the bladder by
intermittent insertion of a bladder catheter
– Insertion of a catheter that remains in the bladder (rare)
43. Treatment
Overflow incontinence
– Goal is to reduce the bladder's size, allowing its walls to
regain some capacity to prevent it from overflowing
– Other measures can help empty the bladder after urinating:
– Trying to urinate again after urination has ended (called
double voiding),
– Bearing down at the end of urination
– Pressing over the lower abdomen at the end of
urination
– Electrical stimulation can be used to help empty the
bladder more completely
44. Incontinence
inOlder People
– Incontinence is more common among older people, but it is not a
normal part of aging
– Older age à bladder capacity decreases, ability to delay urination
declines, involuntary bladder contractions occur more often, and
bladder contractions weaken
– Urination becomes more difficult to postpone and tends to
be incomplete
– Muscles, ligaments, and connective tissue of the pelvis
weaken, contributing to incontinence
– In postmenopausal women, decreased estrogen levels lead to
atrophic urethritis and atrophic vaginitis and to decreasing the
strength of the urethral sphincter
– In men, prostate size increases, partially obstructing the urethra
and leading to incomplete bladder emptying and strain on the
bladder muscle
45. Incontinence
inOlder People
– Incontinence greatly reduces quality of life, causing
embarrassment, isolation, and depression
– Often a reason older people require care in a long-term care
facility
– Urine irritates the skin, contributing to the formation of
pressure sores in people who are bedbound or chairbound
– Older people with urge incontinence are at increased risk of
falls and fractures as they rush to the toilet
– Most effective drugs for various types of incontinence have
anticholinergic side effects
– Constipation, dry mouth, blurred vision, and sometimes
confusion
– Particularly troublesome in older people
47. What is
Bladder
Cancer?
– Bladder cancer most often causes blood in the urine.
– To diagnose, a thin, flexible viewing tube (cystoscope) is inserted
through the urethra into the bladder
– Many cancers are treated with removal, using a cystoscope (for
surface cancers) or by removing the bladder (for deeper cancers)
– About 80,000 new cases of bladder cancer are diagnosed every
year in the United States
– More than 17,500 people die of bladder cancer every year
– About 3 times as many men as women develop bladder
cancer
– Smoking is the greatest single risk factor and seems to be one of
the causes in at least half of all new cases
48. What is
Bladder
Cancer?
– Certain chemicals that are used in industry can become
concentrated in the urine and cause cancer, although exposure to
these chemicals is decreasing
– Include hydrocarbons, aniline dyes (such as naphthylamine
used in the dye industry) and chemicals used in the rubber,
electric, cable, paint, and textile industries
– Long-term exposure to some drugs, especially cyclophosphamide,
increases the risk of bladder cancer
– Chronic irritation that occurs with a parasitic infection called
schistosomiasis or with a bladder stone also predisposes people to
bladder cancer
– Most bladder cancers are of a type called transitional cell, affecting
the same kinds of cells (transitional cells) that are usually the
cancerous cells responsible for cancers of the renal pelvis and
ureters
49. Types of
BladderCancer
– Different types of cells in your bladder can become cancerous
– Type of bladder cell where cancer begins determines the type of bladder
cancer
– Urothelial carcinoma (previously called transitional cell carcinoma): occurs
in the cells that line the inside of the bladder
– Urothelial cells expand when your bladder is full and contract when
your bladder is empty
– These cells line the inside of the ureters and the urethra, and cancers
can form in those places as well
– Most common type of bladder cancer in the US
– Squamous cell carcinoma: associated with chronic irritation of the bladder
(e.g. from an infection or from long-term use of a urinary catheter)
– Squamous cell bladder cancer is rare in the US, but more common
where a certain parasitic infection (schistosomiasis) is a common
– Adenocarcinoma: begins in cells that make up mucus-secreting glands in
the bladder
– Adenocarcinoma of the bladder is very rare
50. Causes
– Bladder cancer begins when cells in the bladder develop
changes (mutations) in their DNA
– A cell's DNA contains instructions that tell the cell what to do:
– Tell the cell to multiply rapidly and to go on living when
healthy cells would die
– Abnormal cells form a tumor that can invade and destroy
normal body tissue
– Abnormal cells can break away and spread (metastasize)
through the body
51. Risk Factors
– Smoking: cigarettes, cigars or pipes may increase the risk of bladder
cancer by causing harmful chemicals to accumulate in the urine
– When you smoke, your body processes the chemicals in the
