U-WIN-ary incontinence

Question 1

stress urinary incontinence

Answer 1

leakage on effort or exertion, sneezing or coughing.
occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
urine leaks whenever urethral resistance is exceeded by increased abdominal pressure

Question 2

urge urinary incontinence

Answer 2

leakage accompanied by or immediately preceded by urgency
may be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone)

Question 3

mixed urinary incontinence

Answer 3

combo of SUI and MUI

Question 4

bedwetting in elderly men (NOT incontinence)

Answer 4

usually indicating high-pressure chronic retention

Question 5

post-micturition dribble (NOT incontinence)

Answer 5

happens in men immediately after leaving toilet and is due to urine pooling in bulbar urethra

Question 6

other types that arent incontinence

Answer 6

• a constant leak of urine suggests a fistulous communication between the bladder (usually) and vagina (e.g. due to surgical injury at the time of hysterectomy or Caesarian section) or rarely the presence of an ectopic ureter draining into the vagina

Question 7

risk factors of incontinence

Answer 7

gender – female > male

race – caucasian > afro-caribbean

genetic predisposition

neurological disorders – spinal cord injury, stroke, MS, parkinson’s

anatomical disorders – vesicovaginal fistula, ectopic ureter in girls, urethral diverticulum, urethral fistula, bladder extrophy, epispadias

childbirth – vaginal delivery, increasing parity, pregnancy

pelvic, perineal and prostate surgery – radical hysterectomy, prostatectomy, TURP leading to pelvic muscle and nerve injury

radical pelvic radiotherapy

diabetes

Question 8

promoting factors of incontinence

Answer 8

smoking – causing cough

obesity (higher BMI puts more pressure on pelvic floor)

infection – UTI

increased fluid intake

poor nutrition

ageing

cognitive deficit

poor mobility

oestrogen deficiency

Question 9

incontinence history

Answer 9

the type, triggering factors, frequency and degree of bother
risk factors, previous surgery, bowel symptoms, symptoms of sexual dysfunction or pelvic organ prolapse in women

Question 10

red flags in incontinence

Answer 10

pain, haematuria, recurrent UTI, significant voiding/obstructive symptoms, history of pelvic surgery/radiotherapy

Question 11

physical exam in women for incontinence

Answer 11

pelvic examination (chaperoned)
ask patient to cough or strain and look for anterior and posterior vaginal wall prolapse, uterine or vaginal vault descent, and urinary leakage.
internal pelvic examination can be performed to assess voluntary pelvic floor muscle strength and bladder neck mobility.
inspect the vulva for oestrogen deficiency – causing vaginal atrophy

Question 12

physical examination in both sexes for incontinence

Answer 12

examine abdomen for palpable bladder (urinary retention).
neurological examination to assess gait, anal reflex, perineal sensation and lower limb function.
DRE to exclude constipation, a rectal mass and to test anal tone

Question 13

incontinence red flags to look out for in examination

Answer 13

new neurological deficit, haematuria, urethral, pelvic or bladder mass and suspected fistula

Question 14

basic investigations for incontinence

Answer 14

bladder diary (frequency/volume chart)
urinalysis +- culture
flow rate and post-void residue
pad testing

Question 15

further investigations for incontinence

Answer 15

blood tests, imaging, cystocopy - for complex cases

Question 16

how cystometry works

Answer 16

urodynamics - seeing pressure to identify whether bladder obstruction etc.

Question 17

conservative treatment for incontinence

Answer 17

pelvic floor exercises – at least 8 contractions, 3x day for min. 3months. Improvement in 30% of women w/ mild SUI

**!! MOST IMPORTANT IMPACT lifestyle – weight loss, stop smoking, avoid constipation, modify fluid intake

biofeedback – ability & strength of pelvic floor contraction is fed back to patient as visual or auditory signal

medication – duloxetine (inhibits reuptake of both serotonin and noradrenaline) acts to increase sphincteric muscle activity during bladder filling

electrical stimulation of pelvic floor – no proven benefit in SUI

Question 18

surgical treatment for incontinence

Answer 18

injection therapy - bulking materials into the bladder neck and periurethral muscles to increase outlet resistance.
main indication is for female stress incontinence secondary to demonstrable intrinsic sphincter deficiency in the presence of normal bladder muscle function, e.g Macroplastique (silicone – polydimethyl siloxane elastomer) or Teflon (polytetrafluoroethylene paste).

