# PBL RG4 Mary Simmons

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### Hx1

* 2/7
* ache pelvic area
* dysuria, frequency, urgency
* generally unwell, _ appetite

#### DDx

* Vascular
* Infective
* cystitis
* **UTI STI**
* **pelvic inflammatory disease (PID)**
* Traumatic
* pelvic trauma
* sexual activity
* ~~pregnancy - recent birth~~
* pelvis fracture
* Autoimmune
* immune-mediated vasculitis affecting bladder
* Musculoskeletal & metabolic
* diabetes
* trauma (see above) - d/t factory work
* renal/ureteric calculi
* Idiopathic/Iatrogenic
* vaginal mesh repair
* self-performed abortion
* recent catherization
* bladder aspirate
* Neoplasm/Neurological
* Cancer - bladder, transitional cell
* Lumbrosacral spinal injury
* Acquired
* Behavioural
* ~~related anxiety~~
* ~~Munchausen's~~
* Congenital
* abnormality of urinary system (e.g. bifid ureters predispose to UTIs)
* Degenerative/Drugs
* interstitial cystitis
* Endocrine
* Karyotype

#### Further Questions

* Menstrual
* Menopause
* Pregnancies
* Sexual Hx
* Age
* Previous UTIs

#### Futher Ix
* Urinalysis MSU
* Dipstick
* Pap smear
* Bladder ultrasound

### Hx2

* Work: asphalt/bitumen
* Smoking: 50g rolled tobacco/wk, since 16yo (3 packs/wk)
* Alcohol: 6 std drinks/wk red wine
* x3 Recurrent UTIs past 6/10
* tx: oral antibiotics
* Urine
* pink, through whole stream
* Abdo/pelvic pain - last few months

*Pt attributes these symptoms to UTIs*

#### Pink Urine

* gross hematuria, food (beetroot)

* cause is likely pre-urethral

### Hx3

* T = 38.5 C
* febrile
* Urine
* cloudy, pink
* dipstick: RBCs, PMNs, nitrites
* Menstrual
* normal
* not currently having period
* pHx UTIs - unknown cause
* ? patient understanding
* ? prior Ix

### Hx4

* Tx: Cephalexin 500 mg 4 per day

* ix further if no improvement
* Need
* temp
* BP
* wiping habits? sanitation?
* sexual Hx

#### Possible Underlying/Predisposing Pathology

* Diabetes
* T1D
* T2D
* Congenital
* bifid ureter
* Incomplete voiding
* neurogenic
* obstruction
* Practices
* Hygiene practices
 * use of spermicides?
* Bladder factors
* Change in bladder pH
* ? urothelium damage due to smoking

### Ix1

* ^ E coli, Gram neg

* non-glomerular macroscopic hematuria
* RBC present
* WBC present
* Urine cytology - abnormal epithelial cells

#### IX Interpretation

* E. coli consistent with UTI

* ? Blockage --> not necessarily
* ? source of abnormal cells
* Urinary tract tumor - bladder, transitional, squamous, adenocarcinoma?
* sloughed urinary tract cells - bladder, ureters, kidneys/nephrons

### Hx5

* Pt feeling better, T = 36.8 C

* Cytology suggests bladder/urinary tract cancer
* urgent referral to urologist
* ? Transitional Cell Carcinoma - multiple risk factors
* exposure to tar/asphalt
* and cigarette smoke
* also 90% of bladder cancers are TCCs (radiopedia.org)
* Other bladder cancers
* squamous cell carcinoma (3-8%)
* adenocarcinoma (1%)

### Hx6

* Urologist Referral
* UTI cleared
* pelvis tender
* IX ordered
* kidney US
* FBE
* urinalysis
* cystoscopy

### Ix2

* Urinalysis
* Na, Cl, Cr, K+, bicarb, urea ALL normal
* FBE
* Urate higher end normal
* Hb normal
* Hct normal
* RBC low
* MCV normal
* WBV high
* Platelets normal
* Ultrasound
* kidneys normal
* Urinalysis
* macroscopic hematuria
* Cystoscopy
* papillary lesions
* consistent with urothelial carcinoma/TCC
* Biopsy
* transitional cell carcinoma, non-invasive, stage 1

### Hx7

* tumor has not spread to muscular layer of bladder

* Refer for transurethral resection
* conservative approach appropriate for low-grade tumors
* then 6/52 intravesical BCG immunotherapy
* to boost immune response
* specific for bladder cancer

Hx8

* transurethral resection
* without complication
* carcinoma successfully removed
* 6/52 Intravesical BCG + Mitomycin
* Mitomycin
* chemotherapy agent for superficial bladder tumors
* Mechanism: crosslinks DNA

## Learning Issues

1. What are the most common bacteria causing UTIs? What antibiotic treatment
options are there?
2. List risk factors for UTI. Classify by:
1. Anatomical
2. Structural
3. Functional
3. Describe possible causes/origins and features of bladder cancer (and other
neoplasms of the urinary tract). Make sure to mention
1. Transitional Cell Carcinoma
2. Squamous Cell Carcinoma of the Bladder
3. Adenocarcinoma of the Bladder
4. Compare and contrast different treatment options for bladder cancer
1. Describe the transurethral resection procedure and how effective it is at
removing bladder carcinoma. Was it the most effective option?
2. Required ongoing monitoring?
3. Steps to reduce risk of developing further tumors?