Obs&Gyn Urinary incontinence Flashcards
What problems does urogynecology deal with?
- urinary incontinence
- bladder-related problems
- prolapse
What’s incontinence?
Incontinence is the involuntary loss of urine which is both a social and hygienic problem
What’s required for continence?
Continence requires:
- normal anatomy
- good closure of the urethral sphincters/muscle
Classifiction of incontinence (4)
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Risk factors for urinary incontinence
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
Pathophysiology of stress incontinence
- Anatomy: decent of bladder neck & superior part of urethra outside of abdo cavity means increased abdo pressure (e.g. during sneezing) only exerted on bladder & not on neck & urethra so urine forced out of bladder
- Decent of bladder neck caused by: inc age, inc parity (especially prolonged 2nd stage of labour), postmenopausal women, chronic raised intra-abdo pressure: obesity, COPD, constipation
- Increased abdo pressure caused by: sneezing, coughing, laughing, activity
Aetiology of urge incontinence
- largely idiopathic
- associated disease: MS, autonomic neuropathy, spinal lesions, pelvic surgery (damaging nerve connections)
- can be exacerbated (but not caused by): caffeine, alcohol & smoking
- urge incontinence can be caused by: infection, stones or tumours
Signs and symptoms of stress incontinence
- Factors provoking leakage: coughing, sneezing, exertion
O/E:
- try to provoke incontinence
- speculum to look for prolapse
- assess severity and impact on daily life
Signs and symptoms of urge incontinence
- frequency
- nocturia
- urgency
Important to assess severity and impact on daily life.
Initial investigations for urinary incontinence
- bladder diary for minimum of 3 days
- urinalysis & mid stream sample to rule out UTI
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
Specialised investigations for urinary incontinence
Urodynamics:
- Uroflowmetery: measurement of flow rate (simple & non-inasive)
- Cystometry: Measures intra-abdominal & urethral pressure, can diagnose urge & stress by exclusion of urge
- Videocystourethrography (VCU): Bladder filled w/ dye then x-rays
Imaging:
- Cystoscopy-visualization of bladder (few indications) can show polyps, calculi and malignancy
When to refer urgently with bladder problems?
Urgent Referral:
- microscopic haematuria (>50yo)
- visible haematuria
- recurrent & persistent UTI w/ hameaturia
- suspected malignancy
Management of urge incontinence
- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line e.g. Oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)*
- Invasive: bladder wall injection w/ botulinum A toxin. Sacral nerve stimulation to reduce detrusor overactivity
* Immediate release oxybutynin should, however, be avoided in ‘frail older women’
*mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management of stress incontinence
- pelvic floor muscle training: at least 8 contractions performed 3 times per day for a minimum of 3 months
- Physiotherapy: to increase muscle tone and strength, & increase cortical connection to these muscles. 40-60% will need no further treatment than physio
*Bladder retraining should be used in conjunction
- Duloxetine as 2nd line
- surgical procedures: e.g. retropubic mid-urethral tape procedures
Surgeries for stress incontinence
- 1st line surgery: Retropubic mid -urethral tape procedure (high efficacy, good recovery rate and decreased cost)
- 2nd line: Colposuspension
- 3rd Line: autologous rectus fascial sling
Definition of vaginal prolapse
- Descent of a pelvic organ beyond its normal anatomical position.
