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Y3 repro > female urinary incontinence > Flashcards

female urinary incontinence Flashcards

1
Q

what are the 2 components of the urinary tract (important!!)

A

upper - kidneys and ureters, low pressure distensible conduit w/ intrinsic peristalsis (verniculation), transports urine from nephrons via ureters to bladder

lower - bladder and urethra, low pressure storage of urine, efficient expulsion of urine at appropriate place and time

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2
Q

rate of bladder filling

A

0.5-5mls/min

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3
Q

rate of bladder filling

A

0.5-5mls/min

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4
Q

what is the vesico-ureteric mechanism

A

between UUT and LUT

one way valve

protects the nephrons from any damage 2y to retrograde transmission of back pressure/infection from the bladder

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5
Q

nerve supply to the bladder

A

s**torage - hypogastric nerve (**symp), T10-L2 - relaxation of bladder and contraction of ureteric sphincter

voiding - p**elvic nerve (**p**arasymp), S2-4 (**power), contraction of bladder and relaxation of sphincter

voluntary - pudendal nerve (somatic), S2-4

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6
Q

bladder filling

A

accomodate increasing volume at constantly low pressure

inhibition of contractions by giving rise to gradual awareness of filling

distensable bladder wall

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7
Q

cortical activity and bladder filling

A

activating a reciprocal guarding reflex by rhabdosphincter contraction, increase sphincter contraction and resistance

activates sympathetic pathway

reciprocal inhibition of the parasympathetic pathway

mediates contraction of bladder base and proximal urethra

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8
Q

bladder emptying

A

detrusor contraction

urethral relaxation

sphincter co-ordination

absence of obstruction (cystocele, diverticulum etc)

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9
Q

cortical influence on bladder emptying

A

pontine micturition centre

activation of parasympathetic pathway and inhibition of sympathetic pathway

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10
Q

what is urinary incontinence - UI

A

ANY involuntary leakage of urine

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11
Q

what is stress urinary incontinence -SUI

A

involuntary leakage on effort or exertion, on sneezing or coughing

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12
Q

what is urge urinary incontinence - UUI

A

involuntary leakage accompanied by or immediately preceded by urgency

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13
Q

what is mixed urinary continence - MUI

A

involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing

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14
Q

epidemiology of UI

A

10-25% of women aged 15-60

15-40% of women >60

>50% of women in nursing homes

WHO international health concern

prevalence increases w/ age

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15
Q

impact of UI

A

UI may significantly impact QOL

reduce social relationships and activities

impair emotional and psychological well being

impair sexual relationships

embarrassment and diminished self esteem

impact on QOL is why women seek help but often after yrs of suffering (~5yrs)

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16
Q

risk factors for UI

A

age

pregnancy

parity

menopause

smoking

medical problems

chronic increased intra-abdo pressure

pelvic floor trauma

denervation

connective tissue disease

surgery

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17
Q

what is the main risk factor for SUI

A

pregnancy and childbirth

large object passing through a constricted channel

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18
Q

patient assessment for UI

A

hx

examination

investigations

management

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19
Q

hx for UI

A

age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT

medical conditions: DM, anti-HT medications, glaucoma, heart/kidney/liver problems, cognitive problems, anti-depressants/psychotics

previous PFMT, surgical treatment of SUI/POP

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20
Q

irritation symptoms

A

urgency - sudden compelling desire to void that is difficult to defer

increased daytime frequency (>7)

nocturia (>1)

dysuria

haematuria (red flag; frank, not cystitis, >50, smoker)

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21
Q

incontinence symptoms

A

SUI

UUI

coital incontinence

severity - how many pads/day

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22
Q

patient assessment - complaint

A

irritation symptoms

incontinence symptoms

voiding symptoms

OAB (overactive bladder) - usually associated w/ frequency, nocturia and urgency

fluid intake - quantity and content

effect on QOL

prolapse symptoms

bowel symptoms

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23
Q

voiding symptoms

A

straining to void

interrupted flow

recurrent UTI - red flag

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24
Q

prolapse symptoms

A

vaginal lump

dragging sensation in vagina

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25
Q

bowel symptoms

A

anal incontinence

constipation

fecal evacuation dysfunction

IBS

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26
Q

patient assessment following hx taking

A

2-3 days urinary diary

urine dipstick

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27
Q

urinary diary

A

fluid intake - quantity and content

urine ouput - excluding nocturnal polyuria

daytime frequency

nocturia

avg voided volume

28
Q

examination of a women w/ bladder/pelvic floor problems

A

general/abdo

neuro - if indicated by hx

gynae - prolapse; stress incontinence; uro-genital atrophy changes; pelvic mass; pelvic floor tone, strength, awareness

29
Q

investigations for urinary incontinence

A

urinalysis - multistix +/- MSSU

post-voiding residual volume assessment - bladder scanning

urodynamics

30
Q

what is urodynamics

A

study of bladder/urethral physiology to detect underlying pathology that may explain symptoms

invasive set of tests that are only indicated if surgical treatment is contemplated

women w/ SUI symptoms may not need urodynamics prior to surgery unless symptoms of voiding difficulties/concomitant prolapse or prev failed continence surgery

31
Q

indications for urodynamics

A

confirm diagnosis

differentiate SUI vs detrusor overactivity vs MUI

investigate voiding symptoms

32
Q

NICE guidelines for urodynamics

A
  • do not perform prior to conservative UI management
    • perform in women w/ refractory OAB
  • women w/ predominant SUI symptoms and demonstratable SUI on examination, perform prior to 1y surgical treatment for SUI if associated prolapse or VD symptoms
33
Q

