)&G - Urogynaecology Flashcards
If a pt presents with Urinary incontinence what causes need to be ruled out?
- Infection e.g. UTI
- Excessive fluid intake i.e. > 2L /day
- Urinary retention –> overflow incontinence
- Neurological disorders e.g. Cauda Equina, MS, normal pressure hydrocephalus
- Cancer
- Urogenital prolapse
What lifestyle modifications are reccommended to pts to improve urinary incontinence?
- Weight loss
-
Adequate hydration:
- consume normal or slightly < normal amount of liquids
- do not drink excessively
- space out liquid consumption throughout the day
- ↓ caffeine
- ↓ alcohol
- Void bladder regularly e.g. every 2-hrs or at specific times of day
What are some indications for referral to incontinence specialist?
- Symptoms / examination suggestive of neurologic disease
- Lifelong hx of incontinence (present since childhood)
- Recurrent symptomatic UTIs
- Pelvic organ prolapse beyond the hymen
-
Elevated postvoid residual
- roughly > 1/3rd total volume or 100 mL in adults, > 150 mL in older patients)
- Long-term catheterization
- Difficulty passing a urethral catheter
- Dominant symptom of pain
- Sterile hematuria (gross or microscopic)
- Diagnostic uncertainty or poor improvement with treatment
In whom is urinary incontinence more common women or men?
Women
(2 x commoner than in men)
- estimated ~ 1/3rd women >60-yrs experience incontinence
What is Stress incontinence?
Stress incontinence = unintentional urine leakage in the absence of detrusor activity when:
- Laughing
- Sneezing
- Coughing
- Any activity that ↑ abdominal pressure e.g. pregnancy or exercise
Stress incontinence is often the result of weakened pelvic floor muscles (due to various reasons e.g. vaginal deliveries / pregnancy) + actions that cause acute ↑ abdominal pressure e.g. sneezing
What is Urge Incontinence?
Urge incontinence = unintentional urine leakage caused by inability to hold/prevent urination when NS is stimulated (e.g. by stretch receptors)
Commonly caused by ‘overative bladder syndrome’ i.e. overactive destrusor –> bladder wall muscles contract in uncontrolled manner (unknown cause - suspected neurological)
What is overflow incontinence?
Overflow incontinence = unintentional urine leakage due to chronically over-full bladder which results from bladder outlet obstruction
Rare in women!
Can be caused by:
- Blocked / narrowed urethra –> ineffective urination resulting in ↑ post-voidal urine left in bladder
- Destrusor muscle weakness (bladder muscle)
What questions are important to ask as part of an incontinence hx?
Specific:
- Are symptoms impacting your QoL? - this influences intervention
- How are you managing symptoms at current?
- When does urine leak occur - urgency vs stress?
- Any nocturia?
- Difficulty passing urine? (overflow incontinence)
- Dysuria? (UTI)
- Haematuria?
- Any fecal incontinence?
- Any difficulties in intercourse?
General:
- Full Gynae Hx
- Full Obstetric Hx - past / recent pregnancies / deliveries can affect bladder
- PMH
- PSH
- DH
- SH - smoking, alcohol, recreational drugs, occupation - impact?
How is urge incontinence (not caused by UTI or underlying pathology) managed?
-
1st line = Bladder retraining (min 6-weeks –> aim to gradually ↑ intervals between voiding) + lifestyle modifications
- Retraining involves - resisting urge to urinate + contracting pelvic floor + distracting yourself from the urge
-
2nd line = Anti-muscarinics –> detrusor relaxation
-
oxybutynin
- Immediate release should be avoided in frail / elderly
- tolterodine
- darifenacin (once daily preparation)
-
oxybutynin
- 3rd line = Mirabegron (beta-3 agonist) - used if concern about anti-cholinergic SEs from anti-muscarinic drugs
- Avoid in frail / elderly
How do you manage stress incontinence?
-
1st line = Pelivc muscle exercises + lifestyle modifications
- Exercises - 8 pelvic floor contractions at least TDS for 3-months
- 2nd line = topical oestrogen (cream or patch) - helps tone muscles and tissue around urethra
-
3rd line = Stress incontinence surgery e.g.:
- Midurethral sling (MUS)
- Colposuspension
- Urethral Bulking
- Fascial sling (similar to MUS but uses strips of fascia from rectus sheath for sling instead of polypropylene mesh)
What are some Uro-gynae Red-Flags?
- Standard - weight loss, fever, night weats
- Visible haematuria –> ?bladder cancer
- Pain associated with bladder filling –> ?bladder cancer
- Abdominal swelling / pelvic mass –> ?cancer
What investigations might you do for incontinence in women?
- Urine dipstick +/- urinalysis - exclude infection + glycosuria
- Abdominal + pelvic exam - exclude masses + prolapse
- Medication review e.g. alpha adrenergic antagonists for BP also relax urethral sphincter
- Bladder diary - minimum of 3-days
- Urodynamic studies - investigate bladder function
How is the urethra in women different to in men?
- Female urethra is shorter
- Women have no internal urethral sphincter (only external)
Which nerve act on external urethral sphincter to cause contraction (hold urine in)?
What type of receptor does it act on?
Pudendal nerve releases ACh which stimulates nicotinic ACh receptors to cause external urethral sphincter contraction
(under Somatic control i.e. conscious)
Which part of the autonomic NS causes micturition and which part prevents micturition?
Parasympathetic NS –> detrusor contraction
Sympathetic NS –> detrusor relaxation + contract internal urethral sphincter (in men)
What is a Cystocele?
Prolapse of anterior vaginal wall (bladder)
Often associated with prolapse of urethra termed cysto-urethrocele
What is a Rectocele?
Prolapse of the lower posterior vaginal wall (rectum)
What is an Enterocele?
Prolapse of the upper posterior vaginal wall (loops of small bowel)
What is a Uterine (apical) prolapse?
Prolapse of the uterus / cervix into the upper vagina
What is Urethral Bulking?
Urethral bulking is a procedure to help stress incontinence
- Bulking material is injected around urethra –> narrowing –> ↓ urine leaks
- Local anaesthetic (can be GA)
- Bulking agents:
- Collagen
- Gels
- Procedure is indicated in:
- pts with stress incontinence due to sphincter muscle deficiency
- women not fit enough for surgery or anaesthesia
What is a Mid-urethral sling (MUS) surgery?
- Vaginal + lower abdomen incisions
- Tapes of polypropylene mesh are inserted via vaginal incision and looped around rectus fascia to form sling
- Work by supporting the mid-urethra during times of ↑ intra-abdominal pressure
What is Colposuspension?
Colposuspension:
- Open or laproscopic
- Uses sutures to elevate neck of bladder via suturing to Cooper’s ligament (pectineal ligament)
- ↓ tendency of urine to flow during ↑ abdominal pressure