smoke and excretes some of them in your urine
– Chemicals may damage the lining of your bladder
– Increasing age: bladder cancer risk increases as you age
– Most people diagnosed with bladder cancer are older than 55
– Being male: men are more likely to develop bladder cancer than
women
– Exposure to certain chemicals: kidneys play a key role in filtering
harmful chemicals from your bloodstream and moving them into your
bladder
– Being around certain chemicals may increase the risk of bladder
cancer
– Chemicals linked to bladder cancer risk include arsenic and
chemicals used in the manufacture of dyes, rubber, leather,
textiles and paint products
52. Risk Factors
– Previous cancer treatment: anti-cancer drug cyclophosphamide
increases the risk of bladder cancer; radiation treatments aimed at the
pelvis for a previous cancer increases risk of bladder cancer
– Chronic bladder inflammation. chronic or repeated urinary infections
or inflammations (cystitis) can increase the risk of a squamous cell
bladder cancer
– Squamous cell carcinoma is sometimes linked to chronic bladder
inflammation caused by the parasitic infection schistosomiasis
– Personal or family history of cancer:
– More likely to get bladder cancer again If you've had it before
– If blood relatives (parent, sibling or child) has a history of bladder
cancer, you may have an increased risk of the disease
– Relatively rare for bladder cancer to run in families
– Family history of Lynch syndrome, also known as hereditary
nonpolyposis colorectal cancer (HNPCC), can increase the risk of
cancer in the urinary system
53. Symptoms
andSigns
– Blood in the urine (hematuria)
– Urine appears bright red or cola colored
– Sometimes the urine appears normal and blood is
detected on a lab test
– Pain and burning during urination
– An urgent, frequent need to urinate
– Back pain
– Symptoms of bladder cancer may be identical to those of a
bladder infection (cystitis) and the two conditions may occur
together:
– A low blood count (anemia) à fatigue, paleness, or
both
54. Diagnosis
– Cystoscopy: examine the inside of your bladder
– Insert a small, narrow tube (cystoscope) through your urethra
– Cystoscope has a lens that allows your doctor to see the inside
of your urethra and bladder, to examine these structures for
signs of disease
– Biopsy: removing a sample of tissue for testing
– During cystoscopy, your doctor may pass a special tool through the
scope and into your bladder to collect a cell sample (biopsy) for
testing
– Procedure is sometimes called transurethral resection of
bladder tumor (TURBT)
– Urine cytology: examining a urine sample (urine cytology)
– Sample of your urine is analyzed under a microscope to check
for cancer cells in a procedure called urine cytology
55. Diagnosis
– Imaging tests: computerized tomography (CT) urogram or
retrograde pyelogram allow your doctor to examine the structures
of your urinary tract
– During a CT urogram, a contrast dye injected into a vein in
your hand eventually flows into your kidneys, ureters and
bladder
– X-ray images taken during the test provide a detailed view of
your urinary tract
– Retrograde pyelogram: X-ray exam used to get a detailed
look at the upper urinary tract
– Doctor threads a thin tube (catheter) through your
urethra and into your bladder to inject contrast dye into
your ureters
56. BladderCancer
Grade
– Grade: bladder cancers are further classified based on how the
cancer cells appear when viewed through a microscope
– Low-grade bladder cancer: cells are closer in appearance and
organization to normal cells (well differentiated)
– Low-grade tumor usually grows more slowly and is less likely to
invade the muscular wall of the bladder than is a high-grade
tumor
– High-grade bladder cancer: cells are abnormal-looking and lack any
resemblance to normal-appearing tissues (poorly differentiated)
– High-grade tumor tends to grow more aggressively than a low-
grade tumor and may be more likely to spread to the muscular
wall of the bladder and other tissues and organs
57. Treatment
– Treatment options for bladder cancer depend on a number of factors: type
of cancer, grade of the cancer, stage of the cancer, overall health,
treatment preferences
Bladder cancer treatment may include:
– Surgery: remove cancer cells
– Chemotherapy in the bladder (intravesical chemotherapy): treat cancers
that are confined to the lining of the bladder but have a high risk of
recurrence or progression to a higher stage
– Chemotherapy: whole body (systemic chemotherapy), increase the chance
for a cure in a person having surgery to remove the bladder, or as a primary
treatment when surgery isn't an option
– Radiation therapy: destroy cancer cells, often as a primary treatment when
surgery isn't an option or isn't desired
– Immunotherapy: trigger the body's immune system to fight cancer cells,
either in the bladder or throughout the body
– Targeted therapy: treat advanced cancer when other treatments are
ineffective
58. Surgery
