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OBGYN > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

What is incontinence?

A

Involuntary urine leakage

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2
Q

What is frequency?

A

Number of voids during waking hours - normally 4-7

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3
Q

What is urgency?

A

Sudden desire to pass urine. Hard to defer

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4
Q

What is nocturia?

A

Having to wake at night to pass urine

Up to age 70 a single void is normal

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5
Q

What are some ways to investigate urinary incontinence?

A

1) Dipstick
2) Urinary diary
3) ultrasound (including post-void)
4) abdominal x-ray
5) CT urogram
6) methylene dye test
7) cystoscopy
8) Urodynamic studies

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6
Q

What are the causes of UI?

A

Stress incontinence 50%

Urge Incontinence 35%

Mixed incontinence: 10%

Bypass sphincter
- Fistula 0.3%
- Ectopic ureter
Overwhelm sphincter
- Overflow incontinence 1%
Others
- UTIs
- unknown
- Functional incontinence

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7
Q

What is the anatomy of the bladder?

A

-detrusor smooth muscle
-can store 500ml
-first urge to void at 200ml

Trigone is the triangular area between ureteral orifices and the urethral orifice

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8
Q

What is the anatomy of urethra?

A

-Drains bladder
-4cm long in women
-muscular wall
-> longitudinal smooth
-> circular striated
-> surrounded by pelvic floor (levator ani)
-opens at vestibule above introitus

Vulval vestibule: posterior 2/3 of labia minora – contains urethral meatus, paraurethral glands, and introitus.

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9
Q

What makes up bladder pressure?

A

detrusor pressure + intra-abdominal pressure

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10
Q

What makes up urethral pressure?

A

Urethral tone + pelvic floor pressure +intra-abdominal pressure

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11
Q

What allows for micturition?

A

bladder pressure > urethral pressure

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12
Q

What allows for continence?

A

dependent on urethral pressure> bladder pressure

Balance between 2 pressures. Normally IAP transferred equally to bladder and urethra as both are in abdomen.

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13
Q

What is cystometry?

A

Measure bladder pressure via catheter (a)
Measure abdominal pressure via a transducer in rectum or vagina (b)
Can calculate true detrusor pressure (a-b)

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14
Q

When is cystometry useful?

A

Very useful in investigating UI as both USI and OAB can have overlapping sx, but treatment very different.

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15
Q

What is the neural control of micturition?

A

Parasympathetic fibres aid voiding
-contraction of detrusor
-relaxation of bladder neck
Sympathetic fibres prevent it
-relaxation of detrusor
-contraction of bladder neck and IUS

Somatic fibres affect pelvic floor and striated muscle of urethra (EUS)

P for pee: parasympathetic for peeing

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16
Q

What is UI?

A
  • involuntary loss of urine
  • demonstrable leakage
  • social or hygienic problem
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17
Q

What is urinary stress incontinence?

A

Urinary stress incontinence is the involuntary leakage of urine on effort/exertion, sneezing or coughing.

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18
Q

What is stress UI called if confirmed on urodynamics?

A

If confirmed on Urodynamic studies it is called Urodynamic stress incontinence (USI) (or genuine stress incontinence)

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19
Q

How common is stress UI?

A

50% of incontinence in females.
Affects up to 10% of women to varying degrees

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20
Q

What is the cause of stress UI?

A

Occurs when proximal urethra drops below pelvic floor due to weak supports
Intra-abdominal pressure is no longer distributed equally to bladder and urethra

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21
Q

What are the etiologies of stress UI?

A

Related to childbirth:
pregnancy and vaginal delivery: prolonged labour and operative vaginal delivery

Others:
Weakened supports
-Post-menopausal
-Previous hysterectomy

Raised IAP
-Obesity
-Mass
-Cough/Smoking/Chest complaint

-Prolapse

[Especially prolonged labour, operative vaginal delivery. Injury to supports of bladder neck
Post-menopausal – oestrogen deficit. Decreased intra-urethral pressure
Prolapse –often present. Not always cause.]

22
Q

What is stress UI shown as on diagrams?

