Incontinence Flashcards
What is the MOST likely side effect after Botox procedure for treatment of overactive bladder?
Urinary Tract Infection
Risk of UTI = 33%
Risk of voiding dysfunction that requires catheterization is only 5%
In an obese woman what is the risk of developing urinary incontinence?
GREATER than 50%!!!
What are the 5 key components of a workup for urinary incontinence?
- H&P
- Cough stress test
- PVR
- Assessment urethral mobility
- UA & UC
At what amount of RBC’s on microscopic UA do ACOG and AUGS recommend eval for microscopic hematuria?
Greater than 25 RBCs per hpf
- This is only true for asymptomatic, low risk, non-smoking women age 35-50
What is the Q tip test?
using q-tip (or straight cath) to assess movement of urethra with Valsalva. Positive is > 30 degrees above the horizontal
The prescence of urethral mobility indicates uncomplicated SUI (lack of urethral mobility is associated with a 2 fold increase in failure rate of mid urethral sling
Patient who lack urethral mobility may be better candidates for urethral bulking agents rather than sling
What is a normal bladder capacity?
What about a normal PVR?
capacity 350 cc
PVR less than 150 cc
What is the mechanism of action of oxybutynin?
Anti muscarinic, blocks M2/M3
Side effects of anti muscarinics?
dry mouth
dry eyes
constipation
Contraindications to anti-muscarinics?
Narrow angle glaucoma
Urinary retention
Gastric retention
Mechanism of Mirabegron?
Beta 3 agonist
Side effects of Mirabegron?
Diarrhea
Tachycardia
Headache
When should Mirabegon be avoided?
Uncontrolled HTN, renal or liver disease
What is an abnormal post void residual?
> 150 cc
Basic Eval of urinary incontinence
History/Bladder Diary
Physical
- Assess for prolapse
- Assess estrogen status
Cough test to observe leakage
Q-tip test to assess urethral hyper mobility
Post void residual
UA/UCx
First line treatment for Urge Incontinence
Behavioral!
Weight loss
Avoiding bladder irritants
Fluid management
Bladder re-training
Timed Voiding
Pelvic Floor Physical Therapy
Second line treatment for Urge Incontinence?
Pharmacologic!
B-3 agonists (mirabegron)
Anti-muscarinics (oxybutinin)
Vaginal estrogen
Botox injection
THEN
Interstim (sacral neuromodulation)
Surgical management of stress urinary incontience?
Retropubic midurethal slings (tension-free vaginal tape)
Inserted through the retropubic space and exit through the abdominal in the suprapubic area
- Local, regional or GETA
- Dorsal lithotomy
- Mark abdominal incisions, 2 cm lateral to the midline
- Hydrodissection - inject into the vaginal wall inferior and lateral to the urethra in addition to downward along the back of the pubi bone to the retropubic space
- Allis clamp at 1 cm proximal to the urethral meatus, about 1.5 cm in legnth to accomodate the sling
- Allis clamps moved to lateral edges of mucosa to retract laterally
- Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fasica is performed bilaterally with Metz
- Catheter guide placed, and bladder deviated to opposite side of trocar insertion
- Insert trocar lateral to the urethra, pass the trocar behind pubic symphysis and exit through the abdominal sites.
- Aim trocar handle in the direction of the outer aspect of patient’s shoulder
- Cystoscopy, if bladder perforation, remove and re-do
- To ensure tension-free sling, 7 mm heegar dilator placed between sling and urethra (should not compress urethra at rest)
- Remove the plastic sheaths, trim mesh at abdmoinal insicisons
- Voiding trial before discharge
**Deviation of the trocar in a cephalad direction may result in injury to bowel, bladder, blood vessels
**Deviation laterally could injury major vasculature (external illiac vessel, obturator vessels, epigastric vessels)
Possible complications of mid-urethral sling?
Failure/ persistent SUI (5%)
90% dry, 95% happy, 5% unchanged
Urinary retention (1/4 of pts)
Infection (15%)
Bleeding (2%)
- surgical site
- hematoma in space of retzius
Injury to near by structures
- Bladder injury with suture/mesh (3%)
- Ureteral injury (< 2%)
- Bowel injury (exceedingly rare < .5%)
Mesh exposure (< 2%)
When is mesh ok to use in pelvic surgery?
Insertion of mid urethral sling
Sacrocolpoexy
Differences between retropubic sling and transobturator sling?
Retropubic - higher efficacy, slightly increased risk of bladder perforation, bowel injury, short-term pubic pain, and post op voiding dysfunction
Transobturator - lower efficacy, lower risk of adverse events, more short term pain but less voiding dysfunction, go through obturator foramen
What is the sling made of?
Type 1 polypropylene mesh
Contraindications to mid urethral sling?
Current UTI
Current pregnancy
Anticoagulation
Previous surgeries in the path of sling placement (vascular graft, bowel, transplant kidney)