– Transurethral resection of bladder tumor (TURBT): procedure to
diagnose bladder cancer and to remove cancers confined to the
inner layers of the bladder (not yet muscle-invasive cancers)
– Surgeon passes an electric wire loop through a cystoscope and
into the bladder
– Electric current in the wire is used to cut away or burn away the
cancer; high-energy laser may also be used
– Performed through the urethra, won't have any cuts (incisions)
in your abdomen
– As part of theTURBT procedure, doctor may recommend a one-
time injection of cancer-killing medication (chemotherapy) into your
bladder to destroy any remaining cancer cells and to prevent cancer
from coming back
59. Surgery
– Cystectomy: surgery to remove all or part of the bladder
– During a partial cystectomy, your surgeon removes only the
portion of the bladder that contains a single cancerous tumor
– Radical cystectomy is an operation to remove the entire bladder
and the surrounding lymph nodes
– In men, radical cystectomy typically includes removal of the
prostate and seminal vesicles
– In women, radical cystectomy may involve removal of the
uterus, ovaries and part of the vagina
– Radical cystectomy can be performed through an incision on
the lower portion of the belly or with multiple small incisions
using robotic surgery
60. Surgery
– Neobladder reconstruction: after a radical cystectomy, surgeon must create
a new way for urine to leave your body (urinary diversion)
– Surgeon creates a sphere-shaped reservoir (neobladder) out of a piece
of your intestine
– Neobladder sits inside your body and is attached to your urethra.
– Allows most people to urinate normally; a small number of people have
difficulty emptying the neobladder and may need to use a catheter
periodically to drain urine
– Ileal conduit: urinary diversion
– Surgeon creates a tube (ileal conduit) using a piece of intestine
– Tube runs from your ureters, which drain your kidneys, to the outside
of your body, where urine empties into a pouch (urostomy bag) you
wear on your abdomen
– Continent urinary reservoir: urinary diversion
– Surgeon uses a section of intestine to create a small pouch (reservoir)
to hold urine, located inside your body
– Drain urine from the reservoir through an opening in your abdomen
using a catheter a few times each day
61. Chemotherapy
– Chemotherapy uses drugs to kill cancer cells
– Chemotherapy treatment for bladder cancer usually involves two or
more chemotherapy drugs used in combination
– Chemotherapy may also be used to kill cancer cells that might
remain after surgery
– Chemotherapy may be combined with radiation therapy.
– Chemotherapy drugs can be given:
– Through a vein (intravenously): frequently used before bladder
removal surgery to increase the chances of curing the cancer
– Directly into the bladder (intravesical therapy, where a tube is
passed through your urethra directly to your bladder)
– Chemotherapy is placed in the bladder for a set period of time
before being drained
– Used as the primary treatment for superficial bladder cancer,
where the cancer cells affect only the lining of the bladder and
not the deeper muscle tissue
62. Radiation
Therapy
– Radiation therapy uses beams of powerful energy, such as
X-rays and protons, to destroy the cancer cells
– Radiation therapy for bladder cancer usually is delivered
from a machine that moves around your body, directing
the energy beams to precise points
– Radiation therapy is sometimes combined with
chemotherapy to treat bladder cancer in certain situations,
such as when surgery isn't an option or isn't desired
63. Immunotherapy
– Immunotherapy is a drug treatment that helps your immune system to
fight cancer.
Immunotherapy can be given:
– Directly into the bladder (intravesical therapy)
– Intravesical immunotherapy might be recommended afterTURBT for
small bladder cancers that haven't grown into the deeper muscle
layers of the bladder
– Treatment uses bacillus Calmette-Guerin (BCG), which was developed
as a vaccine used to protect against tuberculosis
– BCG causes an immune system reaction that directs germ-fighting
cells to the bladder
– Through a vein (intravenously)
– Immunotherapy can be given intravenously for bladder cancer that's
advanced or that comes back after initial treatment
– Several immunotherapy drugs are available and help your immune
system identify and fight the cancer cells
65. What is
Prostate
Enlargement?
– Benign prostatic hyperplasia (BPH) is a noncancerous (benign)
enlargement of the prostate gland that can make urination
difficult
– The prostate gland enlarges as men age
– Men may have difficulty urinating and feel the need to urinate
more often and more urgently
– Diagnosis is based on results of a rectal examination, but a blood
sample may be taken to check for prostate cancer
– If needed, drugs to relax the muscles of the prostate and bladder
(se.g. terazosin) or to shrink the prostate (e.g. finasteride) are used
– Sometimes surgery is necessary
66. What is
Prostate
Enlargement?
