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GYNE 4TH BI > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

the complaint of any involuntary leakage of urine

A

Urinary Incontinence

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2
Q

true or false incontinence can almost always be improved and frequently can be cured, often using relatively simple, nonsurgical interventions

A

true

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3
Q

true or false

If the leakage is distressing to the patient, evaluation and treatment should be offered.

A

true

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4
Q

– peak at 5th decade of life and the most common subtype of urinary incontinence

A

stress incontinence

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5
Q

– the most dominant subtype in late adulthood

A

mixed urinary incontinence

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6
Q

the key urethral support responsible for continence was considered to be at the

A

bladder neck and proximal urethra

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7
Q

were thought to be structurally important to maintain continence

A

pubourethral ligaments, extending from the undersurface of the pubic bone down to the urethra

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8
Q

current most accepted theory of stress urinary incontinence pathogenesis

A
  1. loss of integrity of structures intrinsic to the urethra, and, to a lesser extent, the
  2. pelvic support structures in close proximity, but extrinsic, to the urethra
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9
Q

proposed that the primary support of the bladder neck and urethra to be an intact vaginal wall at the base of the bladder

A

Hammock Theory by DeLancey

  • condensation of the levator ani muscles - the vagina was shown to act as a hammock to support the bladder neck, compress the urethra, and maintain continence
  • Loss of integrity of the hammock resulted in stress urinary incontinence
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10
Q

stress urinary incontinence occurs as a result of connective tissue laxity in the vagina and its supporting ligaments (pubourethral, cardinal/uterosacral, and arcus tendineus fascia pelvis)

A

Integral Theory
by Petros and Ulmsten

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11
Q

highlighted the role of the suspensory ligaments supporting the proximal vagina that supports the mid-urethra

A

Integral Theory by Petros and Ulmsten

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12
Q

multidirectional movement of the pelvic floor muscles coordinated the urethral continence mechanism

  • the forward direction of the pubococcygeus muscle stretches the mid-vagina forward against the pubourethral ligament to close the urethra from behind;
  • the backward direction of the levator plate stretches the upper vagina and bladder base backward and downwards in a plane around the pubourethral ligament to close off the proximal urethra
A

Integral Theory by Petros and Ulmsten

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13
Q

Maintains a positive urethral closure pressure during bladder filling

A

Normal urethral closure mechanism

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14
Q

Pathophysiology is not well developed; often used interchangeably with overactive bladder (OAB)

A

Urgency urinary incontinence

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15
Q

SYNDROME associated with urgency, usually accompanied by frequency, nocturia, with or without urgency urinary incontinence, and in the absence of a urinary tract infection or other obvious pathology

A

OAB “overactive bladder”

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16
Q

Theories for nonneurogenic OAB or idiopathic urgency urinary incontinence

A
  1. Epithelial hypersensitivity theory
  2. Myogenic theory
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17
Q

proposes presence of chemosensitizing agents leading to bladder instability which are believed to be inflammatory substances such as nerve growth factor, prostaglandins, and acetylcholine that increase detrusor muscle sensitivity and neuronal excitability

A

Epithelial hypersensitivity theory

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18
Q

suggests that the pelvic floor sustains a physical strain during the developmental years

A

Myogenic theory

-Myogenic dysfunction ensues secondary to altered structure or disordered function of a group of myocytes within the detrusor smooth muscle independent of its nerve supply

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19
Q

the most common incontinence subtype in later adulthood

A

Mixed urinary incontinence

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20
Q

may represent a combination of bladder storage conditions of different etiologies

A

Mixed urinary incontinence

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21
Q

occur mostly in the distal urethra of women between the ages of 30 and 60 years

A

Urethral diverticuli

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22
Q

a congenital anomaly where the ureter opens distally into the urethra or more commonly into the vagina

A

Ectopic urethra

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23
Q

rare condition that involves a congenital absence of the anterior vaginal wall and base of the bladder/urethra

A

Bladder extrophy

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24
Q

an acquired condition where there are one or more direct communications between the vagina and the following adjacent organs:

A

Fistula (traumatic)

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25
Q

Fistula that is most common and usually arises from a prolonged obstructed labor, in younger and poorly developed women in rural, underdeveloped regions of the world

