Urinary incontinence Flashcards
Population most affected by urinary incontinence
Elderly females
Risk factors for urinary incontinence
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Classification of urinary incontinence
Overactive bladder/urge
Stress
Mixed
Overflow
Functional
What causes urge incontinence
due to detrusor overactivity
the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
What causes stress incontience
weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder
Features of stress incontinence
leaking small amounts when coughing or laughing
Typical description of urge incontinence
suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs
When does overflow incontinence occur
chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine
Causes of overflow incontinence
anticholinergic medications
fibroids
pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries
What should women with suspected overflow incontinence be referred for
Urodynamic testing
Risk factors for urinary incontinence
Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia
Purpose of bimanual examination in urinary incontinence
Examination should assess the pelvic tone and examine for:
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
Grading system used to assess strength of pelvic muscle contractions
Modified Oxford grading system
Initial ix for urinary incontinence
Bladder diary
Urine dip
Post-void residual bladder volume
Modifiable lifestyle factors contributing to urinary incontinence
Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)
Questions to ask about severity of urinary incontinence
Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing
Mx of stress incontinence
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Medication for stress incontinence
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
Surgical options for mx of stress incontinence
Tension-free vaginal tape
Autologous sling procedures
Colposuspension
Mx of urge incontinence
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Invasive procedures where medical treatment fails
Alternative to anticholinergic meds in urge incontinence mx
Mirabegron is an alternative to anticholinergic medications
Invasive options for OAB
Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
Mx of catheter-associated UTI
No treatment if asymptomatic
Abx for 7 days if symptoms
Catheter changed asap
Types of testicular cancer
Seminomas
Non-seminomas
Risk factors for testicular cancers
Undescended testes
Male infertility
Family history
Increased height
Presentation of testicular cancer
Painless non-tender lump Hard Irregular Non fluctuant No transillumination
Association between gynaecomastia and testicular cancer
gynaecomastia (breast enlargement) can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour
IX in testicular cancer
Scrotal ultrasound
AFP(teratomas)
Beta-hCG(both teratomas and seminomas)
LDH
Staging CT
Staging system used for testicular cancer
Royal Marsden staging system
Common sites for mets from testicular cancer
Lymphatics
Lungs
Liver
Brain
Mx of testicular cancer
Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
Chemotherapy
Radiotherapy
Sperm banking
Long term side effects of treatment for testicular cancer
Infertility Hypogonadism (testosterone replacement may be required) Peripheral neuropathy Hearing loss Lasting kidney, liver or heart damage Increased risk of cancer in the future
Examination findings with hydrocele
The testicle is palpable within the hydrocele
Soft, fluctuant and may be large
Irreducible and has no bowel sounds (distinguishing it from a hernia)
Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
Causes of hydroceles
Idiopathic Testicular cancer Testicular torsion Epididymo-orchitis Trauma
Mx of hydroceles
Exclude cancer
Conservatively if idiopathic
Surgery,aspiration or sclerotherapy in large and symptomatic cases
What is a varicocele
veins in the pampiniform plexus become swollen
Presentation of varicocele
Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility
Which side to most varicoceles occur and what can it indicate
The right testicular vein drains directly into the inferior vena cava. The left testicular vein drains into the left renal vein.
Most varicoceles (90%) occur on the left due to increased resistance in the left testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.
Examination findings in varicocele
A scrotal mass that feels like a “bag of worms”
More prominent on standing
Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
Mx of varicoceles
Uncomplicated cases can be managed conservatively.
Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.
Examination findings - epididymal cysts
Soft, round lump Typically at the top of the testicle Associated with the epididymis Separate from the testicle May be able to transilluminate large cysts
Mx of epididymal cysts
Usually harmless
Can occasionally cause pain/discomfort - may need removal
Can be torsion of cyst causing acute pain and swelling
Most common types of RCCs
Clear cell(80%) Papillary(15%)
Risk factors for RCC
Smoking Obesity Hypertension End-stage renal failure Von Hippel-Lindau Disease Tuberous sclerosis
Presentation of RCC
Haematuria
Vague loin pain
Non-specific symptoms of cancer
Asymptomatic
When should patients be referred for haematuria
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
What does cannonball metastases refer to
“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.
Parneoplastic features of RCC
Polycythaemia
Hypercalcaemia
HTN
Stauffer’s syndrome
Staging system for RCC
TNM
Mx of RCC- surgical
Partial nephrectomy
Radical nephrectomy
MDT
Mx of RCC - less invasive procedures
Arterial embolisation
Percutaneous cryotherapy
Radiofrequency ablation
Chemo/radiotherapy
Mx of renal stones pain - medication
NSAIDs(diclofenac)
Why is clotting an important investigation in renal stones management
if percutaneous intervention planned
Main imaging ix in renal stones
non-contrast CT KUB within 14 hrs of admission
Ultrasound
Mx of renal stones <5mm
will usually pass spontaneously(within 4 weeks)
Mx of renal stones < 2cm in aggregate
Shockwave lithotripsy
Mx of renal stones < 2 cm in pregnant females
Ureteroscopy
Mx of complex renal calculi and staghorn calculi
Percutaneous nephrolithotomy
