Management of lower urinary tract dysfunction

Question 1

1 - In terms of embryology, the urinary trigone is derived from from the urogenital sinus

2 - The sympathetic innervation of the bladder is via the hypogastric nerve

3 - Detrusor muscle contractions are mediated by the parasympathetic nervous system

4 - Urinary incontinence is defined as a condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable

5 - Lower urinary tract symptoms have been shown to be common in postmenopausal women

Answer 1

1 - False. During the division of the cloaca the caudal portions of the mesonephric duct become absorbed into the urinary bladder, forming the trigone. As a consequence, the trigonal mucosa is mesodermal in origin whilst the remainder of the bladder and urethra are derived from the urogenital sinus and are, therefore, endodermal in origin.

2 - True. The sympathetic innervation of the bladder and urethra arises mainly from the thoraco-lumbar region T10–L2 of the spinal cord. The axons travel mainly in the hypogastric nerve but also pass through paravertabral chain and enter the pelvic nerve. The predominant effects of the sympathetic innervation of lower urinary tract are inhibition of parasympathetic pathways at spinal and ganglion levels.

3 - True. Contraction of the detrusor smooth muscle and relaxation of the outflow tract result from activation of parasympathetic neurons located in the sacral parasympathetic nucleus at the level of S2–S4.

4 - False. The new definition is ‘the complaint of any involuntary leakage of urine’.

5 - True. In women attending a menopause clinic, 20% complained of severe urgency and almost 50% complained of stress incontinence.

Question 2

1 - Overactive bladder is a symptom-based diagnosis

2 - Pelvic floor exercises are effective in the management of women with stress incontinence

3 - Colposuspension remains most commonly performed procedure for urodynamic stress incontinence

4 - Transobturator tapes are associated with lower cure rates than retropubic tapes

5 - Less than 20% of women continue to take antimuscarinic medication after 6 months

Answer 2

1 - True. Overactive bladder describes the symptom complex of urgency with or without urgency incontinence, usually with frequency and nocturia, in the absence of urinary tract infection or other obvious pathology.

2 - true. Cure rates between 21% and 84% have been reported.

3 - False. Retropubic suspension procedures have now been largely replaced by mid-urethral tape procedures following the reporting of the Integral Theory.

4 - False. Recent comparative studies have supported the use of transobturator tapes and have shown that they are comparative to the retropubic tape procedures.

5 - True. Antimuscarinics are associated with low compliance and persistence rates. This is thought to be due to poor efficacy and troublesome side effects. Long-acting agents are no better than the immediate-release agents.

Question 3

Tips for clinical practice

SUI : Conservative MX

Answer 3

1. Discuss the risks and benefits of surgical and nonsurgical options.
   - Consider the woman’s childbearing wishes during the discussion.
   - Always consider conservative options in the first instance.

Question 4

2. If conservative treatments have failed, consider:

SUI

Answer 4

1 - retropubic midurethral tape procedures using a bottom-up approach with macroporous (type 1) polypropylene meshes, open colposuspension or autologous rectus fascial sling

2 -synthetic slings using a retropubic top-down or a transobturator foramen approach. Explain the lack of long-term outcome data

3 - intramural bulking agents (glutaraldehyde crosslinked collagen, silicone, carbon-coated zirconium beads, hyaluronic acid/dextran copolymer).

• Explain that:
  
  • • repeat injections may be needed
  • • effect decreases over time
  • • technique is less effective than retropubic suspension or sling

4 - Artificial urinary sphincter if previous surgery has failed.

Question 5

3. The following are not recommended for stress urinary incontinence:

Answer 5

1 - routine use of laparoscopic colposuspension as a primary procedure

2 - synthetic slings using materials other than polypropylene that are not of macroporous (type 1) construction

3 - anterior colporrhaphy, needle suspensions, paravaginal defect repair and Marshall–Marchetti–Krantz procedure

4 - autologous fat and polytetrafluoroethylene as intramural bulking agents.

