Outpatient- Incontinence

Question 1

A 35F has been referred to your clinic with urinary frequency, urgency, urge incontinence and nocturia. How would you proceed?

Answer 1

-Review in an outpatient urology clinic or in a specialist continence urology clinic. Patient to attend with urine for urinalysis and bHCG test for all women of child bearing age. Also a complete 3 day bladder diary and given patient a SFICIQ questionnaire

Focussed Hx:
-duration, LUTs [storage/voiding], associated STI/UTIs, incontinence [urge/stress], pain, PV discharge/bleeding
-Trigger factors- previous vaginal deliveries, undiagnosed diabetes, post-menopausal, previous surgery, fluid diet
-red flags: VH, weight loss, bony pain, Abnormal PV bleeding
PHx- gynae/urol hx, surgical hx, performance status
DHx
Shx- smoking, occupational hazards

Clinical Exam with chaperone:
Abdo exam-scars, palpable bladder
PV exam: lichen sclerosus, atrophic vaginitis, suspicious lesions, cystocele, cough test for test of pelvic floor

Question 2

A 35F has been referred to your clinic with urinary frequency, urgency, urge incontinence and nocturia.
What initial tests would you perform?

Answer 2

• urinalysis, bHCG test, MSSU
• Uroflowmetry and PVS
• 3 day Bladder diary
• flexible cystoscopy and urine cytology for NVH and suprapubic pain [CIS]
• UDs done only if trial of conservative and medical therapy has failed and surgical intervention is considered

Question 3

How would diagnose nocturnal polyuria from a bladder diary?

Answer 3

increased proportion of 24 hour output is at night, >20% of 24 urine output

Question 4

A 35F has been referred to your clinic with urinary frequency, urgency, urge incontinence and nocturia.
What is you differential diagnosis?

Answer 4

Urological:

• UTI
• Detrusor overactivity
• cystitis
• bladder cancer
• Bladder dysfunction

Gynae:

• Cystocele
• Cancer

Genital:

• urethral caruncle
• urethritis
• vulval vaginitis

Medical:

• diabetes
• upper motor neuron lesion

General:

• anxiety
• pregnancy
• fluid diet

Question 5

What is the treatment of OAB?

Answer 5

Conservative measures:

• Fluid diet, cut caffeine/carbonated drinks, sugary
• pelvic floor exercise and bladder training [double voiding]
• oestrogen creams
• pessary if vaginal pessary

Medical:
1st line: anticholinergic [solifenacin, tolterodine]
2nd line: beta 3 adrenergic agonist. Mirabegron

Surgical- needs UDs first:

• Intravesical botox
• neuromodulation
• augmentation cystoplasty
• urinary diversion

Question 6

What is an anticholinergic?

Answer 6

competes with the muscarinic cholinergic receptors so prevent ACh being attached to the post-synapic membrane which causes smooth muscle contraction in the bladder.
Contraindications: Myathena gravis, uncontrolled narrow angle glaucoma, significant BOO, GI obstruction or megacolon
SE: dry mouth, increased risk of dementia compared to no use

Question 7

What is Mirabegron?

Answer 7

beta 3 adrenergic agonist with relaxes the detrusor muscle
Contraindication: uncontrolled HTN
SEs: Tachycardia, UTI

Question 8

What is Botox?

Answer 8

Neurotoxin derived from clostridium botulinum. There are seven serotypes but Type A and B have been used for clinical use.
Blocks the pre-synaptic vesicular release of ACh at the NMJ of the parasympathetic nerves supplying the detrusor mm. Results in temporary paralysis of the the mm.
Often start with 100units but can be increased to 200units
Effects last 4-10 months
SEs-: Pain, UTI, retention needing ISC, VH, allergy to botox