Incontinence and FGM

Question 1

What is stress UI

Answer 1

Involuntary leakage on effort or exertion

Question 2

What is urge UI

Answer 2

Involuntary leakage accompanied by or preceded by urgency due to overactivity of bladder

Question 3

What nerve allows storage of urine

Answer 3

Hypogastric sympathetic
T10-L2
B-receptor on detrusor relaxes

Question 4

What nerve allows internal sphincter to contract

Answer 4

Same

Acts on adrenergic receptor

Question 5

What nerve stimulates voiding

Answer 5

Pelvic
Parasympathetic S2-S4
Relax internal sphincter
Contract detrusor

Question 6

What nerve is responsible for voluntary control

Answer 6

Pudendal
S2-S4
Contraction of external sphincter

Question 7

What causes SUI

Answer 7

Increase in intra-ado pressure > urethral
Defect / weakness in pelvic floor
Hammock laxity

Question 8

What are other causes / DDx

Answer 8

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

Question 9

What are symptoms associated with incontinence

Answer 9

Urgency
Frequency
Nocturia
Dysuria
Haematuria
Incontinence
Strain to void
Interrupted flow
Recurrent UTI
Prolapse Sx
Bowel Sx

Question 10

What are RF for SUI

Answer 10

Age
Menopause 
Female 
Parity
Instrumental birth 
Obesity 
Hysterectomy
FH
Smoking
Increase in intra-abdominal pressure - cough 
Pelvic floor trauma / surgery 
Connective tissue 
Denervation

Question 11

What are initial investigations

Answer 11

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

Question 12

When do you do post void residual volume

Answer 12

If difficulty voiding

Suggestive of overflow

Question 13

When do you do urodynamics

Answer 13

If surgery contemplated or uncertainty over Dx or think prostate

Question 14

What is important in Hx

Answer 14

Obstetric
Gynae
Medical
Previous PFMT
Surgery

Question 15

What is lifestyle measures

Answer 15

Smoking
Weight loss
Avoid constipation
Stop alcohol and coffee
Oestrogen clream

Question 16

What is 1st line Rx

Answer 16

PFMT

Question 17

What else can you do

Answer 17

Biofeedback if can’t contract

Question 18

What pharmacological measures

Answer 18

Duloxetine - SNRI
Yentreve
If PFMT and surgery not an option

Question 19

What surgery

Answer 19

TVT = 1st line

COlposuspension

Question 20

What are risks of TVT

Answer 20

Bladder perforation
Vaginal and urethral erosion
Vascular injury

Question 21

What does a vesicle-vaginal fistula present like

Answer 21

Continuous dribbling
Prolong labour
Poor access to services e.g. poor country

Question 22

How do you Dx

Answer 22

Urinary dye study

Question 23

What causes overactive / urge

Answer 23

Destrusor overactivity = form of urge 
Neurogenic
MS
Parkinson
DM
Stones

Question 24

What are symptoms

Answer 24

Urgency
Incontinence
Frequency
Nocturia 
Small vol
Overflow

Question 25

What are RF

Answer 25

Age DM UTI Smoking

Question 26

How do you Dx

Answer 26

Bladder diary Dipstick VE or DRE in men Urodynamic study

Question 27

How do you treat

Answer 27

Normalise intake Stop smoking Weight. loss Bladder retraining programme

Question 28

What are pharmacological intervention

Answer 28

``` Anti-muscarininc - Oxybutynin - never in elderly - Toldierone - Mirebegron if >75 TCA Botox Neuromodulation if refractory ```

Question 29

What are SE of anti-muscarininc

Answer 29

Dry eyes and mouth | CNS

Question 30

When should you caution with anti-muscarininc

Answer 30

Narrow angle glaucoma Myasthenia gravis Poor contracted bladder

Question 31

Oxybutynin

Answer 31

DO NOT USE IN FRAIL as immediate release | Use mirebegron if >75

Question 32

What causes overflow

Answer 32

Bladder outlet obstruction usually due to BPH leading to retention Nerve damage - Neuropathy - Pelvic surgery

Question 33

What are Sx

Answer 33

``` Strain Poor flow Incomplete emptying Overflow Palpable bladder after urination ```

Question 34

How do you Dx

Answer 34

``` Urine dip VE Bladder diary Urodynamic Bladder scan for residual ```

Question 35

What does it look like on urodynamic study

Answer 35

High voiding pressure | Low flow rate

Question 36

What is FGM

Answer 36

``` 1 = removal of clitoris 2 = clitoris + labia 3 = infibulation (narrowing of vaginal) 4 = any other ```

Question 37

How do you deal with FGM

Answer 37

OFFEENSE IN UK | Reinfibulation = illegal

Question 38

What are shot term complications

Answer 38

``` Pain Shock Bleeding Infection Fatal haemorrhage ```

Question 39

What are long term complications

Answer 39

``` Retention Difficulty menstruation Infection Cyst Obstructed labour Fistula PTSD Sexual dysfunction ```

Question 40

What should you always ask in Hx

Answer 40

Psychological / QOL

Question 41

If present in acute setting what Ix

Answer 41

``` 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 ```