Urinary incontinence Flashcards by yeswanth AKULA

Population most affected by urinary incontinence

Elderly females

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Risk factors for urinary incontinence

advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history

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Classification of urinary incontinence

Overactive bladder/urge

Stress

Mixed

Overflow

Functional

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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

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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

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Features of stress incontinence

leaking small amounts when coughing or laughing

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Typical description of urge incontinence

suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs

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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

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Causes of overflow incontinence

anticholinergic medications

fibroids

pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries

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What should women with suspected overflow incontinence be referred for

Urodynamic testing

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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

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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

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Grading system used to assess strength of pelvic muscle contractions

Modified Oxford grading system

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Initial ix for urinary incontinence

Bladder diary
Urine dip
Post-void residual bladder volume

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Modifiable lifestyle factors contributing to urinary incontinence

Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)

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Questions to ask about severity of urinary incontinence

Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing

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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

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Medication for stress incontinence

Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

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Surgical options for mx of stress incontinence

Tension-free vaginal tape

Autologous sling procedures

Colposuspension

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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

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Alternative to anticholinergic meds in urge incontinence mx

Mirabegron is an alternative to anticholinergic medications

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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

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Mx of catheter-associated UTI

No treatment if asymptomatic

Abx for 7 days if symptoms

Catheter changed asap

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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