Urinary Incontinence Flashcards
Define urinary incontinence
Involuntary leakage of urine
Types of Urinary incontinence
Types - Stress, Urge, Mixed
SUI - Involuntary leakage of urine during effort or exertion
UUI - Involuntary leakage of urine associated with or preceded by urgency
OAB - Symptoms of frequency, urgency, nocturia with or without leakage called OAB wet or OAB dry respectively. (Overactive bladder)
Once you have categorized as SUI, what will you see on examination?
- Look for leak on cough
- Associated prolapse
- Any pelvic masses
Also very important - is digital assessment of pelvic floor muscle contraction
You have diagnosed SUI after history and examination
What will be the management?
Management includes both investigation and treatment
SUI is a clinical diagnosis does not require investigation for diagnosis confirmation
BUT FIRST EXCLUDE UTI BY DIPSTICK, then start conservative management.
What is conservative treatment of SUI?
- Lifestyle modification along with SUPERVISED PFMT
- BMI > 30 - Ask to lose weight
- Modification of fluid intake if high or low
- Supervised PFMT for 12 wks or 3 months, 8 contractions 3 times a day
How will you do Pelvic floor muscle training (PFMT) if the patient is unable to contract the pelvic floor muscles?
Electrical stimulation and / or biofeedback for motivation and adherence to therapy.
But no role of using it routinely for patients who can contract their muscles.
Now I have done PFMT for 12 weeks, still no effect. My symptoms are as it is . Now what ?
Surgical management.
But before any invasive procedure for Incontinence or prolapse, a local MDT (multidisciplinary team) review is required
Is urodynamic testing necessary prior to surgical management?
No
Indications for Urodynamic testing prior to surgery for SUI ?
- When the diagnosis is in doubt or its urge predominant mixed UI
- Voiding dysfunction
- Apical or anterior prolapse
- Previous failed continence surgery
What are the surgical options in ttting SUI?
- Colposuspension - Open / Lap
- Autologous rectus fascial Sling
- Retropubic mid urethral mesh sling
- Trans-Obutrator tape TOT - only if retropubic is not possible due to previous pelvic surgery
Will you record the details of the surgery anywhere ?
In the national registry
All the surgical procedures done for Incontinence or prolapse are recorded along with their complications
You have to take consent of the woman prior to recording the data and give her a copy of the record
After the surgery, When will you call for a follow up and what will you check for ?
Within 6 months
- Ask for relief of symptoms to check if the surgery was successful
- Ask for any new symptoms
- If mesh, symptoms of mesh complication
- Do a vaginal examination
- If mesh, check for mesh exposure or extrusion
What material is the mesh used in surgery
Type 1 - Macroporous polypropylene
After surgery patient come to follow up, still has symptoms, what to do?
Refer to regional MDT or manage her urinary symptoms if she is not willing for a surgery
- also You can consider artificial urinary sphincter if the surgery fails
What if PFMT fails and patient doesn’t want a surgery ?
Is there any option ?
Medical - Duloxetine. Explain side effects
Or
Intramural bulking agents. Explain the need for repeat injections
We have categorized patient as OAB based on history and excluded a UTI, what next ?
Bladder diary for 3 days
Then proceed to conservative management:
- Lifestyle modification along with bladder training for 6 weeks
- BMI > 30 - Reduce weight
- Modification of fluid intake
- Reduce caffeine and alcohol
In treating OAB, What if conservative management fails ?
Medical management - Anticholinergics:
- Oxybutynin - Avoid in frail and elderly
- Tolterodine
- Darifenacin
How much time it takes anticholinergic to has an effect in treating OAB?
Medications take 4 weeks to be effective
When should we decide to use oxybutynin oral or patch?
If the oral is not tolerated, use patch.
Which anti-cholinergic used in ttt of nocturia
Desmopressin
Caution in:
- More than 65 yrs with CVD or HTN
- In cystic fibrosis patients
Women with OAB age more than 75y or having dementia, what anticholinergic to avoid?
Oxybutynin
What adverse effects of anticholinergics that indicates that its effect has started?
dry mouth, blurred vision and constipation
in treating OAB, When and how do you review post medications ?
After 4 wks
- Either telephone or face to face
- If optimal improvement - continue
- If no or suboptimal improvement or intolerable adverse effects - change the dose or drug
Before 4 weeks - if adverse effects are intolerable
- If initially successful but later stopped working - further telephone or face to face review
- If on long-term medications, annual review in primary care or 6 monthly If > 75 years
- If medical not successful - refer to secondary care
in treating OAB, What if medical management fails ?
Local MDT review before invasive
And
Urodynamic testing
After failure of medical management in treating OAB, what is 1st line non surgical option?
Botulinum toxin A injection
(Initially 100 units and if inadequate symptom relief in 12 weeks increase dose to 200)
What do you explain before offering Botox A ?
- That she might require self catheterization in case of significant Voiding dysfunction.
- Complete or partial relief of symptoms
- Risk of UTI
What is the action of Botox?
Botox paralyses the detrusor muscle
Which can lead to urinary retention which can lead to Voiding dysfunction in the event of which the woman might require self catheterization to avoid overflow Incontinence
When and how do you review post Botox?
