assessment of LUTS (lower urinary tract SX)

Question 1

1 - Stress urinary leakage is the most common type of urinary incontinence.

2 - The overactive bladder is characterised by the presence of urgency

3 - The prevalence of LUTS increases with age

4 - LUTS only describes the different types of urinary incontinence

5 - Approximately 10% of women have lower urinary tract symptoms

Answer 1

1 - True
2 - True
3 - True
4 - False
5  - false

Question 2

Regarding risk factors for urinary incontinence:

1 - Studies have shown that systemic hormone replacement therapy decreases the risk of urinary incontinence

2- Cognitive state and mobility do not influence the risk of urinary incontinence

3 - Parity increases the risk of urinary incontinence

4 - Obesity increases the risk of urinary incontinence

5 - Smoking decreases the risk of urinary incontinence

Answer 2

1 - False
2 - False
3 - True
4 - True
5  - False

Question 3

Regarding history taking and physical examination:

1 - Pain and haematuria are commonly associated with stress and urge urinary leakage

2 - Conservative treatment can be initiated based on the history alone

3 - Stress and urge leakage can be differentiated based on the history alone

4 - Past medical, surgical and drug history are not important when taking a urogynaecological history

5 - Radiotherapy only affects the lower urinary tract in the short term

Answer 3

1 - False
2 - True
3 - True
4 - False
5 - False

Question 4

Regarding urogynaecological investigations:

1 - Haematuria should always be investigated promptly

2 - Cystoscopy is recommended for all cases of urinary incontinence

3 - NICE recommend that dipstick testing of urine should be done only when urinary incontinence is associated with dysuria

4 - Urodynamics should always be performed before starting treatment for LUTS

5 - The postvoid residual urine volume should be checked if a woman reports the sensation of incomplete bladder emptying

Answer 4

1 - True
2 - False
3 - False
4 - False
5 - True

Question 5

1 - The feeling of incomplete emptying is postmicturition symptom

2 - Women with LUTS can have a single symptom or a combination of symptoms

3 - Lower urinary tract symptoms (LUTS) are catagorised into storage, voiding and postmicturition symptoms

4 - Stress, urge and mixed urinary incontinence are storage symptoms

5 - Frequency and urgency are voiding symptoms

6 - The prevalence of LUTS is only influenced characteristics of the participants

7 - Approximately 10% of women have LUTS

8 - Storage symptoms are the most common LUTS

9 - LUTS are less common with increasing age

10 - Nocturia and UI are the most common LUTS

Answer 5

1 - True
2 - True
3 - True
4 - True

5 - False

6 - false. The study methods and definition used for LUTS can also affect prevelance.

7 - false. The prevalence of women with at least one LUTS ranges from 39 to 67%.

8 -True

9 - False

10 - True

Question 6

1 - Urinary incontinence is an under-reported problem

2 - The severity of urinary incontinence is linked to age

3 - A third of women with urinary incontinence will experience worsening symptoms over 2 years

4 - Overall, stress urinary incontinence is the least prevalent form of leakage

5 - Mixed and urge urinary incontinence are the commonest forms of leakage in the elderly

6 - The 2-year incidence rate of urinary incontinence is approximately 10%

7 - Mixed and urge urinary incontinence are less inconvenient to the patient than stress urinary incontinence

8 - Over 2 years, 50% of women with urinary incontinence will experience complete remission of their symptoms

Answer 6

1 - True
2 - true. The severity of urianry incontinence increases with age.

3 - True

4 - False

5 -

6 - True

7 - False

8 - False

Question 7

1 - The hallmark of OAB is urgency.

2 - Women with OAB may have frequency irregularities, nocturia and urge leakage

3 - Approximately 25% of women have OAB.

4 - The majority of women with OAB have urge leakage.

Answer 7

1 - True

2 - True

3 - False. Prevelance ranges from 13 to 16%

4 - False. Only approximately a thrid of women with OAB also have urge leakage.

