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Y3- Reproductive System 1/3 R > Female Urinary Incontinence > Flashcards

Female Urinary Incontinence Flashcards

1
Q

upper tract in the urinary system includes

A

kidneys and ureters

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2
Q

what is the characteristic of the upper tract?

A

low pressure distensible conduit with intrinsic peristalsis which transport urine from nephrons via ureters to the bladders

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3
Q

Lower tract in the urinary system includes

A

bladder and urethra

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4
Q

rate at which bladder fills

A

0.5 - 5 ml/min

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5
Q

what is the characteristic of the lower tract ?

A

low pressure storage of urine with efficient expulsion of urine at appropriate place and time

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6
Q

what is urinary incontinence?

A

involuntary leakage of urine

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7
Q

what is stress urinary incontinence?

A

involuntary leakage of urine on exertion/coughing/ sneezing

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8
Q

what is urge urinary incontinence?

A

any involuntary leakage of urine accompanied by or immediately preceded by urgency

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9
Q

what is mixed urinary incontinence?

A

involuntary leakage of urine accompanied or immediately preceded by urgency which occur on exertion or coughing or sneezing

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10
Q

what is the function of the vesico ureteric mechanism?

A

to protect the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder

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11
Q

what are the sympathetic nerve supply of the micturition system?

A

hypogastric nerve

T10-L2

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12
Q

what happen to the muscle and urethra during storage phase ?

A

detrusor muscle relaxes and urethral sphincter contracts

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13
Q

which nerve supply is active during storage?

A

sympathetic

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14
Q

what is the parasympathetic nerve supply

A

pelvic nerve

S2-S4

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15
Q

what effect does this have on the bladder and urethra ?

A

contraction of bladder and relaxation of the urethra

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16
Q

what is the somatic nerve supply of the micturition system?

A

pudendal nerve

S2-S4

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17
Q

why is somatic innervation important ?

A

for voluntary control of the micturition system

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18
Q

explain the process of bladder filling

A
  • bladder accomodate increasing volume at constantly low pressure
  • there is a gradual rise of awareness of filling
  • cortical acitivity - activates reciprocal guarding reflex by the rhabdosphincter contraction which increase sphincter contraction and resistance
  • there is also an activation of the sympathetic pathway and reciprocal inhibition of the parasympathetic pathway
  • which mediates the contraction of the bladder base and proximal urethra
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19
Q

explain the process of bladder emptying

A
  • detrusor muscle contraction
  • urethra relaxation
  • coordination of sphincter
  • absence of obstruction of anatomical shunt such as cystocele or diverticulum
  • cortical influence by the pontine micturition centre –> activation of the parasympathetic system and reciprocal inhibition of the sympathetic pathway
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20
Q

how many % of women aged 15-60 y experience urinary incontinence?

A

10-25%

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21
Q

how many % of women aged >60 y experience urinary incontinence ?

A

15-40%

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22
Q

prevalence increase with …..

A

age

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23
Q

impact of urinary incontinence (UI)

A
  • may impair QoL
  • reduce social activities and relationship
  • impair emotional and psychological wellbeing
  • impair sexual relationship
  • embarassment and diminished self esteem
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24
Q

QoL is important, on average women sought mediacl help after how long bcs of the impact of UI on their QoL?

A

5 years

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25
Q

what are the risk factors for UI ? (12)

A 
age 
menopause 
parity 
surgery
pelvic floor trauma 
medical problems 
denervation 
pregnancy and childbirth 
smoking 
connective tissue disease 
increased intraabdominal pressure
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26
Q

out of those what are the main rf for stress incontinence?

A

childbirth and pregnancy

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27
Q

questions to be asked during hx taking for UI

A 
age 
parity 
mode of delivery 
weight of heaviest baby 
smoking 
HRT 
medical condition 
previous PFMT, surgical treatment for POP or SUI - especially any failed ones
28
Q

which medical condition and medication is important to be asked?

A

Diabetes mellitus
antihypertensive
- diuretics increase frequency of urinating
diazoxide - is used to treat hypoglycaemia and they reduce urethral resistance and thus precipitate SUI
glaucoma
heart or kidney or liver problems - need to reduce dose of meds given
cognitive problems- some meds can worse their cognitive problems
antidepressants or anti-psychotics

29
Q

what are the irritation symptoms ?

A 
increased daytime frequency(>7)
urgency 
nocturia (>1)
haematuria 
dysuria
30
Q

which of the irritation symptoms may need to go through another pathway depending on how patient present ?

A

haematuria - frank haematuria may not be due to cystitis esp in those over 50 y and may have to go through the haematuria pathway

31
Q

what are the incontinence symptoms ?

A

stress UI
urgency UI
coital incontinence

32
Q

what are the voiding symptoms ?

A

interrupted flow
straining
recurrent UTI

33
Q

which of the voiding symptoms may go through another pathway if significant ?

A

recurrent UTI

34
Q

what do you have to check in terms of fluid intake ?

A

quantity and quality

35
Q

what are the prolapse symptoms ?

A

vaginal lump or dragging sensation in vagina

36
Q

what are the bowel symptoms ?

A

anal incotinence, constipation, faecal evacuation dysfunction, IBS

37
Q

what method of assessment do you use ?

A

3 day urinary diary recording - fluid intake (quantity and quality), urine output, day time frequency, nocturia, average voided volume

urine dipstick

38
Q

what are the examination that should be done ?

