Bladder Disease

Question 1

What are the causes of bladder outflow obstruction (BOO)?

Answer 1

Benign prostatic hyperplasia (BPH).

Urethral stricture.

Prostatic cancer.

Bladder stones.

Extrinsic - cystocoele, pelvic non-urological cancers.

Drugs such as anticholinergic and nasal decongestants.

Question 2

What are the 2 main groups of lower urinary tract symptoms?

Answer 2

Storage (when the bladder is filling with urine):

• Frequency.
• Urgency.
• Nocturia.

Voiding (when the patient is trying to pass urine):

• Hesitancy.
• Poor flow.
• Intermittent flow.
• The sensation of incomplete emptying.
• Post-micturition dribbling.

Question 3

What are the red flag symptoms of the lower urinary tract?

Answer 3

Haematuria.

Suprapubic pain.

Recurrent UTIs.

If present, suspect bladder cancer.

Need to ask about: bedwetting (high-pressure chronic retention); back pain and neurological symptoms (sciatica, lower limb weakness or sensory symptoms).

Question 4

What medications can be used to manage lower urinary tract symptoms?

Answer 4

Alpha blockers: tamsulosin - acts on smooth muscle.

5 alpha-reductase inhibitors: inhibits the conversion of testosterone to dihydrotestosterone.

Anticholinergic: inhibits bladder smooth muscle contraction.

Beta-agonist: inhibits bladder smooth muscle contraction.

Question 5

What surgical procedures can be used to manage lower urinary tract symptoms?

Answer 5

Transurethral resection of the prostate gland.

Holmium laser enucleation of the prostate.

Question 6

What is urinary incontinence?

Answer 6

involuntary leakage of urine.

Question 7

What is stress urinary incontinence?

Answer 7

Leakage on effort, exertion, sneezing or coughing.

Occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency.

Urine leaks whenever urethral resistance is exceeded by increased abdominal pressure.

Question 8

What is urge urinary incontinence?

Answer 8

Leakage accompanied by or immediately preceded by urgency.

May be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone).

Question 9

What is mixed urinary incontinence?

Answer 9

A combination of stress and urge urinary incontinence.

Question 10

What does bedwetting in elderly men usually indicate?

Answer 10

High-pressure retention.

Question 11

What is post-micturition dribble?

Answer 11

Happens in men immediately after leaving the toilet and is due to urine pooling in the bulbar urethra.

Question 12

What does a constant leak of urine suggest?

Answer 12

A fistulous communication between the bladder (usually) and the vagina (e.g. due to surgical injury at the time of hysterectomy or Caesarian section).

Or rarely the presence of an ectopic under ureter draining into the vagina.

Question 13

What are the risk factors for urinary incontinence?

Answer 13

Female.

Caucasian.

Genetic predisposition.

Neurological disorders - spinal cord injury, stroke, MS, Parkinson’s.

Anatomical disorders - vesicovaginal fistula, ectopic ureter in girls, urethral diverticulum, urethral fistula, bladder exstrophy, epispadias.

Childbirth - vaginal delivery, increasing parity, pregnancy.

Pelvic, perineal and prostate injury - radical hysterectomy, prostatectomy, TURP leading to pelvic muscle and nerve injury.

Radical pelvic radiotherapy.

Diabetes.

Question 14

What factors can promote (cause) urinary incontinence?

Answer 14

Smoking - causing cough.

Obesity.

Infection (UTI).

Increased fluid intake.

Poor nutrition.

Ageing.

Cognitive deficit.

Poor mobility.

Oestrogen deficiency.

Question 15

When examining women for urinary incontinence, what are you looking for?

Answer 15

Chaperoned pelvic examination.

Ask patient to cough or strain and look for anterior and posterior vaginal wall prolapse, uterine or vaginal vault descent, and urinary leakage.

Internal pelvic examination can be performed to assess voluntary pelvic floor muscle strength and bladder neck mobility.

Inspect the vulva for oestrogen deficiency – causing vaginal atrophy.

Question 16

When examining men and women for urinary incontinence, what are you looking for?

Answer 16

Examine the abdomen for palpable bladder (urinary retention).

Neurological examination to assess gait, anal reflex, perineal sensation and lower limb function.

Digital rectal exam to exclude constipation, a rectal mass and to test anal tone.

Question 17

What investigations are done for suspected urinary incontinence?

Answer 17

Basic investigations:

• Bladder diary (frequency/volume chart).
• Urinalysis +/- culture.
• Flow rate and post-void residue.
• Pad testing.

Further investigations:

• Blood tests.
• Imaging.
• Cystoscopy - for complex cases.

Question 18

What are the conservative treatments for urinary incontinence?

Answer 18

Pelvic floor exercises.

Lifestyle modification.

Biofeedback (a technique whereby the ability and strength of pelvic floor contraction is fed back to the patient as a visual or auditory signal).

Medication.

Electrical stimulation of the pelvic floor - no proven benefit in stress urinary incontinence.

Question 19

What medication is commonly given for urinary incontinence and what is its effect?

Answer 19

Duloxetine.

Inhibits reuptake of both serotonin and noradrenaline.

Acts to increase sphincteric muscle activity during bladder filling.

Question 20

What is the surgical treatment for urinary incontinence?

Answer 20

Injection therapy.

Retropubic suspension.

Suburethral tapes and slings.

Artificial urinary sphincter.