Question 8

1 - LUTS affects women physically, psychologically and socially

2- Approximately a third of women with LUTS report that it has a detrimental effect on their quality of life

3 - LUTS is associated with fractures and falls in the elderly

4 - Perineal dermatitis due to UI affects approximately 10% of women in long-term care

5 - In most cases, UI does not affect sexual function

6 - UI is associated with loss of independence and institutionalisation in the elderly

Answer 8

1 - True
2 - True
3 - True

4 - False, It can range in severity, from erythema with or without loss of skin integrity, to severe infection. It affects as many as 41% of adults in long-term care

5 - False

6 - True

Question 9

1 - UI is aggravated by decreased mobility and impaired cognitive function

2 - Diabetes mellitus and congestive cardiac failure are causes of LUTS

3 - Up to 25% of pregnant women report UI in the third trimester

4 - Developing UI during the antenatal and postnatal periods are risk factors for UI later in life

5 - Smoking does not increase the risk of UI

6 - Being overweight increases the prevalence and severity of UI

7 - Hysterectomy increases the risk of UI

8 - Systemic estrogens increase the risk of UI

9 - NICE recommend systemic estrogens for UI

10 - Vaginal estrogens are effective for overactive bladder symptoms in women with vaginal atrophy

Answer 9

1 - True
2 - True

3 - False

4 - True

5 - False

6 - True
7 - True
8 - True

9 - False

10 - True

Question 10

1 -In women, the urethra is 3–5 cm in length

2 - The striated and smooth muscle layers of the urethra each contribute to 50% of the urethral resting tone

3 - SUI can be the result of urethral hypermobility or intrinsic sphincter deficiency

4 - The cause of SUI in intrinsic sphincter deficiency is defective suburethral support

5 - The pubocervical fascia along the anterior vaginal wall acts as a hammock to prevent SUI

6 - Levator trauma at the time of vaginal delivery can lead to loss of suburethral support and SUI

7 - Surgery and radiotherapy can cause ISD as a result of denervation and scarring

8 - There is no evidence for pudendal nerve damage occurring at the time of vaginal delivery

Answer 10

1 - True

2 - False. They contribute to two-thirds of the resting tone.

3 - True

4 - False

5 - True
6 - True
7 - True

8 - False

Question 11

1 - Parasympathetics activation occurs during voiding and results in detrusor muscle contraction and urethral smooth muscle relaxation

2 - Sympathetic activation occurs during bladder filling and results in bladder neck smooth muscle contraction

3 - Activation of the pontine micturition centre allows bladder filling

4 - The on–off switch of the pontine micturition centre is under voluntary control by higher brain centres

5 - The guarding reflex during bladder filling results in the contraction of the smooth muscle of the bladder neck

6 - The majority of cases of detrusor overactivity are caused by neurological problems

Answer 11

1 - True
2 - True

3 - False, pontine micturition centre triggers micturition when it is switched on.The pontine micturition centre is switched on or off, depending on the level of bladder stretch receptor activity; this occurs automatically

4 - True, The switching on-and-off of the pontine micturition centre is under voluntary control in continient individuals and is controlled by the higher brain centres

5 - False

6 - False, involuntary detrusor contractions
Detrusor overactivity can be due to diseases affecting the central nervous system, bladder outlet obstruction or idiopathic.

Question 12

1 - History is usually unreliable when trying to determine the patient’s type of UI

2 - Urodynamics is needed before nonsurgical treatment for LUTS can be initiated

3 - Visible haematuria can be ignored

4 - Bladder pain is commonly associated with SUI and OAB symptoms

5 - Approximately a third of women with LUTS have coexisting prolapse and bowel symptoms

6 - Both neurological and cardiac conditions can cause LUTS

7 - Radiotherapy does not usually cause many LUTS

8 - The patient’s desire for future childbearing influences the choice of treatment for LUTS

Answer 12

1 - False, History should attempt to categories symptoms into SUI, OAB (with or without UUI) and mixed symptoms

2 - False, Initial non-invasive treatment for storage symptoms is started based on one of the following three symptom categories: SUI, OAB symptoms or mixed symptoms

3 - False, The detailed history and examination must identify red flags requiring further investigation.

4 - False
5 - True, Pelvic organ prolapse and bowel symptoms commonly coexist with LUTS
Associated conditions such as pelvic organ prolapse and bowel dysfunction are common and need to be identified and addressed.

6 - True
7 - False
8 - True, The desire for future childbearing is an important factor.

• Ensure that other pathology is not missed
• The severity of symptoms and their impact should be determined rather than just the presence or absence of symptoms. This guides the choice of treatment
• If mixed symptoms are present, treatment should be directed at the predominant problem

Question 13

1 - A urine dipstick test should be done for all women with LUTS

2 - Women who have voiding symptoms should have their PVR checked

3 - A PVR of less than 200 ml is normal

4 - A voiding diary should be used for the initial assessment of all women with UI

5 - Verbally reported voiding frequency has been shown to be as accurate as recorded voiding frequency

6 - Voiding up to 12 times during the day and up to three times at night is normal

7 - Pad testing to objectively quantify urinary leakage is recommended by NICE in the assessment of women with UI

8 - Quality-of-life questionnaires are useful for assessing the impact of UI

9 - Urodynamics should be performed to objectively diagnose the type of urinary dysfunction present before the patient commences practising pelvic floor exercises and bladder retraining

10 - Urodynamics is a non-invasive test with no risks

Answer 13

1 - True,
2 - True
Basic investigations for women with UI include urine dipstick (MSU for MCS ifdipstick or symptoms are indicative of possible UTI), voiding diary and measurement of postvoid residual (in women reporting incomplete emptying).