Question 6

1 - Detrusor overactivity is an urodynamic diagnosis

2 - Detrusor overactivity is the same as the overactive bladder

3 - Detrusor overactivity is often characterised by leaking during exercise

4 - Detrusor overactivity is most common in children

5 - Detrusor overactivity is usually amenable to surgical correction

Answer 6

1 - True

2 - False

3 - False

4 - False

5 - False

Question 7

Detrusor overactivity can be treated with:

1 - Bladder retraining

2 - Tospium chloride

3 - Oxybutynin

4 - Doxazosin

5 - Propiverine

Answer 7

1 - True

2 - True

3 - True

4 - False

5 - True

Question 8

Regarding urodynamic stress incontinence…

1 - It is a urodynamic diagnosis

2 - It is characterised by leaking when the patient coughs/sneezes

3 - It is usually treated with medication

4 - Anterior colporrhaphy is a good first-line treatment

5 - It is associated with recurrent urinary tract infection

Answer 8

1 -True

2 - True

3 - False

4 -False

5 - False

Question 9

Behavioural modification and conservative therapy should be offered to…

Women with symptoms suggestive of overactive bladder (OAB)
Women complaining of urge incontinence
Women complaining of stress incontinence
All of these options

Answer 9

1 -The answer is all of these options.

Question 10

Antimuscarinic therapy…

May be associated with adverse effects of dry mouth and constipation
Is generally associated with good patient compliance and persistence with therapy
May exacerbate voiding difficulties
Should be offered to women complaining of stress incontinence

Answer 10

may be associated with adverse effects of dry mouth and constipation

Question 11

Duloxetine…

Has no additional benefit over pelvic floor exercises
Is associated with dry mouth
Acts on muscarinic receptors in the bladder
Is the only licensed drug for stress urinary incontinence

Answer 11

Is the only licensed drug for stress urinary incontinence

Question 12

Urethral bulking agents…

• Are not associated with postoperative voiding difficulties
• Generally have a cure and improvement rate of 60% at two years
• A treatment for urodynamic stress incontinence in selected cases
  Must be performed using a cystoscope

Answer 12

A treatment for urodynamic stress incontinence in selected cases

Question 13

1 - Overactive bladder is a symptom-based diagnosis

2 - Pelvic floor exercises are effective in the management of women with stress incontinence

3 - Colposuspension remains the most commonly performed procedure for urodynamic stress incontinence

4 - Transobturator tapes are associated with lower cure rates than retropubic tapes

5 - less than 20% of women continue to take antimuscarinic medication 6 months after starting the medication

Answer 13

1 - True. Overactive bladder describes the symptom complex of urgency with or without urge incontinence, usually with frequency and nocturia.

2 - True. Cure rates varying between 21% and 84% have been reported.

3 - False. Retropubic suspension procedures have now been largely replaced by midurethral tape procedures following the publication of the Integral Theory.

4 - False. Recent comparative studies have supported the use of transobturator tapes and have shown that they are comparative to the retropubic tape procedures.

5 - True. Antimuscarinics are associated with low compliance and persistence rates. This is thought to be owing to poor efficacy and troublesome side effects. Long-acting agents are no better than the immediate-release agents.

Question 14

A 57-year-old mother of two presents with a history of frequent daytime micturition, rising twice at night to void and having to rush to the bathroom. More recently she has noticed episodes of leakage associated with coughing and sneezing. Both pregnancies were complicated by mild stress incontinence and she went on to have spontaneous vaginal deliveries at term. Whilst she has no history of previous surgery, she is known to be hypertensive and a diet-controlled diabetic. Currently, she is not using HRT and is taking doxasosin to control her blood pressure. On examination she appears well, although overweight (BMI = 32). Vaginal examination is unremarkable and there is no evidence of urogenital prolapse.

1 - What is the role of HRT in women with lower urinary tract symptoms?

2 - What should first-line therapy include?

3 - What percentage of women remain symptomatic from incontinence following delivery?

4 - What is the relevance of treatment with doxasosin?

5 - What is doxasosin?

6 - What is the clinical diagnosis?

7 - What is the definition of nocturia?
7 - The complaint of rising at night to void

8 - What is the definition of frequency of micturition

Answer 14

1 - Vaginal HRT preparations tend to be more efficacious

2 - Conservative therapy with pelvic floor exercises and bladder retraining

3 - 12% of women remain symptomatic from incontinence following delivery

4 - Alpha-receptor antagonists may be associated with worsening stress incontinence

5 - An alpha-antagonist is used in treatment of hypertension

6 - Mixed incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

7 - The complaint of rising at night to void

8 - The complaint of having to void too often during day