– The prostate is a gland in men that lies just under the bladder and
surrounds the urethra
– Produces much of the fluid that makes up a man’s semen
– As prostate enlarges, it gradually compresses the urethra and blocks
the flow of urine (urinary obstruction)
– When men with BPH urinate, the bladder may not empty completely.
– Urine stagnates in the bladder, making men susceptible to urinary
tract infections (UTIs) and bladder stones; prolonged obstruction can
weaken the bladder and ultimately damage the kidneys
67. Causes
– Benign prostatic hyperplasia (BPH) becomes increasingly common
as men age, especially after age 50
– Precise cause is not known but probably involves changes caused
by hormones, including testosterone and especially
dihydrotestosterone (a hormone related to testosterone)
– Drugs such as over-the-counter antihistamines and nasal
decongestants can increase resistance to the flow of urine or
reduce the bladder’s ability to contract
– Temporary blockage of urine flow out of the bladder in men
with BPH
68. Risk Factors
– Aging: prostate gland enlargement rarely causes signs and
symptoms in men younger than age 40
– 1/3 of men experience moderate to severe symptoms by age
60, and half do so by age 80
– Family history: having a blood relative, such as a father or a
brother, with prostate problems means you're more likely to have
problems
– Diabetes and heart disease: diabetes, as well as heart disease
and use of beta blockers, may increase the risk of BPH
– Lifestyle: obesity increases the risk of BPH, while exercise can
lower your risk
69. Symptoms
andSigns
– The severity of symptoms in people who have prostate gland
enlargement varies, but symptoms tend to gradually worsen over
time
– Common signs and symptoms of BPH include:
– Frequent or urgent need to urinate
– Increased frequency of urination at night (nocturia)
– Difficulty starting urination
– Weak urine stream or a stream that stops and starts
– Dribbling at the end of urination
– Inability to completely empty the bladder
70. Symptoms
andSigns
– Less common signs and symptoms include:
– Urinary tract infection
– Inability to urinate
– Blood in the urine
– The size of your prostate doesn't necessarily determine the
severity of your symptoms
– Some men with only slightly enlarged prostates can have
significant symptoms, while other men with very enlarged
prostates can have only minor urinary symptoms
– In some men, symptoms eventually stabilize and might even
improve over time
71. Complications
– Sudden inability to urinate (urinary retention): may need to have a tube
(catheter) inserted into your bladder to drain the urine or even surgery to
relieve urinary retention
– Urinary tract infections (UTIs): inability to fully empty the bladder can
increase the risk of infection in your urinary tract
– If UTIs occur frequently, you might need surgery to remove part of the
prostate
– Bladder stones: caused by an inability to completely empty the bladder
– Can cause infection, bladder irritation, blood in the urine and
obstruction of urine flow
– Bladder damage: bladder that hasn't emptied completely can stretch and
weaken over time
– Muscular wall of the bladder no longer contracts properly, making it
harder to fully empty your bladder
– Kidney damage: pressure in the bladder from urinary retention can directly
damage the kidneys or allow bladder infections to reach the kidneys
72. Diagnosis
– Digital rectal exam: doctor inserts a finger into the rectum to check your
prostate for enlargement
– Urine test: analyzing a sample of your urine can help rule out an infection or
other conditions
– Blood test: look for indications of kidney problems
– Prostate-specific antigen (PSA) blood test: PSA is a substance produced in
your prostate and levels increase when you have an enlarged prostate
– Urinary flow test: urinate into a receptacle attached to a machine that
measures the strength and amount of your urine flow
– Postvoid residual volume test: measures whether you can empty your
bladder completely
– Done using ultrasound or by inserting a catheter into your bladder after
you urinate to measure how much urine is left in your bladder
– 24-hour voiding diary: recording the frequency and amount of urine,
especially if more than one-third of your daily urinary output occurs at night
73. Diagnosis –
MoreComplex
Cases
– Transrectal ultrasound: ultrasound probe is inserted into your
rectum to measure and evaluate your prostate
– Prostate biopsy: transrectal ultrasound guides needles used to
take tissue samples (biopsies) of the prostate; examining the
tissue can help your doctor diagnose or rule out cancer
– Urodynamic and pressure flow studies: catheter is threaded
through your urethra into your bladder
– Water is slowly injected into your bladder and doctor
measures bladder pressure and determine how well your
bladder muscles are working
– Cystoscopy: lighted, flexible instrument (cystoscope) is inserted