3 - False
4 - True
5 - False
6 - False
7 - False
8 - True, UI is a common problem. It affects women physically, psychologically and socially.

9 - False, A detailed history is important. Categorising UI into SUI, UUI/OAB and MUI, based on the history, is all that is required in order to direct initial noninvasive treatment.
Urodynamics, imaging and cystoscopy are not required in the initial management of UI.

10 - False

Question 14

1 - Uroflowmetry is useful as a predictor of urinary retention after continence procedures such as midurethral tapes

2 - Abnormal uroflowmetry may be due to a urethral obstruction or a hypocontractile bladder

3 - Detrusor overactivity is defined as the presence of urgency, frequency, nocturia and urge leakage

4 - Urodynamic stress incontinence is defined as involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction

5 - In cystometry, Pdet = Pves – Pabd

6 - Videourodynamics, urethral pressure profilometry and ambulatory urodynamics should be performed routinely when investigating LUTS

7 - Cystoscopy is not needed in the initial evaluation of women with straightforward LUTS

8 - Urinary tract imaging should be performed for straightforward LUTS

Answer 14

1 - True
2 - True
3 - False
4 - True
5 - True
6 - False
7 - True
8 - False

Urodynamic investigations are recommended prior to surgical treatment.
Its aim is to objectively diagnose the cause of UI and to confirm the suitability of surgery.
It also identifies problems such as detrusor overactivity and voiding dysfunction which can detrimentally affect the results of continence surgery.

Question 15

Which of the following examinations/investigations would be relevant in the first instance?

1 - Speculum examination

2 - Cervical smear

3 - Vaginal examination

4 - Urinalysis

5 - Blood pressure

Answer 15

1 - True

2 - False: Although many women may be opportunistically offered screening for hypertension and cervical abnormality, they are not indicated for this clinical scenario.

3 - True

4 - True

5 - False: Although many women may be opportunistically offered screening for hypertension and cervical abnormality, they are not indicated for this clinical scenario.

Question 16

What investigations would you recommend to her?

1 - Blood sugar

2 - Midsteam specimen of urine

3 - Intravenous urogram

4 - Pelvic ultrasound (including a postvoid residual)

5 - Bladder diary (frequency–volume chart)

6 - Pelvic CT

Answer 16

1 - False, Blood sugars are not measured routinely unless the urine dipstick shows glycosuria.

2 - True, A midstream specimen of urine will exclude infection

3 - False

4 - True. A pelvic ultrasound is useful to investigate her bulky uterus and exclude a chronic residual of urine and overflow incontinence

5 - True

6 - False. Pelvic CT and intravenous urogram are not indicated as first-line investigations. She does, however, warrant screening for diabetes and a frequency–volume chart to quantify her fluid intake and output.

Question 17

Case study 1
A 63-year-old woman comes to the surgery. She is normally fit and well, but has noticed that over the previous 18 months, she has had problems with a ‘weak bladder’. She also notices that she leaked urine in the last three months, which has driven her to seek help.

She has always taken regular exercise and eaten a healthy diet. She has two grown children, both born normally at term, weighing less than 3.7 kg.

She takes no regular medications other than cod liver oil capsules and vitamins. She does not smoke. She lives with her husband, who is a milkman. He leaves for work at 03:45 every day, and wakes her up with the alarm clock.

Answer 17

US: several small fibroids not impinging on bladder, & bladder empties completely.
Culture: no infection urine.
Frequency–volume charting:normal fluid intake of 1500 ml per day, but confirms diurnal frequency of 14 times, with nocturia of three times per night.

Advice:

• avoiding caffeine-containing drinks and alcohol, and
• commence bladder-retraining.

Question 18

Case study 2
A 72-year-old lady , gynaecology outpatient clinic. She complains of urinary frequency, urgency and leaking whilst climbing the stairs. She wears sanitary towels whenever she leaves the house and is extremely embarrassed about her symptoms.

