Bladder/Urinary disorders

Question 1

Background

Answer 1

3 main types:
1. Urinary frequency, 2. Enuresis (bed wetting), 3. Incontinence

Key terms
Urinary retention - Inability to pee
Urinary incontinence - Leaking pee
Stress incontinence - Leak from cough or sneeze (a cause)
Urgency incontinence - Sudden need to badly pee
Mixed incontinence - Stress + Urgency 1 can be more dominant
Over flow incontinence - When bladder cant be emptied properly

Question 2

Incontinence Non-drug treatment

Answer 2

Modify fluid intake, BMI>30 need to be decreased, if overreactive reduce caffeine intake.
Devices can be used to prevent time specific leakage. Surgery RARE

Urgency incontinence - Bladder training for at least 6 week = 1ST LINE. FAIL then DRUG

Stress incontinence- Supervised pelvic floor muscle training for at least 3 months.

Mixed incontinence
BOTH of the above treatments FAIL THEN drugs

Question 3

Incontinence Drug treatment

Answer 3

Do urine dip stick in all women with incontinence to test for infection or haematuria and check symptoms.

Urgency incontinence/Frequency
Anticholinergic drug when non drug fails.
1st line - (D.O.T.) IR Darifenacin, Oxybutynin, IR Tolterodine
- AVOID oxybutynin in frail elderly and PT at risk of health deterioration. if needed used lowest dose and titrate up.
NON ORAL ALT - Transdermal oxybutynin.
Anticholinergic ALT Mirabegron

Review treatment after 4 weeks if works review again at 3 months then annually/every 6 months if >75.
TREATMENT FAIL - Try ALT anticholinergic or adjust dose or mirabegron trial. Review again 4 weeks

• ALT anticholinergic fesoterodine, proviverrine, solifenacin, trospium, MR oxybutynin or tolterodine.

THEN BOTOX A
Troublesome nocturia - Desmopressin.

Stress incontinence
- Duloxetine (women only) 2nd line 1st line is NON DRUG

Mixed incontinence
Treat depending on dominant type

Question 4

Refer women IF

Answer 4

• Persistent bladder or urethral pain
• Pelvic mass that is clinically benign
• Associated faecal incontinence
• Sus neurological disease, or urogenital fistulae
• Hx of previous incontinence surgery, pelvic cancer surgery or pelvic radiation therapy
• Recurrent or persistent UTI for >60
• Palpable bladder after voiding, or symptoms of voiding difficulty

Question 5

Nocturnal enuresis

Answer 5

Involuntary discharge of urine at night.

<5 yrs no treatment should go on its own.

NON drug
Fluid intake, diet, toilet behaviour.
Can use enuresis alarm.

DRUG
Oral/sublingual desmopressin if >5.
Combo of desmo + alarm preferred.
- Specialist can give desmo + oxybutynin or tolterodine.
ALT if ALL fail - TCA Imipramine

Question 6

Drug info

Answer 6

Mirabegron - Prolong QT interval

Anitmuscraninc/ Anticholinergic (same class) - - DOTS (Darifenacin, oxybutynin, tolterodine, solifenacin)

MR preps = less AEs

Desmopressin (exam Q) - Hyponatraemia (too much water kept in), Nausea
- Can lead to hyponatraemic convulsion.
AVOID FLUID OVERLOAD and IN route (more AEs)
Limit fluid to minimum from 1 hr b4 and until 8 hr after desmo use

Question 7

Urinary retention

Answer 7

Acute vs Chronic.
Acute is medical emergency if happen abruptly, its painful and need catheter.
- B4 catheter removed Alpha blocker given for 2 days (Tamsulosin etc)

Chronic is gradual and unable to empty bladder.

Treated surgically or with alpha blockers
ALT Finasteride, Dutasteride
- Others - bethanechol, neostigmine, pyridostigmine

Most common cause in men is BPH

Surgery reserved for more severe cases, or complications i.e. recurrent UTI