- Descent is into the only potential space → the vagina
- Pressure can force wall of vagina, uterus or cervix through vaginal orifice
Types of urogenital prolapse
Type of prolapse depends on organ which has descended:
- Cystourethrocele: (most common) bladder or urethra descend
- Uterine Prolapse: descent of uterus
- Rectocele: prolapse of the front wall of rectum into posterior vaginal wall
- Enterocele: prolapse of pouch of douglas with small intestine into the vagina
- Vaginal Vault Prolapse: descent of vaginal vault (post hysterectomy) often with combination of above prolapses
The classification system of urogenital prolapse (3)
Baden-Walker Classification
1st Degree: cervix visible when perineum depressed (w/in vagina)
2nd degree: cervix prolapsed through introitus (fundus remains in vagina)
3rd Degree: (procidentia) entire uterus outside introitus
Epidemiology of urogenital prolapse
- 50% of parous women have some level of prolapse
- 10-20% seek medical help
- Leading cause of hysterectomy in women >50yo
- By age of 80 1 in 10 women will have had surgery for prolapse
Aetiology of urogenital prolapse
- Defect of ligaments & muscles (or no nerve connection) of pelvic floor
- 2% in nulliparous women (? congenital cause: ?connective tissue disease)
Risk factors for urogenital prolapse
- Childbirth (leading cause): parity, instrumental delivery, delayed 2nd stage
- Ageing: post-menopausal atrophy
- Chronic conditions: cough, constipation, masses (inc abdo pressures e.g. obesity)
- Previous pelvic surgery
General signs and symptoms of urogenital prolapse
- local discomfort
- awareness of “something coming down”
- difficulty retaining tampon
- spotting
- dysparaeunia/loss of sensation
- can be exacerbated by coughing, sneezing & straining
Signs and symptoms of cystourethrocele
- incontinence
- frequency
- urgency
- poor stream
- may require manipulation of prolapse to micturate
Symptoms of rectocele
- constipation
- urgency to pass stool
- tenesmus
- may require manipulation to defecate
What to examine in suspected urogenital prolapse?
Assess vagina using a sims speculum, observing movement of prolapse and urinary incontinence on straining
Investigations in suspected urogenital prolapse
- Clinical diagnosis
- Swabs/urinalysis/MSSU → if infection suspected
- Referral for urodynamics if associated incontinence
Management of urogenital prolapse
- Conservative: weight loss, stop smoking, treat chronic cough/constipation, avoid lifting and high impact physical exercise
- Pelvic floor exercises: referral to specialist physiotherapy
- HRT replacement (topical or oral) → improve collagen content
- Vaginal pessaries: simple measure, difficulty finding correct size initially, may occasionally cause local irritation. Sex possible w/ pessary
- Surgery
Types of surgery for urogenital prolapse
- anterior/posterior colporrhaphy
- hysterectomy
- Manchester repair
- Fothergill procedure
- sacrospinous fixation
- sacral colpopexy
Questions in history for suspected urinary incontinence
- Daytime frequency and nocturia
- Presence of urgency
- Any leakage and when this occurs
- Any feeling of incomplete bladder emptying
- Presence of bladder pain/symptoms of cystitis
- Any haematuria
- Presence of recurrent proven urine infections
- Symptoms of a bulge/discomfort within the vagina
- Need to assess length and severity of symptoms
- Ask about any previous treatment
- Establish usual fluid intake and what this comprises
- Ask about potential co-morbidities, eg chronic cough, constipation
- Ask about whether a patient is sexually active and if there are any complications
- Ensure full medical, surgical and medication history is taken
What information ‘Bladder dairy’ should include?
- Fluid input
- Type of fluid
- Volume voided
- Day
- Night
- Episodes of leakage
How does a urodynamic assessment look like? (1 stage)
•Involves a measurement of pressures and flow
It’s comprised of two stages:
1.Storage/Filling phase
- Bladder filled at a pre-determined rate
- Patient is asked to describe bladder sensations such as: first and normal desire to void, urgency, bladder pain
- Patient is asked to cough, listen to taps or perform other activities that may cause leakage
Information is gained as to: actual bladder capacity, presence of detrusor contractions, type of leakage
How does detrusor overactivity look on cystometry?
How does stress incontinence look on cystometry?
2nd stage of urodynamic assessment
Voiding phase
- starts when the patient is given permission to void
It gives information about:
- Flow rates and stream
- Complete/Incomplete bladder emptying
- Detrusor muscle pressure required to empty bladder i.e. if the patient strains to void
Mirabegron
- class
- use
- caution
- SEs
Class: b3 receptor agonist and activates b3 adrenoreceptors in the bladder causing
- Relaxation of the bladder
- Improved filling and storage of urine
Use if:
- Antimuscarinics are contra-indicated or clinically ineffective
- In patients who cannot tolerate the side effects of antimuscarinics
Caution: Lower doses should be used if renal or hepatic impairment
Common side effects: UTIs, palpitations and increase in blood pressure (hence do not used if severe or uncontrolled hypertension