Question 21

What is injection therapy?

Answer 21

The injection of bulking materials into the bladder neck and periurethral muscles to increase outlet resistance.

Macroplastique (silicone – polydimethylsiloxane elastomer) or Teflon (polytetrafluoroethylene paste).

Question 22

What is the main indication for injection therapy?

Answer 22

Female stress incontinence secondary to demonstrable intrinsic sphincter deficiency in the presence of normal bladder muscle function.

Question 23

What are the contraindications for injection therapy?

Answer 23

UTI.

Untreated bladder overactivity.

Bladder neck stenosis.

Question 24

What is retropubic suspension?

Answer 24

To treat female stress incontinence predominantly caused by urethral hypermobility.

The aim is to elevate and fix the bladder neck and proximal urethra in a retropubic position in order to support the bladder neck and regain continence.

Lower chance of benefit in the presence of significant intrinsic sphincter deficiency.

Question 25

What are suburethral tapes and slings?

Answer 25

Synthetic tapes – e.g. the retropubic tension-free vaginal tape (TVT).

Small mid-line anterior vaginal incision.

The tape has long trochars on each end which are inserted either side of the urethra and perforate through the endopelvic fascia.

They are then pushed up behind the symphysis pubis and out onto lower abdominal wall in the midline, just above the pubic bone.

Once the tape is positioned loosely (tension-free) over the mid-urethra its covering is removed and the ends cut flush to the abdomen.

Vaginal epithelium is closed over the top.

Question 26

What are the complications of using suburethral tapes and slings for urinary incontinence?

Answer 26

Voiding dysfunction (retention or de novo bladder overactivity).

Vagina, urethral and bladder perforation/erosion.

Pain.

Damage to bowel or blood vessels.

Question 27

What is an artificial sphincter?

Answer 27

A closed pressurised system with 3 components:

1. An inflatable cuff placed around the bulbar urethra or bladder neck.
2. A pressure-regulating balloon placed extraperitoneally in the abdomen.
3. An activating pump in the scrotum or labia majora.

The cuff provides a constant circumferential pressure to compress the urethra.

To void, the pump is squeezed, which transfers fluid to the reservoir balloon, thereby deflating the cuff.

The cuff then automatically re-fills within 3 minutes.

Question 28

What are the complications of an artificial sphincter?

Answer 28

Urethral atrophy.

Mechanical failure.

Urethral erosion.

Bladder overactivity or reduced compliance.

Infection.

Question 29

What is an overactive bladder?

Answer 29

A syndrome that includes urgency, with or without urge incontinence, usually with frequency and nocturia.

Usually caused by bladder (detrusor) overactivity.

Question 30

What are the conservative treatment options for an overactive bladder?

Answer 30

Pelvic floor exercises.

Biofeedback.

Acupuncture.

Electrical stimulation.

Modify fluid intake.

Avoid stimulants (caffeine, alcohol).

Bladder training.

Anticholinergic medication.

B-adrenoceptor agonists.

Question 31

Which anticholinergic medications are used for overactive bladder?

Answer 31

Oxybutynin.

Solifenacin.

Tolterodine.

Trospium.

Propiverine.

Question 32

What are the contraindications for using anticholinergic medication for overactive bladder?

Answer 32

Uncontrolled closed-angle glaucoma.

Myasthenia gravis.

Bladder outflow obstruction.

Bowel disorders (active ulcerative colitis, bowel obstruction).

Question 33

What are the common side effects of anticholinergic medication?

Answer 33

Dry mouth.

Constipation.

Blurred vision.

Urinary retention.

Cognitive impairment.

Question 34

How do B-adrenoceptor agonists work in overactive bladder?

Answer 34

They induce detrusor relaxation.

B3-adrenoceptor agonists increase bladder capacity with no change in micturition pressure and the residual volume.

Question 35

Which B-adrenoreceptor agonist is used for overactive bladder?

Answer 35

Mirabegron (Betmiga).

Question 36

What are the contraindications for the use of beta-adrenoreceptor agonists in overactive bladder?

Answer 36

Uncontrolled hypertension.

Question 37

What are the treatment options for failed conventional therapy for overactive bladder?

Answer 37

Intravesical botulinum toxin-A (injected at 20 sites under the bladder mucosa or into the detrusor muscle, sparing the trigone).

Neuromodulation.

Augmentation ‘clam’ ileocystoplasty.

Ileal conduit urinary diversion.

Question 38

What does neuromodulation for overactive bladder involve?

Answer 38

Sacral nerve stimulation involves electrical stimulation of the bladder’s nerve supply to suppress reflexes responsible for involuntary detrusor contraction.

The Interstim device stimulates the S3 afferent nerve, which then inhibits detrusor activity at the level of the sacral spinal cord.

An initial percutaneous nerve evaluation is performed, followed by surgical implantation of permanent electrode leads into the sacral foramen, with a pulse generator which is programmed externally.

Question 39

What is an augmentation ‘clam’ ileocystoplasty?

Answer 39

Relieves intractable frequency, urge and urge urinary incontinence in 90% of patients.

Bladder dome is bivalved and a detubularised segment of ileum is anastomosed, creating a larger bladder volume.

Question 40

What is an ileal conduit urinary diversion?

Answer 40

Used for intractable cases of overactive bladder only.

Both ureters are anastomosed and connected to a short length of ileum which is brought out cutaneously as a stoma (urostomy).