Within 12 wks
Face to face or telephone
- If optimal - ask to return if symptoms return
- If optimal and symptoms return within 6 months - increase to 200 units
- If suboptimal - increase to 200 units and review again after 12 wks
- If none - local MDT
What if patient is not willing for self catheterization, or Botox failed?
- Percutaneous sacral nerve stimulation
if fails: - Percutaneous posterior tibial nerve if sacral nerve not acceptable
if fails: - augmentation cystoplasty
Complications of Augmentation Cystoplasty?
- Mucus production
- Metabolic acidosis
- UTI
- Urinary Retention
- Bowel disturbance
(Small risk of malignancy)
How long is the follow up of augmentation cystoplasty ?
Lifelong
In ttt of OAB, what if surgery isn’t acceptable?
Urinary diversion
Life long follow up
What do you treat first in Mixed UI ?
Predominant Symptom is treated first
Any role of ultrasound in a patient with Incontinence?
Only to assess post void residual urine in suspected Voiding dysfunction
Which system for grading type and degree of prolapse on examination ?
Pelvic Organ Prolapse Quantification system (Pop Q) (Please memorize the table)
What if symptoms suggest prolapse but it is not evident on examination?
Repeat examination in standing or squatting position or at a different time
Is there any role of imaging in diagnosis of prolapse?
Not if examination confirms the diagnosis
first line management of prolapse
- Lifestyle modification
- BMI > 30 - Lose weight
- Avoid heavy weight lifting
- Treat the aggravation factors - cough, constipation
- PFMT × 16 wks (only if state 1 or 2)
- Topical estrogen if vaginal atrophy
-Pessaries
Pessaries’ Common complications & when is it reviewed
- Vaginal discharge, bleeding, expulsion, difficulty in removing
- Should be removed once every 6 months to prevent complications.
- If can’t do at home, face to face review 6 monthly
in ttt of prolapse, what If conservative ttt fails?
Surgical:
If no desire for fertility - Vaginal hysterectomy
If fertility desired -
- Abdominal sacrohysteropexy
- Vaginal sacrospinous hysteropexy
- Manchester repair (for cx elongation)
If at risk of complications from surgery and sexually inactive - colpocleisis
Which other condition should you preserve the uterus apart from desire of fertility?
Bladder exstrophy
pessary relieves prolapse symptoms in how many patients ?
92% satisfaction rate
And 50% improvement in urinary symptoms
Colpocleisis is an obliterative or reconstructive procedure?
obliterative
closure of vagina by suturing ant & post vag. wall
Colpocleisis success rate and disadvantages?
Success rate 98%
Disadvantage - in the event of future pathology - you lose access to Cervix and uterus
Is Incontinence surgery necessary at the time of prolapse surgery ?
Not if no symptoms of Incontinence
Also for apical or anterior prolapse surgery, explain the patient that she might develop Incontinence symptoms post surgery
Mesh complications are reported to ?
MHRA (Medicines and Health Regulatory Agency)
So SUI & POP affect how many females ?
1 in 3 sui
1 in 10 pop
SUI coexist with POP in how many ?
80%
First line management for SUI & mild to moderate POP?
Supervised PFMT
If conservative fails - surgical
Life time risk for parous women to undergo at least 1 surgery for SUI or POP?
1 in 10
So for females with POP & asymptomatic for SUI, should concomitant surgery be done ?
Is it beneficial?
Yes
So for abdominal procedures - ASC & BC:
CARE trial showed benefit
A study by Costantini did not - likely due to anterior traction on bladder neck during BC increasing risk for SUI
But both studies said that only 1/3 undergoing concomitant surgery developed post op SUI
For vaginal procedures - prolapse repair with mid urethral sling - they are beneficial
Postoperative SUI incidence reduced by 90% with mid urethral sling for SUI in stage 3 or 4 POP
Similar benefit not seen when BC used for SUI
It’s beneficial
But 1/3 will still develop post op SUI
And complications increase with concomitant surgery
Incidence of moderate to severe SUI following Lap ASC ? And how many require surgery ?
- 23.6%
- 11%
Define occult SUI ?
Why is it occult ?
How is it diagnosed ?
Occult SUI - SUI demonstrated on reduction of prolapse in a patient who’s asymptomatic
It’s occult because kinking of the urethra by the prolapse masks the symptoms - so visible after reducing prolapse
Speculum testing 5 times more sensitive than ring pessary reduction
No test for diagnosis
What about role of concomitant surgery in POP with occult SUI ?
The conclusion is same for patients with POP with asymptomatic SUI - whether no SUI or occult
Concomitant surgery is beneficial
But inspite of surgery, 1/3 or 30% develop postoperative symptomatic SUI
And complications are more in concomitant surgery, so you will have to individualize for each patient
Now the next group - POP with symptomatic SUI - Concomitant surgery is beneficial or you can do an interval surgery
Which combination of surgery provides the best result - ASC with BC or ASC with TVT ?
ASC with TVT
BC is associated with post operative urine retention and storage symptoms
For this group, if you do only a prolapse repair, how many still experience cure of SUI ?
One third
would you repair an asymptomatic POP along with symptomatic SUI ?
No
An asymptomatic POP is unlikely to be of a higher stage
So only conservative can help