A
23
Q

What are the clinical features of stress UI?

A

stress incontinence
Mild –cough/sneeze/jog
Mod – up/down stairs
Severe- on standing

Also:
overlaps with OAB: Frequency, urgency, urge incontinence,
faecal incontinence

Prioritise symptoms
Ask re impact on life

24
Q

What are the clinical features of stress UI on exam?

A

Abdominal exam: exclude palpable bladder
Bimanual: pelvic floor tone, mass
Speculum (sims): prolapse, incontinence (coughing),

25
Q

What investigations would you do for stress UI?

A

-dipstick/ MSU
(consider) post void Ultrasound
-Cystometry-> previously advised before surgery

26
Q

What is the treatment for stress UI (USI)?

A

General: Weight loss, cough (smoking cessation), fluid intake, meds( diuretics)

Conservative : first line
1) Pelvic floor muscle training
Physio led x 3/12. 8 contractions 3 times
/day.
2) vaginal cones: training to hold weighted cones
in the vagina.

Medications:
-Duloxetine (SNRI) licensed in moderate to
severe.
-Works on striated sphincter
-NICE advise possible second line but not for
routine use (if prefer pharmacological
treatment or not suitable for surgical
treatment).

Surgery

27
Q

What surgery is done for USI? (3)

A

If failure of conservative and QOL reduced

‘Mid-urethral sling procedures’
tension-free vaginal tape (TVT),
trans-obturator tape
cure rates of 90%
On Hold at present (from mid-2018) due to concern over
complications

Laparoscopic Burch Colposuspension:
More invasive. 80-85% success.

Periuretheral bulking agents: 40-60% success

28
Q

What is done in a mid-urethral sling procedure for USI?

A

U-shaped polypropylene tape
Via an anterior vaginal wall incision under local, regional or GA
Placed under mid-urethra
Free ends anchored
Tension adjusted to prevent leakage on coughing
If TVT – cystoscopy. If transobturator – no cystoscopy

29
Q

What are complications seen with mid-urethral sling procedures for stress UI? (6)

A

Bladder perforation
Failure (10%) or Voiding difficulties (10% short term, 3% longer-term)
Detrusor overactivity: 12%
Infection, bleeding, anaesthetic risks
Mesh erosion

Dyspareunia: scar tissue at vagina: rare

30
Q

What are some other surgeries that can be done USI? (3)

A

1) Colposuspension: Paravaginal fascia sutured to inguinal ligaments. Open or laparoscopic.

2) Autologous rectal fascial slings

3) Periurethral bulking agents: biomaterial, silicone.
Usually: If not suitable for surgery or surgery failed. Older people, not completed childbirth or failed surgery.
(? Becoming more common)

31
Q

What do the NICE 2019 recommend that isn’t currently on offer in Ireland for USI with regard to mesh operations?

A

When offering a mid-urethral mesh sling:
Advise permanent implant. Complete removal may not be possible
Give info on name, manufacturer, date of insertion, surgeons name and contact details
Use type 1 macroporous polypropolene mesh coloured for high visibility for ease of insertion and revision.
Do not offer a transobturator approach unless previous pelvic surgery

32
Q

What is urge incontinence (urge UI)?

A

Involuntary leakage of urine accompanied with or proceeded by urgency

33
Q

How is urge UI described? (ie clinical features in history)

A

Overactive bladder:
‘I’ve got to go and I’ve got to go now’
Urgency (+/-urge incontinence)
usually with frequency or nocturia
in the absence of infection

34
Q

What casues urge UI?

A

Detrusor instability: Urodynamic diagnosis.
Involuntary detrusor contractions during filling
phase. (either spontaneous or provoked)

35
Q

What is important to remember about OAB and urge urge UI?

A

Not all woman with OAB have overactive detrusors
Not all women with overactive detrusors have OAB

36
Q

How common is urge UI?

A

35 % of female incontinence.

37
Q

What is the etiology of urge UI? (3)

A

Idiopathic

Post USI surgery (bladder neck obstruction)

Neurological: MS/stroke/spinal cord injury

38
Q

What is happening in urge UI?