A

Vesicovaginal fistula

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26
Q

Causes of genitourinary fistula in developed countries

A

Gynecologic causes

-pelvic malignancies
-gynecologic surgeries such as HYSTERECTOMY, AND PELVIC IRRADIATION

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27
Q

What type of urinary incontinence are at higher risk to developed in

  1. White women
  2. Black women
A
  1. White women—STRESS urinary incontinence
  2. Black women—URGENCY urinary incontinence
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28
Q

Prevalence for STRESS urinary incontinence peaks in the

A

5th decade and then declines thereafter

-vaginal birth is strongly associated with stress urinary incontinence in the FIRST 2 DECADES after childbirth, but has little to no effect beyond that

-ADVANCING AGE IS A STRONG PREDICTOR OF BOTH URGENCY AND MIXED URINARY INCONTINENCE

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29
Q

major risk factor for urinary incontinence and its subtypes

A

OBESITY

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30
Q
  1. Previous hysterectomy
  2. Surgery for prolapse
  3. Surgery for stress incontinence
A
  1. Stress and urgency urinary incontinence
  2. New onset stress urinary incontinence
  3. De novo or worsening urgency urinary incontinence
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31
Q

REVERSIBLE CAUSES OF URINARY INCONTINENCE

A

Delirium
Infection
Atrophic urethritis and vaginitis
Pharmacologic causes
Excessive urine production
Restricted mobility
Stool impaction

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32
Q

DIAGNOSIS FOR URINARY INCONTINENCE

A

-2 to 3 day diary
-cystoscopy—rarely an indication for uncomplicated urinary incontinence
-urodynamics—no longer necessary prior to treatment

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33
Q

Urine loss associated mostly with activities such as coughing, sneezing, or laughing is suggestive of

A

stress urinary incontinence;

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34
Q

Symptoms associated with or immediately preceded by an urgency episode are indicative of

A

urgency urinary incontinence.

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35
Q

Medications that May Affect the Function of the Urinary Tract

A
  1. Sedatives
  2. Alcohol
  3. Anticholinergic drugs
  4. Alpha agonists
  5. Alpha blockers
  6. Calcium channel blockers
  7. Angiotensin-converting enzyme inhibitors
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36
Q

May cause confusion and secondary incontinence, particularly for elderly patients

A

Sedatives such as benzodiazepines

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37
Q

May have similar effects to benzodiazepines and also impair mobility and causes diuresis

A

Alcohol

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38
Q

May impair detrusor contractility and may lead to voiding difficulty and overflow incontinence.

A

Anticholinergics

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39
Q

Increase outlet resistance and may lead to voiding difficulty

A

Alpha agonists

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40
Q

Decrease urethral closure pressure and leads to stress incontinence

A

Alpha blockers
(Prazosin, teazosin)

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41
Q

Reduce bladder smooth muscle contractility and lead to voiding problems or incontinence; they may also cause peripheral edema, which may lead to nocturia or nighttime urine loss

A

Calcium channel blockers

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42
Q

Result in a chronic and bothersome cough that can result in increasing stress urinary incontinence in an otherwise asymptomatic patient

A

ACE inhibitors

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43
Q

involves introducing a cotton-tipped swab into the urethra and asking the patient to Valsalva to measure the angle deviation of the urethra from baseline

A

Q-tip test

More than a 30-degree deviation is consistent with hypermobility of the urethra, and/or urethrovesical angle.

• Minimal to no angle deviation in a woman with stress urinary incontinence may indicate intrinsic sphincter deficiency, also known as stove-pipe urethra

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44
Q

Done During the pelvic examination

• can be done either with a full or an empty bladder

A

Cough stress test

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45
Q

the amount of urine remaining in the bladder within 10 minutes from voiding

A

Postvoid residual

46
Q

Normal value of PVR

A

< 50 ml

PVR > 150 ml is abnormally elevated

47
Q

can be administered before (bladder diary), during (urinalysis), or after (pad test) a clinical encounter - to assist the clinician in making a firm diagnosis

A

Simple bladder testing

48
Q

represent the total amount of fluid intake, by type, in a 24-hour period done within 2- to 3- days

A

Bladder diary/voiding diary

49
Q

helpful to rule out a urinary tract infection, especially in the presence of irritative lower urinary tract symptoms such as urgency, frequency, nocturia, and dysuria.

