Urinary Incontinenc

Question 1

Which nevre roots supply the parasympathetics and pudendal nerves

Answer 1

S 2 3 4

Question 2

Describe lower motor neurone lesion

Answer 2

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

Question 3

What happens in an upper cord transecition

Answer 3

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

Question 4

Outline the classification of LOWER URINARY TRACT SYMPTOMS (LUTS)

Answer 4

Ss

Question 5

What is Sui

Answer 5

Stress Urinary Incontinence (SUI)
“the complaint of involuntary leakage on effort or exertion, or on
sneezing or coughing”

Question 6

What is uui

Answer 6

Urge Urinary incontinence (UUI)
“the complaint of involuntary leakage (of urine) accompanied by or
immediately proceeded by urgency”

Question 7

What is mui

Answer 7

Mixed Urinary Incontinence (MUI)
“the complaint of involuntary leakage (of urine) associated with
urgency and also with exertion, effort, sneezing or coughing” Overflow Incontinence

Question 8

Describe teh epidemiology of oabsuui

Answer 8

Ss

Question 9

What are the risk factors for ui

Answer 9

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

Question 10

Describe th. hairstyle and examination

Answer 10

 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

Question 11

Discernible ethe investigations

Answer 11

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

Question 12

What is a pressure-for study

Answer 12

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

Question 13

Describe the management for UI

Answer 13

 Depends on
 Which symptoms?
 Degree of bother / nuisance
 Effects of treatment on other symptoms
 Previous or current treatments
 Should be
 Individualised
 Systematic approach

Question 14

Describe conservative management for UI

Answer 14

 General lifestyle interventions:
 Modify fluid intake
 Weight loss
 Stop smoking
 Decrease caffeine intake (UUI)
 Avoid constipation
 Timed voiding - fixed schedule

Question 15

What is the management for patients unsuitable for surgery who have failed conservative.medica management

Answer 15

 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.

Question 16

What is the initial management for Sui

Answer 16

 Pelvic floor muscle training (PFMT)
 8 contractions x3/day
 At least 3 months duration

Question 17

Describe pharmacological management for Sui

Answer 17

 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

Question 18

What are the surgery options for Sui

Answer 18

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

Question 19

What are low tension vaginal tapes

Answer 19

Low-tension vaginal tapes
 Supports mid urethra
 Polypropylene mesh

 Minimally invasive techniques
 Tension-free vaginal tape (TVT)
 Transobturator tape (TOT)

 Success rates >90%

Question 20

What are retropubis suspension procedures

Answer 20

 Retropubic suspension procedures
 Correct anatomical position of proximal urethra and improve
urethral support

Question 21

Describe classic asocial sling procedure

Answer 21

 Classical fascial sling procedures
 Supports the urethra and augments bladder outflow resistance
 Autologous
 Fascia lata
 Rectus fascia
 Allograft fascia lata

Question 22

What are intramural bulking agents

Answer 22

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

Question 23

Describe male artificial urinary sphincter

Answer 23

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

Question 24

What si the initial management for uui

Answer 24

 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

Question 25

What is the pharmacological management for uui

Answer 25

 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.

Question 26

What is an invasive pharmacological management for uui

Answer 26

 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

Question 27

What are the surgery options for uui

Answer 27

 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)