A

Essentially bladder muscle becomes irritated and contracts earlier than normal before the bladder needs to be emptied.

This cases frequency, urgency and possibly incontinence.

39
Q

What is urge UI made worse by? (7)

A

Caffeine: tea/coffee/cola drinks
Alcohol
Stress
Cough/Smoking
Obesity
Medication: diuretics
Medical conditions: Diabetes

40
Q

What is the diagram of urge UI?

A
41
Q

What is the mechanism of urge UI?

A

Detrusor contraction is felt as urgency.
If strong enough bladder pressure can overcome urethral pressure and cause incontinence.

This can be spontaneous or with a rise in intra-abdominal pressure like coughing
(so can be confused with stress incontinence)

42
Q

What are the clinical features on history for urge UI?

A

FUNI (frequency, urgency, nocturia and urge incontinece)

also stress incontinence, nocturnal enuresis, faecal urgency.

43
Q

What is seen on exam in urge UI?

A

normal exam or incidental cystocoele

44
Q

What investigations should be done for suspected urge UI? (3)

A
  • Urinary diary
  • MSU
  • cystometry if failure of lifestyle changes and drug tx
45
Q

How is urge UI managed generally?

A

General measures
-Fluid intake: max 1 litre/day
-Stop drinking fluids after 6pm

Avoid
-caffeine-containing drinks
-alcohol

Losing weight (if overweight will reduce the severity of your symptoms). Treat cough

Consider medical problems and medications (diuretics)

46
Q

How is urge UI managed conservatively?

A

-Bladder training: train bladder to accept
larger volumes of urine
educate, timed void, positive reinforcement
for >6/52

47
Q

What medications are used to manage urge UI? (3)

A

Anticholinergics
-block muscarinic receptors on detrusor smooth muscle and decrease contraction/overactivity
-> oxybutynin first line (lyrinel)
->tolteradine (detrusitol)
->solfenacin (vesitirim)
? S/E

Mirabegron (betmiga): activates b3 adrenergic receptors on the bladder smooth muscle
(associated with htn so monitor BP)

If no improvement after 1-2 months of these agents consider referral to specialist clinic

Vaginal oestrogens in post-menopausal women
-decrease vaginal atrophy, dryness and irritation + FUNI
-e.g. vagifem (eastradiol)

48
Q

What are some other treatments for urge UI? (3)

A

Botulinum toxin if anticholinergics fail
-good success rate
-problems with voiding dysfunction and retention (up to 20%)

Sacral nerve stimulation
-electrical pulse generator. S3. refractory cases.

No longer used: tricylics – imipramine

Surgery: Clam augmentation ileocystoplasty
Urinary diversion

49
Q

What are other issues that people can have with UI?

A

Mixed USI and OAB
Acute urinary retention
Chronic urinary retention
Painful bladder syndrome and interstitial cystitis
fistulae

50
Q

A 28y/o woman underwent obstetrics forceps delivery 2/12 ago. She delivered a boy weighing 4.4kg. The delivery was complicated by a third degree tear. She has experienced continuous leakage since childbirth, which worsens when she coughs. Select the most likely diagnosis
A) OAB
B) Cystocoele
C) Vesicovaginal fistula
D) Rectovaginal fistula
E) Mixed stress and urinary incontinence

A

Vesicovaginal fistula (T):
Pressure necrosis of anterior vaginal wall during prolonged obstructed delivery or instrumental delivery-leads to fistula formation.

51
Q

Which of the following best describes stress incontinence?

A) Involuntary leakage of urine preceded by a strong urge
B) Continuous urinary leakage
C) Involuntary leakage due to anatomical or functional weakness of urethral sphincter
D) Involuntary leakage of urine associated with
E) Frequency, urgency, nocturia and coughing
F) Involuntary leakage of urine from a flaccid bladder

A

C) Involuntary leakage due to anatomical or functional weakness of urethral sphincter (T)

52
Q

What does Urge UI have similar symptoms with?

A

-> Bladder irritants: UTIs/stones
-> Vaginal atrophy

OBGYN (25 decks)

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