A

Urinalysis

50
Q

The hallmark of advanced bladder testing

A

Urodynamics

51
Q

Simple urodynamics consists of

A
  1. Uroflowmetry
  2. PVR
  3. Simple filling cystometry
52
Q

First becomes aware of bladder filling

A

Bladder sensation
-First sensation

53
Q

Feeling that would lead the person to void at next convenient moment, but voiding can be delayed if necessary

A

First desire to void

54
Q

Persistent desire to void without the fear of leakage

A

Strong desire to void

55
Q

Detrusor function:

-allows bladder filling with little or no change in pressure; no involuntary phasic contractions

A

Normal detrusor function

56
Q

Involuntary detrusor contractions during filling

A

Detrusor overactivity

57
Q

Characteristic wave form; may or may not lead to incontinence

A

Phasic detrusor overactivity

58
Q

Single involuntary detrusor contractions occurring at cystometric capacity, which cannot be suppressed, and results in incontinence usually resulting in bladder emptying

A

Terminal detrusor overactivity

59
Q

Incontinence that is due to an involuntary leakage episode

A

Detrusor overactivity incontinence

60
Q

There is a relevant neurologic condition (replaces term detrusor hypereflexia)

A

Neurogenic detrusor overactivity

61
Q

No definite cause
Replaces term detrusor instability

A

Idiopathic detrusor overactivity

62
Q

Fill volume/change in detrusor pressure (Pdet)

A

Bladder compliance

63
Q

Volume at the end of cystometrogram; capacity is c volume voided together with any residual urine

A

Cystometric capacity

64
Q

Volume at which person feels she can no longer delay voiding

A

Maximum cytometric capacity

65
Q

Allows leakage of urine in the absence of a detrusor contraction

A

Incompetent urethral closure mechanism

66
Q

Leakage that is due to urethral relaxation in the absence of raised abdominal pressure or detrusor overactivity

A

Urethral relaxation incontinence

67
Q

Involuntary leakage of urine during increased abdominal pressure, in the absence of detrusor contraction
-replaces the term genuine stress incontinence

A

Urodynamic stress incontinence

68
Q

Fluid pressure needed to open a closed urethra

A

Urethral pressure

69
Q

Pressure along length of urethra

A

Pressure profile

70
Q

Increment in urethral pressure on stress as percentage of simultaneously recorded increment in intravesical pressure

A

Pressure transmission ratio

71
Q

Intravesical pressure at which urine leakage occurs because of increased abdominal pressure

A

Abdominal leak point pressure

72
Q

Volume voided/unit time

A

Flow rate

73
Q

Total volume voided

A

Voided volume

74
Q

Time over which measurable flow actually occurs

A

Flow time

75
Q

Voided volume/flow time

A

Average flow rate

76
Q

Pressure measured at the end of measured flow

A

Closing pressure

77
Q

Contraction of reduced strength resulting in prolonged bladder emptying an/or failure to achieve complete bladder emptying

A

Detrusor underactivity

78
Q

Cannot be demonstrated to contract

A

Acontractile

79
Q

Normal urethral function during voiding

A

Continuously relaxed

80
Q

Intermittent and/or fluctuating flow rate that is due otherwise involuntary intermittent contractions of the periuethral striated muscle during voiding in neurologically normal people

A

Dysfunctional voiding

81
Q

Detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle

A

Detrusor sphincter dyssynergia

82
Q

Usually occurs in people with a neurologic lesion

A

Nonrelaxing urethral sphincter obstruction

83
Q

A study that assessed voiding function

A

Uroflowmetry

84
Q

A normal uroflow

A
  1. Continuous bell-shaped configuration
  2. A short time to peak flow
  3. A high peak flow
85
Q

An obstructed flow may

A
  1. Have two or more lower peaks with an interrupted flow pattern or a prolonged tail
86
Q

After completion of the uroflowmetry, the patient is placed in a lithotomy position and a catheter is placed to measure the PVR volume

A

Filling cystometry

NORMAL IS LESS THAN 50 ML

87
Q

several sensory parameters that are measured during the filling phase (with
their typical normal values)

A
  1. FIRST filling sensation - 50 ML
  2. First DESIRE to void - 150 ML
  3. STRONG desire to void - 250 ml
  4. Maximum cystometric capacity- 400 ML
88
Q

Loss of urine associated with an increased abdominal pressure is indicative of

A

Stress urinary incontinence

89
Q

suited for women with predominant urgency urinary incontinence, mixed or complex symptoms, with previous failed incontinence surgery, or neurologic conditions

• includes complex filling cystometry, urethral pressure profilometry, and pressure flow studies

A

Complex urodynamics

90
Q

False NEGATIVE test of complex urodynamics can occur in

A

woman with subjective stress urinary incontinence where no urine loss is observed even with a full bladder in the lying or standing position;

• it can also occur with urgency urinary incontinence where a patient may report sensory urgency, but no detrusor activity is visible.

