URINARY INCONTINENCE Flashcards
Define urinary incontinence
Involuntary leakage of urine that is a social and
hygienic problem and is objectively
demonstrable
What is the prevalence of urinary incontinence
25%
3 types of urinary incontinence
Stress
Urge
Mixed
% of stress incontinence
49%
% of urge incontinence
29%
% of mixed incontinence
22%
4 areas of interest in the physical examination for urinary incontinence
Atrophy
Prolapse
Pelvic floor strength
Focused neurological
assessment
2 investigations for urinary incontinence
urine microscopy and culture
post void residual volume
What is the scale for assessing pelvic floor strength
Oxford scale
From the oxford scale, pelvic floor exercises should be done with a score of
3 or more
A score of 2 or less in the oxford scale will require these 3 interventions
electrical stimulation, biofeedback or vaginal cones
0 in the oxford scale means
No response
1 in the oxford scale means
Flicker
2 in the oxford scale
Weak contraction
3 in the oxford scale signifies
Moderate contraction, degree of lift
4 in the oxford scale signifies
Good contraction and can squeeze muscle against some
resistance
5 in the oxford scale signifies
Normal contraction, strong squeeze and lift against
resistance
To rule out reversible causes of urinary incontinence use the – assessment
DIPPERS assessment
Components of the DIPPERS assessment
D - Delirium
I - Infection
P - Pharmaceuticals
P - Psychological morbidity
E - Excess fluid intake
R - Restricted mobility
S - Stool impaction
At what post void residual volume do you refer to a urologist
> 50ml
T/F: The post void residual volume for the 3 types of incontinence is < 50ml
T
In what type of incontinence is nocturia seen
Urge and mixed incontinence
T/F: Small volume leakage of urine (5-10ml) is seen on voiding diary with stress incontinence
T
T/F: Variable volume loss on voiding diary with urge and mixed incontinence
T
3 parameters to look out in the intake portion of the voiding diary
Quantity, quality and timing
Parameters to look out for the output portion of the voiding diary
Quantity
Frequency D/N
Urgency
Incontinence
QOL
Pads, etc
T/F: The pad test objectively quantifies leakage
T
The 2 types of pad test
1 hour
24 hours
Weight for the 1 hr pad test
< 1g
Weight for the 24hr pad test
< 5g
The QOL questionnaire is the —
King’s Health Questionnaire
What scores are possible in the king’s health questionnaire
0 - 100
T/F: Increasing score in the king’s health questionnaire
represents worsening QoL
T
T/F: Urodynamics includes all measurements that assess the function and dysfunction of the LUT by any appropriate method, including cystometry and pressure-flow studies
T
4 basic requirements for urodynamics include:
- Representative uroflowmetry
with post-void residual (PVR) - Transurethral cystometry
- Pressure-flow studies
- Urethral pressure profilometry
(UPP): Not part of Standars
Urodynamics
5 reasons for doing urodynamics
- To identify the factors contributing to the incontinence and their relative importance
- Obtain information about other aspects of upper and lower urinary tract dysfunction.
- To predict the outcome including undesirable
side-effects of a contemplated treatment - To understand the reason for failure of previous treatments for incontinence or to confirm the
effects of treatment - Part of surveillance or research programs
5 indications for urodynamics
- Mixed incontinence
- After failed conservative measures
- Before and after experimental treatment
- LUT suggestive of neurological involvement
- In those with substantial risk of renal complications
(e.g. spina bifida, spinal cord injury or anorectal
abnormalities)
When is urodynamics not recommended by NICE
if pure SUI has been diagnosed
based on history and examination, unless there is a suggestion of
voiding dysfunction, anterior compartment prolapse or previous
surgical management
Conservative management for stress leakage involves – and –
Pelvic floor exercises ±
duloxetine for stress
leakage
Conservative management for overactive bladder symptoms
Bladder retraining ±
anticholinergics
T/F: UTI invalidates results of urodynamic studies
T
In urodynamic studies, iatrogenic UTI occurs what % of cases
5 - 10%
The 3 positions for urodynamic studies
Standing, sitting and squatting
What is urodynamic stress incontinence
A condition in which there is involuntary loss of urine when intra-vesical pressure exceeds
maximum urethral closure pressure in the absence of detrusor activity
What maintains urethral competence
Anterior vaginal wall support
- Bladder neck and midurethral support
Functioning levator ani and external urethral sphincter (voluntary)
Functioning internal sphincter (involuntary)
Damage to endopelvic fascia results in –
Loss of support