In past, she has had four children by spontaneous vaginal delivery. She lives alone and smokes 20 cigarettes a day.

She provides a urine specimen which shows microscopic haematuria on urinalysis.

Having considered your differential diagnoses, which of the following investigations are initially indicated?

1 - Urodynamics
2 - Urinalysis
3 - Midstream specimen of urine
4 - Urine cytology
5 - Frequency–volume chart
6 - Urgent cystoscopy
7 - Colonoscopy

Answer 18

1 - False: Urodynamics would be indicated only if surgery was being considered.invasive urodynamics tests should not be undertaken until any infection is treated

2 - True
3 - True: MSU mandatory, as UTI could be at least partly responsible for this woman’s symptoms

4 - True: urine sample should also be sent for cytology as the possibility of a urinary tract malignancy is raised by the presence of haematuria

5 - True
6 - True: urgent cystoscopy should also be arranged either as an outpatient or a day case providing she is medically fit enough. The possible presence of bladder stones, tumours and inflammatory conditions needs to be determined. Bladder biopsies at the time of cystoscopy may be indicated.

7 - False

Detailed history
1 - severity of the dysfunction, .
2 - Any co-morbid conditions,
3 - gauge effect that these symptoms have on her social functioning and ability to perform everyday tasks

general examination
1 - fitness for medical or surgical treatment.
2 - abdominal examination, looking for palpable bladder,
3 - renal angle tenderness and
4 - abdominal masses.

pelvic examination
1 - associated pelvic prolapse and
2 - size of uterus and ovaries.

Pelvic US: size and morphology of pelvic viscera

Upper tracts imaged by either intravenous urogram or an ultrasound of the kidneys, ureters and bladder to look for tumours and calculi

Definitive MX: depend upon what found on investigation, but almost certainly benefit from advice of continence advisor and supply of proper incontinence pads, rather than using sanitary towels.

Question 19

Having excluded sinister underlying pathology, which of the following conservative measures are advisable?

1 - Bladder drill
2 -Referral to a continence advisor
3 -Increase fluid intake
4 - Reduce smoking
5 - Prophylactic antibiotics

Answer 19

1 - True
2 - True. Definitive management will depend upon what is found on investigation. This woman would almost certainly benefit from the advice of a continence advisor and a supply of proper incontinence pads

3 - False

4 - True

5 - False

Question 20

A 45-year-old woman attends GOPD after saline cystometry has demonstrated urodynamic stress incontinence. She is contemplating undergoing a transvaginal midurethral tape procedure but requests further investigations as she is concerned about the risk of failure.

Which investigation could you offer her to give extra information on prognosis?

Cystoscopy under general anaesthetic
Electromyography
Nerve conduction studies
Pelvic ultrasound
Urethral pressure profilometry

Answer 20

The correct answer is urethral pressure profilometry. This is a test of urethral function and assesses the closure pressure of the urethra and, thus, the ability of the urethra to prevent leakage. This test is of limited value in isolation but has been found to confer some information about surgical success after continence surgery. A maximum urethral closure pressure (MUCP) <20 cm H20 has been associated with a worse functional outcome.

Question 21

What findings of Pves, Pdet and Pabd indicate a diagnosis of urodynamic stress incontinence?

1 - Absence of peaks of pressure rise on running taps

2 - Peaks of pressure rise in Pves, Pdet and Pabd on coughing with leaking

3 - Peaks of pressure rise in Pves and Pdet but not in Pabd in filling phase

4 - Sharp rises in Pves and Pabd without rise in Pdet with leakage of urine on coughing

5 - Sharp rises in Pves and Pabd without rise in Pdet with no leakage of urine on coughing

Answer 21

Sharp rises in Pves and Pabd without rise in Pdet with leakage of urine on coughing
The answer is Sharp rises in Pves and Pabd without rise in Pdet with leakage of urine on coughing. Urodynamics findings in peaks of pressure rise in Pves and Pdet but not in Pabd in filling phase means a diagnosis of detrusor overactivity, sharp rises in Pves and Pabd without rise in Pdet with no leakage of urine on coughing shows a stable bladder with no USI (normal). Sharp rises in Pves and Pabd without rise in Pdet with leakage of urine on coughing show that the sharp rise in Pves is due to rise in Pabd due to coughing and leakage is consistent with the diagnosis of USI. Absence of peaks of pressure rise on running taps signifies stable bladder and Peaks of pressure rise in Pves, Pdet and Pabd on coughing with leaking shows a diagnosis of cough induced detrusor overactivity as there is peak of pressure rise in Pdet with leaking.