A 
general 
abdominal 
neuro 
gynaecological 
pelvic floor assessment
39
Q

Gynaecological assessment incl?

A 
prolapse 
stress incontinence 
urogenital atrophy changes 
pelvic mass
pelvic floor tone, strenngth and awareness
40
Q

what scale is used for pelvic floor assessment?

A

oxford scale

41
Q

what are the possible investigations to be used

A
  • urinalysis: multistix +/- MSSU
  • post voiding residual volume using bladder scan
  • urogram
42
Q

when do you do post voiding residual volume scan ?

A

if have voiding symptoms

43
Q

who are investigated using urodynamics ?

A

in those where surgery is contemplated
those with urge incontinence may not need this prior to surgery unless-those with voiding difficulties , concomitant prolapse , previous failed continence surgery

those with overactive bladder

as well as those with predominant SUI symptoms as well as on clinical examination will need urodynamics prior to primary surgical treatment if it is associated with prolapse or voiding difficulties

44
Q

if someone have OAB on scan what do you do? what if not ?

A

if + –> offer SNM or botox

if -ve –> consider botox or SNM

45
Q

ranking the investigations required for UI

A

1st is urine dipstix or MSSU
2nd - urodynamics
3rd - assessment of residual urine volume using bladder scan

46
Q

management of urinary incontinence

A
  1. lifestyle changes
    - normalise fluid intake
    - stop smoking
    - lose weight
    - eat moer healthily to avoid constipation
    - stop drinking caffeinated drinks and alcohol
  2. medical treatment
    - for modeate to severe SUI - duloxetine and should be in combination with PFMT
    - For OAB - anticholinergic mirabegron and vaginal oestrogen
    - urethral bulking
  3. physiotherapy
    - PFMT +/- electrical stimulation or vaginal cones
  4. surgery
    - synthetic MUS / mesh –> no longer used now
    - autologous or rectus fascial sling
    - colposuspension
47
Q

everyone should first get conservative treatment unless?

A

patient do not wish
previously failed
no facilities

48
Q

when do we go for medical treatment ?

A 
when PFMT has failed or would be enhanced by this drug 
or if do not wish for surgery
not fit for surgery
after failed surgery 
when patient's family is not complete `
49
Q

what are the first choice surgical treatment ?

A
  • colposuspension

- autologous or rectus fascial sling

50
Q

Colposuspension procedure is based on what theory?

A

pressure transmission theory

51
Q

what do they do in colposuspension ?

A

can be done open or laparoscopic
lift the lateal vaginal wall to the level of bladder neck up to the ischiotibal ligament
so hammock around bladder neck and thus when patient cough or sneeze - it is supporting the bladder neck and prevent incontienence

52
Q

both SUI and UUI arise from same anatomical defect in ……

A

anterior vaginal wall and the pubourethral ligament

53
Q

why does breakdown of the pubourethral ligament cause incontinence?

A

because that ligament act as a hammock below mid urethral level and keeps urethra well supported and the area in the mid urethral level as high pressure zone and keeps the continence

54
Q

when do we do periurethral bulking ?

A

not medically fit

not complete family

55
Q

succes rate for the periurethral bulking

A

70% at 1 y and 45% at 2 y and has long term success tho the long term adverse effect is not really known

56
Q

who wont be referred to PFMT?

A

those who score 3 or 4 on the oxford scale as it wont be effective

57
Q

what happen in PFMT?

A

it will reinforce the cortical awareness of muscle groups

aim to hypertrophy the existing muscle group as well as general increase in tone and strength of the muscle

58
Q

what are the definining symptoms of the OAB ?

A

urgency with or without urgency incontinence

usually with frequency and nocturia

59
Q

Detrusor overactivty is further classified as

A

neurogenic
or
idiopathic

60
Q

prevalence of OAB increases with …. and is slightly higher in …

A

age

women

61
Q

risk factor for urge urinary incontinence

A

advanced age
diabetes
UTI
smoking

62
Q

management of OAB

A

treat symptoms
no immediate care
MDT
conservative management:
- lifestyle intervention - normalise fluid intake, reduce fizzy drinks and chocolate and caffeine, stop smoking and weight loss
- bladder training program - timed voiding with gradually increased interval

pharmacological:
- antimuscarinic (oral or transdermal)
- tricyclic antidepressants - imipramine
- B3 agonist - mirabigone

more recent advances

  • botox
  • neuromodulation
63
Q

oral antimuscarinics includes?

A 
solifenacin 
feosteridine 
trospium 
darifencain 
lyrinel 
oxybutinin
64
Q

explain about the use of botox

A

botulinum toxin
inserted using cystoscopy
effect last 6-9 months
some may require CISC - 10% may require self catheterisation

65
Q

is there a different dose for neurogenic or idiopathic OAB?

A

yes
idiopathic - 100-150 unit
200-300 in neurogenic

66
Q

explain about the use of neuromodulation

A

needle stimulates S2-S4
reflex inhibition of the detrusor muscle
minimally invasive and cheap
continuously give impulses to this area to inhibit impulses going to the pontine micturition centre and thus reduce sensation of urgency

67
Q

needle in neuromodulation stimulate which level of nerve?

A

S2-S4

Y3- Reproductive System 1/3 R (2 decks)

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