Incontinence and FGM Flashcards
What is stress UI
Involuntary leakage on effort or exertion
What is urge UI
Involuntary leakage accompanied by or preceded by urgency due to overactivity of bladder
What nerve allows storage of urine
Hypogastric sympathetic
T10-L2
B-receptor on detrusor relaxes
What nerve allows internal sphincter to contract
Same
Acts on adrenergic receptor
What nerve stimulates voiding
Pelvic
Parasympathetic S2-S4
Relax internal sphincter
Contract detrusor
What nerve is responsible for voluntary control
Pudendal
S2-S4
Contraction of external sphincter
What causes SUI
Increase in intra-ado pressure > urethral
Defect / weakness in pelvic floor
Hammock laxity
What are other causes / DDx
DIAPERS Delerium Infection - UTI / cystitis Atrophic vagintiis Pharamceutic or prolapse - Diuretic - Anticholinergic / cholinergic Endocrine - DM - DI - Hypercalcaemia Restricted mobility Stool impaction / stones
Other
Excess fluid
Anxiety
What are symptoms associated with incontinence
Urgency Frequency Nocturia Dysuria Haematuria Incontinence Strain to void Interrupted flow Recurrent UTI Prolapse Sx Bowel Sx
What are RF for SUI
Age Menopause Female Parity Instrumental birth Obesity Hysterectomy FH Smoking Increase in intra-abdominal pressure - cough Pelvic floor trauma / surgery Connective tissue Denervation
What are initial investigations
VE for prolapse / strength of PFM
Urine dip and MSSU
3 day urine diary with intake, output, volume
U+E / glucose
Post void residual volume
USS renal tract - hydronephrosisi if retention
When do you do post void residual volume
If difficulty voiding
Suggestive of overflow
When do you do urodynamics
If surgery contemplated or uncertainty over Dx or think prostate
What is important in Hx
Obstetric Gynae Medical Previous PFMT Surgery
What is lifestyle measures
Smoking Weight loss Avoid constipation Stop alcohol and coffee Oestrogen clream
What is 1st line Rx
PFMT
What else can you do
Biofeedback if can’t contract
What pharmacological measures
Duloxetine - SNRI
Yentreve
If PFMT and surgery not an option
What surgery
TVT = 1st line
COlposuspension
What are risks of TVT
Bladder perforation
Vaginal and urethral erosion
Vascular injury
What does a vesicle-vaginal fistula present like
Continuous dribbling
Prolong labour
Poor access to services e.g. poor country
How do you Dx
Urinary dye study
What causes overactive / urge
Destrusor overactivity = form of urge Neurogenic MS Parkinson DM Stones
What are symptoms
Urgency Incontinence Frequency Nocturia Small vol Overflow
What are RF
Age
DM
UTI
Smoking
How do you Dx
Bladder diary
Dipstick
VE or DRE in men
Urodynamic study
How do you treat
Normalise intake
Stop smoking
Weight. loss
Bladder retraining programme
What are pharmacological intervention
Anti-muscarininc - Oxybutynin - never in elderly - Toldierone - Mirebegron if >75 TCA Botox Neuromodulation if refractory
What are SE of anti-muscarininc
Dry eyes and mouth
CNS
When should you caution with anti-muscarininc
Narrow angle glaucoma
Myasthenia gravis
Poor contracted bladder
Oxybutynin
DO NOT USE IN FRAIL as immediate release
Use mirebegron if >75
What causes overflow
Bladder outlet obstruction usually due to BPH leading to retention
Nerve damage
- Neuropathy
- Pelvic surgery
What are Sx
Strain Poor flow Incomplete emptying Overflow Palpable bladder after urination
How do you Dx
Urine dip VE Bladder diary Urodynamic Bladder scan for residual
What does it look like on urodynamic study
High voiding pressure
Low flow rate
What is FGM
1 = removal of clitoris 2 = clitoris + labia 3 = infibulation (narrowing of vaginal) 4 = any other
How do you deal with FGM
OFFEENSE IN UK
Reinfibulation = illegal
What are shot term complications
Pain Shock Bleeding Infection Fatal haemorrhage
What are long term complications
Retention Difficulty menstruation Infection Cyst Obstructed labour Fistula PTSD Sexual dysfunction
What should you always ask in Hx
Psychological / QOL
If present in acute setting what Ix
DRE men for any urinary Sx Bimanual for women Urine dip - rule out UTI U+E / glucose Post void residual to see if retention and rule out overfllow Renal USS - hydronephrosis