DO management following urodynamics for refractory OAB

A

if DO confirmed → offer botox, SNM

if no DO confirmed → consider botox/SNM

34
Q

management of UI

A

lifestyle changes

medical

physiotherapy

surgical

35
Q

conservative management for UI

A

MUST be offered to ALL women w/ UI

  • 60-70% of women will not come back for further surgery

should be completed prior to contemplating surgical treatment

where not possible (rare) - documentation and MDT discussion

36
Q

lifestyle changes for UI

A

normalise fluid intake (1.5-2L/day)

reduce caffeine, fizzy drinks, chocolate

stop smoking

weight loss

avoid constipation and chronic cough

37
Q

what is offered to every woman w/ UI

A

physiotherapist for pelvic floor muscle training (unless score of 3 or 4)

(+/- electrical stimulation, vaginal cones)

38
Q

pharmacological treatment for UI

A

SUI - duloxetine

OAB - anticholinergics - Mirabegron and vaginal oestrogen

39
Q

PFMT

A
  1. reinforcement of cortical awareness of muscle groups
  2. hypertrophy of existing muscle fibres
    1. general increase in muscle tone and strength
40
Q

evidence for PFMT

A

more effective than no treatment

more effective than electrical stimulation

more effective than vaginal cones

60-70% cure/significant improvement - experienced physio w/ special interest and well motivated patient

41
Q

what is PFMT

A

pelvic floor muscle training

42
Q

Duloxetine for SUI

A

aka Yentreve

selective noradrenaline reuptake inhibitor

  • 1st and currently only drug licensed for treatment of moderate - severe SUI
  • should be part of overall management strategy including PFMT
43
Q

continence theory and surgical management - NICE guidelines

A

synthetic MUS (mesh)

autologus (rectus) fascial slings

colposuspension

urethral bulking

44
Q

surgical management of UI - synthetic MUS

A
  • RP-TVT (retro-pubic approach, tension-free vaginal tape) = all mesh based procedures continue to be suspended in UK for concerns on safety

native tissue surgery is now the most common

45
Q

surgical management of UI - autologous (recuts) fascial slings

A

modified aldrige vs sling on string

46
Q

how can colposuspension be carried out

A

open

laparoscopic

47
Q

what is colposuspension and what does it depend on

A

uses stitches to support the neck of the bladder so that it can’t move about and cause stress incontinence

pressure - transmission theory

lifts lateral vaginal wall up at the level of the neck of the bladder

stitch it to the iliopectineal ligament

creates a hammock around the bladder neck

48
Q

what is the integral theory of female UI

A

SUI and UUI arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament (PUL)

→ urethral/bladder neck closure dysfunction and SUI

suburethral hammock laxity might result in stimulation of bladder neck stretch receptors, provoking premature micturation reflex and UUI

49
Q

synthetic (mesh) mid-urethral slings - retropubic TVT

  • what is it
  • what does it rely on
  • effectiveness
A

tension free vaginal tape - introduced as a minimally invasive procedure to reinforce the structures supporting the urethra

depends on the hammock theory for continence

80% cure at 11yrs

polypropylene permanent synthetic tape

50
Q

autologous (rectal) fascial sling

A

abdominal incision

create sling from abdominal rectus sheath

insert vaginally as with TVT

creates hammock around mid-urethral level

51
Q

peri-urethral bulking

  • who is it for
  • success rate
A
  • not medically fit for surgery or not completed family
    • success rate 70% at 1yr, 45% at 2yrs
    • ? long term success and adverse effects
52
Q

SUI surgery rates

A

2007-2016

48% reduction in MUS in 2016 vs 2008

53
Q

defining symptoms of OAB

A

urgency (w/ or w/o urgency incontinence)

usually associated w/ frequency and nocturia

usually (but not always) related to urodynamically demonstratable detrusor overactivity

54
Q

define urgency

A

sudden, compelling desire to pass urine that is difficult to defer

55
Q

define urge incontinence

A

involuntary leakage of urine accompanied or immediately preceded by urgency

56
Q

define frequency

A

usually accompanies urgency w/ or w/o urge incontinence

pt considers that they void too often during the day

57
Q

define nocturia

A

usually accompanies urgency w/ or w/o UI and is the complaint that the individual has to wake at night ≥1 time to void

58
Q

risk factors for OAB and UI

A

advanced age

DM

UTI

smoking

OAB is a chronic condition therefore symptoms may come and go

59
Q

OAB management

A

treat symptoms

no immediate care

MDT approach

60
Q

OAB conservative management

A

lifestyle interventions - normalise fluid intake; reduce caffeine, fizzy drinks and chocolate; stop smoking; weight loss

bladder training programme - time voiding w/ gradually increasing intervals w/ continence nurse

61
Q

OAB pharmacological treament

A

anti-muscarinic

mirabegron - beta 3 agonist andispasmodic

tri-cyclic antidepressant - imipramine

62
Q

antimuscarinics for OAB

A

oral

  • solifenacin (vesicare 5-10mg)
  • fesoteridine (toviaz 4-8mg)
  • trospium chloride (60mg XL)
  • darifencain (emselex 7.5-15mg)
  • lyrinel XL (10-20mg)
  • oxybutinin (5-10mg/tds)

transdermal

  • kentera patches

don’t need to know all individual names, just that there is oral or transdermal

63
Q

botox for OAB

A

botulinum toxin

Neurogenic DO/Idiopathic DO

200-300 unit (12U/kg) - for NDO, 1001-50U for IDO

cytoscopy/GA

75% cure and sig improvement

effects last 6-9mths

CISC - 10% pts

64
Q

neuromodulation for OAB

A

needle stimulation - S2-S4

reflex inhibition to detrusor muscle

cheap

minimally invasive

70% improvement in refractory OAB

65
Q

what are the management options for OAB if medication fails

A

botox

sacral neuromodulation

Y3 repro (47 decks)

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