Urinary Incontinenc Flashcards
Which nevre roots supply the parasympathetics and pudendal nerves
S 2 3 4
Describe lower motor neurone lesion
Low detrusor pressure Large residual urine +/- Overflow incontinence (S2, 3, 4) Reduced perianal sensation Lax anal tone Low detrusor pressure Large residual urine +/- Overflow incontinence (S2, 3, 4) Reduced perianal sensation Lax anal tone Treated by self catheterisation
What happens in an upper cord transecition
High pressure detrusor contractions
Poor coordination with sphincters
Detrusor sphincter dyssynergia
Loss of inhibition of parasympathetics. Too high pressure. Contractions. Sphincter no longer co ordinated by bladder. Contracting against closed sphincter. Thick walled bladder. - thicker detrusor.. Pressure on ureters. Dilated hurdlers. Classic - rod traffic accident - first few weeks flaccid bladder. Then thickens. Sometimes cant get catheter in. Can develop kidney impairment/failure
Outline the classification of LOWER URINARY TRACT SYMPTOMS (LUTS)
Ss
What is Sui
Stress Urinary Incontinence (SUI)
“the complaint of involuntary leakage on effort or exertion, or on
sneezing or coughing”
What is uui
Urge Urinary incontinence (UUI)
“the complaint of involuntary leakage (of urine) accompanied by or
immediately proceeded by urgency”
What is mui
Mixed Urinary Incontinence (MUI)
“the complaint of involuntary leakage (of urine) associated with
urgency and also with exertion, effort, sneezing or coughing” Overflow Incontinence
Describe teh epidemiology of oabsuui
Ss
What are the risk factors for ui
O&G - pregnancy, childbirth, pelvic surgery, DXT, pelvic prolapse
Promoting - co-morbities, obesity ,age, increase intra abdo pressure, congnitive imparment, UTi, drugs, menopause
Predisposing - Race, family predisposition, anatomical abnormalities, neurological abnormalities
Describe th. hairstyle and examination
History - categorise type of UI Examination BMI Abdominal exam to exclude palpable bladder Digital rectal examination (DRE) Prostate (male) Limited neurological examination Females External genitalia (stress test) Vaginal exam
Discernible ethe investigations
Mandatory
Urine dipstick - UTI, haematuria, proteinuria, glucosuria
Consider basic non-invasive urodynamics
Frequency-volume chart - Measure how much they drink. Measure how much they urinate. How often going, how much voiding each time
Bladder diary (≥3 days)
Post-micturition residual volume - in patients with voiding dysfunction
Optional
Invasive Urodynamics (Pressure-flow studies +/- video)
Pad tests
Cystoscopy
What is a pressure-for study
Measure abdominal pressure - use rectom. If they have no rectum - put in stomach. Put pressure probe into bladder. Gives total bladder pressure - combination of detrusorr pressure and abdominal pressure.subtract to give detrusor pressure, if they are pressing on their tummy - looks like low detrusor pressure but actually very high abdo pressure. Need to calibrate detrusor flat like - eg if cough detrusor line should not move but the others should
Describe the management for UI
Depends on Which symptoms? Degree of bother / nuisance Effects of treatment on other symptoms Previous or current treatments Should be Individualised Systematic approach
Describe conservative management for UI
General lifestyle interventions: Modify fluid intake Weight loss Stop smoking Decrease caffeine intake (UUI) Avoid constipation Timed voiding - fixed schedule
What is the management for patients unsuitable for surgery who have failed conservative.medica management
For patients unsuitable for surgery who have failed
conservative or medical management:
Indwelling Catheter - Urethral or Suprapubic
Sheath device - Analogous to an adhesive condom attached to
catheter tubing and bag
Incontinence Pads
On ward - full bladder ro else hit Boswell (associated morbidity). If they dont have full bladder. Use telescope - ultrasound, or put long needle in. If they have scares on abdomen. Open abdomen bc risk of hitting bowel.
What is the initial management for Sui
Pelvic floor muscle training (PFMT)
8 contractions x3/day
At least 3 months duration
Describe pharmacological management for Sui
Duloxetine
Combined noradrenaline and serotonin uptake inhibitor
↑ activity in the striated sphincter during filling phase
Not recommended by NICE as first-line or routine second-line
treatment but may be offered as alternative to surgery
What are the surgery options for Sui
Females Permanent intention Low-tension vaginal tapes (commonest) Open retropubic suspension procedures Classical sling procedures Temporary intention e.g. if further pregnancies are planned (sling would get damaged in this case) Intramural bulking agents
Males
Artificial urinary sphincter (eg if prostate removed and urinary tract damaged)
Male sling procedure
What are low tension vaginal tapes
Low-tension vaginal tapes
Supports mid urethra
Polypropylene mesh
Minimally invasive techniques
Tension-free vaginal tape (TVT)
Transobturator tape (TOT)
Success rates >90%
What are retropubis suspension procedures
Retropubic suspension procedures
Correct anatomical position of proximal urethra and improve
urethral support
Describe classic asocial sling procedure
Classical fascial sling procedures Supports the urethra and augments bladder outflow resistance Autologous Fascia lata Rectus fascia Allograft fascia lata
What are intramural bulking agents
Intramural bulking agents
Improve ability of urethra to resist
abdominal pressure by improving
urethral coaptation
Injections under GA/LA Autologous fat Silicone Collagen Hyaluron-dextran polymers
Describe male artificial urinary sphincter
Male artificial urinary sphincter Gold standard Urethral sphincter deficiency Neurological Post-DXT or surgery
Cuff simulates action of normal sphincter to circumferentially close the urethra Mechanical (hydraulic) device Device in scrotum - button to release sphincter
What si the initial management for uui
Bladder training
Schedule of voiding:
Void every hour during the day
Must not void in between - wait or leak
Intervals increased by 15-30 minutes a week until interval of 2-3
hours reached
At least 6 weeks duration
What is the pharmacological management for uui
Anticholinergics - act on muscarinic receptors (M2, M3)
side effects due to affects on M receptors at other sites
M1 - CNS, salivary glands
M2 - heart smooth muscle
M3 - smooth muscle (ocular and intestinal - dry eyes, constipation)), salivary glands
M4 - CNS
M5 - CNS, eye
If they are being investgated for glaucoma or have it - dont give it totem
Oxybutynin (NICE price – ie. Cheap!)
β3-adrenoceptor agonist (licensed in 2014)
Mirabegron
↑ bladder’s capacity to store urine
Might not respond well to anticholinergics. But do not start of have problems with hypertension. If start, check BP the next week.
What is an invasive pharmacological management for uui
Intravesical injection of Botulinum toxin Invasive, intravesicle, Potent biological neurotoxin Inhibits release of Ach at pre-synaptic neuromuscular junction causing targeted flaccid paralysis Mainly Type-A used clinically GA or LA procedure Duration of action 3-6 months
What are the surgery options for uui
Sacral nerve neuromodulation
Autoaugmentation
Augmentation cystoplasty (using a niece of bowel, sewing onto bladder, disrupts bladder, gives it more capacity 0 but growing out of ashion)
Urinary diversion (most common - urine no longer goes to bladder - goes to bag - better quality of life)