into your urethra, allowing your doctor to see inside your urethra
and bladder
74. Treatment
– A wide variety of treatments are available for enlarged prostate,
including medication, minimally invasive therapies and surgery
– The best treatment choice for you depends on several factors,
including:
– Size of your prostate
– Age
– Overall health
– Amount of discomfort or bother you are experiencing
– If your symptoms are tolerable, you might decide to postpone
treatment and simply monitor your symptoms
– For some men, symptoms can ease without treatment
75. Treatment -
Medications
– Medication is the most common treatment for mild to moderate symptoms of
prostate enlargement
– Alpha blockers: relax bladder neck muscles and muscle fibers in the prostate,
making urination easier
– Examples: alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax)
and silodosin (Rapaflo)
– Work quickly in men with relatively small prostates
– Side effects might include dizziness and a harmless condition in which
semen goes back into the bladder (retrograde ejaculation)
– 5-alpha reductase inhibitors: shrink your prostate by preventing hormonal
changes that cause prostate growth
– Examples: finasteride (Proscar) and dutasteride (Avodart)
– Can take up to six months to be effective
– Side effects include retrograde ejaculation
– Combination drug therapy: taking an alpha blocker + 5-alpha reductase inhibitor
– Tadalafil (Cialis): recent studies suggest this medication for erectile dysfunction
can also treat prostate enlargement
76. Treatment –
Minimally
Invasive
Procedures or
Surgeries
– Transurethral resection of the prostate (TURP)
– A lighted scope is inserted into your urethra, and the surgeon
removes all but the outer part of the prostate
– TURP relieves symptoms quickly, and most men have a stronger
urine flow soon after the procedure
– AfterTURP you might temporarily need a catheter to drain your
bladder
– Transurethral incision of the prostate (TUIP)
– A lighted scope is inserted into your urethra, and the surgeon
makes one or two small cuts in the prostate gland
– Makes it easier for urine to pass through the urethra
– Might be an option if you have a small or moderately enlarged
prostate gland, especially if you have health problems that
make other surgeries too risky
77. Treatment –
Minimally
Invasive
Procedures or
Surgeries
– Transurethral microwave thermotherapy (TUMT)
– Inserts a special electrode through your urethra into your prostate area
– Microwave energy from the electrode destroys the inner portion of the
enlarged prostate gland, shrinking it and easing urine flow.
– TUMT might only partially relieve your symptoms, and it might take
some time before you notice results
– Used only on small prostates in special circumstances because re-
treatment might be necessary
– Transurethral needle ablation (TUNA)
– A scope is passed into your urethra, allowing your doctor to place
needles into your prostate gland
– Radio waves pass through the needles, heating and destroying excess
prostate tissue that's blocking urine flow
– TUNA may be an option in select cases, but the procedure is rarely used
any longer
78. Treatment –
Minimally
Invasive
Procedures or
Surgeries
– Laser therapy
– High-energy laser destroys or removes overgrown prostate tissue
– Relieves symptoms right away and has a lower risk of side effects than
does nonlaser surgery
– Used in men who shouldn't have other prostate procedures because
they take blood-thinning medications
The options for laser therapy include:
– Ablative procedures: vaporize obstructive prostate tissue to increase urine
flow
– Examples: photoselective vaporization of the prostate (PVP) and
holmium laser ablation of the prostate (HoLAP)
– Ablative procedures can cause irritating urinary symptoms after surgery
– Enucleative procedures: remove all the prostate tissue blocking urine flow
and prevent regrowth of tissue
– Examples: holmium laser enucleation of the prostate (HoLEP)
– Removed tissue can be examined for prostate cancer and other
conditions
79. Treatment –
Minimally
Invasive
Procedures or
Surgeries
– Prostatic urethral lift (PUL)
– Special tags are used to compress the sides of the prostate to increase
the flow of urine
– Recommended if you have lower urinary tract symptoms
– PUL also might be offered to some men concerned about treatment
impact on erectile dysfunction and ejaculatory problems
– Embolization
– Blood supply to or from the prostate is selectively blocked, causing the
prostate to decrease in size
– Long-term data on the effectiveness of this procedure aren't available
– Open or robot-assisted prostatectomy
– Surgeon makes an incision in your lower abdomen to reach the prostate
and remove tissue
– Open prostatectomy is done if you have a very large prostate, bladder
damage or other complicating factors
– Requires a short hospital stay and is associated with a higher risk of
needing a blood transfusion