Question 19

how injection therapy acts for urinary incontinence

Answer 19

injected submucosally under endoscopic guidance – aim is to achieve urethral mucosal apposition and closure of the lumen. Success rate 50-80% but tends to deteriorate with time and repeat treatments often needed

Question 20

contraindications for injection therapy for urinary incontinence

Answer 20

UTI, untreated bladder overactibity, bladder neck stenosis

Question 21

complications of injection therapy for urinary incontinence

Answer 21

temporary urinary retention (2-15%), de novo urge incontinence (6-12%), UTI (5%), haematuria (5%)

Question 22

retropubic suspension

Answer 22

treat sfemale stress incontinence predominantly caused by urethral hypermobility.
elevates and fixes the bladder neck and proximal urethra in a retropubic position in order to support the bladder neck and regain continence.
lower chance of benefit in presence of significant ISD

Question 23

burch colposuspension

Answer 23

requires good vaginal mobility as the vaginal wall is elevated and attached to the lateral pelvic wall.
also an option in patients with concurrent SUI and anterior vaginal wall prolapse.
success rate of 70% at 5 years

Question 24

suburethral tapes and slings
(synthetic tape)

Answer 24

e.g. the retropubic tension-free vaginal tape (TVT).
Small mid-line anterior vaginal incision.
tape has long trochars on each end which are inserted either side of the urethra and perforate through the endopelvic fascia.
pushed up behind the symphysis pubis and out onto lower abdominal wall in the midline, just above the pubic bone.
tape is positioned loosely (tension-free) over the mid-urethra its covering is removed and the ends cut flush to the abdomen.
vaginal epithelium is closed over the top.
success rates up to 80% at 5 years

Question 25

complications of suburethral tapes and slings

Answer 25

voiding dysfunction (retention or de novo bladder overactivity - vaginal, urethral and bladder perforation/erosion
- pain
- damage to bowel or blood vessels

Question 26

pubovaginal (autologous) slings

Answer 26

use segment of rectus fascia 10-20cm in length harvested via a Pfannenstiel approach, long non-absorbable sutures on both ends.
sling placed under mid-urethra and sutures placed through the endopelvic fascia to the remaining rectus fascia where the suture ends are tied using the minimal amount of tension to prevent urethral movement.

Question 27

artificial urinary sphincter

Answer 27

closed pressurised system with three components:

1.inflatable cuff placed around the bulbar urethra or bladder neck
2. pressure-regulating balloon placed extraperitoneally in the abdomen
3. activating pump in the scrotum or labia majora

Question 28

how artificial urinary sphincterworks

Answer 28

The cuff provides a constant circumferential pressure to compress the urethra. To void, the pump is squeezed, which transfers fluid to the reservoir balloon, thereby deflating the cuff. The cuff then automatically re-fills within 3 minutes

Used for moderate to severe SUI secondary to urethral sphincter deficiency in patients with normal bladder capacity and compliance.

Long-term success 70-90%

Question 29

complications of artifical urinary sphincter

Answer 29

urethral atrophy, mechanical failure, urethral erosion, bladder overactivity or reduced compliance, infection

Question 30

overactive bladder (OAB)

Answer 30

symptom syndrome that includes urgency, with or without urge incontinence, usually with frequency and nocturia. usually caused by bladder (detrusor) overactivity.
affects 40% of the population >40y in Europe

Question 31

conservative treatment of overactive bladder

Answer 31

MDT approach – urologists, urogynaecologists, continence nurse specialists, physiotherapists

pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy may provide some benefit

behavioural modification – modify fluid intake, avoid stimulants (caffeine, alcohol), bladder training

Question 32

anticholigernic medication

Answer 32

acetylcholine acts on muscarinic receptors on the bladder smooth muscle to cause involuntary contractions and provoke the symptoms of bladder overactivity
receptors are the targets of anticholinergic (antimuscarinic) drugs which inhibit contractions and increase bladder capacity.

(e.g: Oxybutynin, Solifenacin, Tolterodine, Fesoterodine, Trospium, Propiverine)

Question 33

contraindications of anticholinergic medicatIon

Answer 33

uncontrolled narrow-angle glaucoma, myasthenia gravis, BOO, bowel disorders (active ulcerative colitis, bowel obstruction)

Question 34

common side effects of anticholinergic medicatIon

Answer 34

dry mouth, constipation, blurred vision, urinary retention, cognitive impairment

Question 35

β-Adrenoreceptor agonists

Answer 35

β-ARs induce detrusor relaxation and it is the β3 sub-type that is predominant in human detrusor.
β3-AR agonists increase bladder capacity with no change in micturition pressure and the residual volume

Mirabegron (Betmiga)

Contraindication: uncontrolled hypertension

Question 36

oab - options for failed conventional therapy

Answer 36

Intravesical Botulinum toxin-A: injected at multiple (20) sites under the bladder mucosa or into detrusor, sparing the trigone

Question 37

neuromodulation

Answer 37

sacral nerve stimulation involves electrical stimulation of the bladder’s nerve supply to suppress reflexes responsible for involuntary detrusor contrcation.

device stimulates the S3 afferent nerve, which then inhibits detrusor activity at the level of the sacral spinal cord. initial percutaneous nerve evaluation is performed, followed by surgical implantation of permanent electrode leads into the sacral foramen, with a pulse generator which is programmed externally

Question 38

augmentation “Clam” ileocystoplasty:

Answer 38

relieves intractable frequency, urge and UUI in 90% patients. bladder dome is bivalved and a detubularised segment of ileum is anastomosed, creating a larger bladder volume

1. bladder opened laterally and incised down to the trigone
2. segment of ileum + its mesentery are sutured onto the bladder

Question 39

ileal conduit urinary diversion

Answer 39

for intractable cases only – both ureters anastomosed and connected to a short length of ileum which is brought out cutaneously as a stoma (urostomy)