Damage to levator ani results in – and –
Loss of support and occlusive pressure
Damage to the nerves will result in – and –
Loss of support and occlusive pressure
Improvement and cure rate with pelvic floor exercises
17 - 79%
Cure/improvement rate with duloxetine
50% reduction in incontinence episodes in 50%
% of patients experiencing nausea with duloxetine
23%
When is surgery done for urodynamic stress incontinence
After failure of conservative measures
After urodynamics
3 surgical mechanisms for correcting urodynamic stress incontinence
§ Bladder neck elevation (colposuspension)
§ Midurethral support (midurethral tape)
§ Urethral compression (bladder neck injection)
The most effective surgical
procedure for stress incontinence
Burch colposuspension
What is the continence rate with Burch colposuspension at 1yr, 5yrs and 12yrs
85 -90% at 1yr
70% at 5yrs
69% at 12yrs
T/F: Colposuspension is an abdominal procedure, corrects cystocele and elevates bladder neck
T
5 complications of colposuspension
10% voiding dysfunction
17% detrusor overactivity
Urinary tract injury
14% Subsequent prolapse
Major surgery
Retropubic midurethral tape also known as
TVT: Tension-free vaginal tape
What is the 7yr cure rate of TVT
81%
T/F: Postoperative catheterisation not routine for TVT
T
How many incisions are required for TVT
2 suprapubic incisions and 1 midurethral incision
Anaesthesia for TVT
IV sedation and local anaesthesia
7 complications of TVT
Bladder injury
Retropubic haematoma
Nerve, bowel and vascular injury
UTI
Voiding difficulty
Detrusor overactivity
Erosion
% objective cure rate of TVT and colposuspension at 6 months
approx 72%
% objective cure rate of TVT and colposuspension at 2 years
approx 80%
How many incisions are required for the TOT technique
1 midurethral and 2 thigh fold incisions
T/F: Cystoscopy and postoperative catheterisation not
routine for TOT
T
T/F: Other suburethral tapes are fascia lata and rectus sheath
T
3 synthetic preparations used for periurethral injections
Bovine collagen
Porcine collagen
Silicone
Cure rate for periurethral injection
48% cure rate at 1 year (worsens with time)
T/F: Repeat injections often necessary with periurethral injections
T
7 injectable implants
- Collagen
- Silicone Microparticles
- Carbon Beads (Durasphere)
- Polytetrafluoroethylene Paste
(PTFE, Teflon, Urethrin) - Autologous Fat
- Autologous Chondrocytes
- Calcium Hydroxyl Apatite
Define detrusor overactivity
A condition in which the detrusor is objectively shown to contract either spontaneously, or on
provocation, during bladder filling while the subject is trying to inhibit micturition
4 symptoms of detrusor overactivity
Frequency, urgency, nocturia and urge incontinence
T/F: With bladder retraining initial interval between voids guided by urinary diary
T
T/F: Bladder retraining should be combined with pelvic floor exercises
T
How long does it take to see improvement with bladder retraining
2 to 3 weeks
T/F: With bladder retraining 75% of patients reduce no. of incontinence episodes by 50%
T
5 examples of antimuscarinics
Oxybutynin
Tolterodine
Trospium chloride
Solifenacin
Transdermal oxybutinin
% efficacy of antimuscarinics
25 - 50%
5 side effects of antimuscarinics
Dry mouth
Blurred vision
Tachycardia
Drowsiness
Constipation
Bladder-selective, long-acting, (od) antagonist.
Solifenacin
T/F: Solifenacin has same efficacy as Long-release tolteridine but
?better with Incontinence Episode Frequency (IEF)
T
Highly selective M3 receptor antagonist
Darifenacin
T/F: Darifenacin is effective in reducing number, amplitude, and
duration of overactive bladder contractions
T
Darifenacin reduces weekly incontinence episodes by – %
77%
First in class beta 3 adrenoceptor agonist
Mirabegron (Betmiga)
What is the mechanism of action of Mirabegron
Agonises ß3 receptors on the bladder leading to detrusor mm relaxation
T/F: Mirabegron has minimal intrinsic activity on ß1 and ß2
T
3 adverse effects of Mirabegron
Hypertension, UTI, nasopharyngitis
T/F: Botulinum toxin is currently licenced for incontinence
F
Mode of administration of the botulinum toxin
Intravesical administration to inhibit release of acetylcholine
% improvement with botulinum toxin administration
70%
Where are electrodes implanted for sacral nerve stimulation
S3/4
With sacral nerve stimulation major clinical benefit is seen in up to –%
83%
4 complications of sacral nerve stimulation
Pain at the electrode and
neurostimulator site
§ Change in bowel function
§ Technical problems
§ Infection
T/F: Clam cystoplasty has cure rates up to 90%
T
With repeated treatment failures for incontinence what do you do?
- Urologist:
- Artificial sphincters
- Urinary diversion - Supportive therapy
- Supplying incontinence aids
pads etc
- Catheterisation
- Housing