91
Q

False POSITIVE test of complex urodynamics can occur in

A

uncommon with stress but may happen with urgency urinary incontinence where the presence of the catheter or patient’s anxiety may provoke an iatrogenic bladder contraction

92
Q

performed to assess bladder and urethral function during the filling phase

A

Filling cystometry

93
Q

a measure of the detrusor pressure (Pdet) plus the pressure of the abdomen and surrounding organs (Pabd)

A

Intravesical pressure (Pves)

94
Q

Pves = Pdet + Pabd

Pdet = Pves - Pabd

A
95
Q

a measure of the function of the urethra

The pressure inside the bladder (Pves), and that of the urethra (Pure) are noted

A

Urethral pressure profilometry

96
Q

What is the result of Pure and Pves in a healthy normal bladder and urethra

A

Pure is HIGHER than Pves during FILLING

Pves is HIGHER than Pure during VOIDING

97
Q

test of urethral integrity which represents the value of the intra-abdominal or intravesical pressure at which point urine loss occurs

A

Valsalva leak point pressure (VLPP)

98
Q

What is the value VLPP that is used as a cut-off representing normal urethral function

A

> 60 cm of H2O

99
Q

leads are usually placed around the external anus to indirectly assess the activity in the urethral sphincter

A

Electromyography (EMG)

100
Q

generally represents a good estimation of the urethral striated muscle activity.

A

EMG

Since the anal sphincter and urethra are primarily innervated by the pudendal nerve,

101
Q

Result of EMG during filling and voiding phase

A

Filling phase - INCREASED EMG ACTIVITY

Voiding phase - DECREASED EMG ACTIVITY

102
Q

Also called voiding cystometrogram

• Here the Pves, Pabd, and Pure are measured concurrently as the patient is asked to void.

• This study offers information on the voiding mechanism of the bladder, presence of dysfunctional voiding, and the potential risk for retention or incomplete bladder emptying after surgery for incontinence

A

Pressure flow studies

103
Q

sometimes used, but generally not recommended, in conjunction with urodynamics (also referred to as video urodynamics) to assess for a cystocele and hypermobility of the urethrovesical junction

A

Fluoroscopy

104
Q

A typical office-rigid cystoscope consists of a 17-French caliber sheath, through
which the endoscope is introduced

• attached to a fiber-optic light source, camera, and distending medium (sterile water or normal saline).

• The lenses on the endoscope are 0, 12, 30, 70, or 120 degrees.

A

Cytoscopy

105
Q

Normal values of female bladder function

A

-residual volume < 50 mL
-first desire to void occurs: 150-250 mL infused
-strong desire to void: > 250 mL
-cystometric capacity: 400-600 mL
-bladder compliance: 20-100 mL/cm H2O measured 60 sec after reaching cystometric capacity
-no uninhibited detrusor contractions during filling, despite provocation
-no stress or urge incontinence demonstrated, despite provocation
-voiding occurs as a a result of a voluntarily initiated and sustained detrusor contraction
-flow rate during voiding is > 15 mL/sec with a detrusor pressure of < 50 cm H2O

106
Q

Indications for cystoscopy

A

-stones
-BLADDER tumors
-foreign bodies
-CHRONIC cystitis

107
Q

Other indications in women include:

A

a) microscopic hematuria (presence of red blood cells in the urine) that is unrelated to a urinary tract infection;

b) OAB that is refractory to conservative or medical treatment, especially in older women;

c) urinary incontinence with suspected vesicovaginal fistula;

d) symptoms such as frequency, urgency, dysuria, in the absence of a urinary tract infection;

e) women presenting with recurrent urinary tract infections;

f) recurrent urinary incontinence or OAB symptoms following previous anti-incontinence surgery;

g) complications from previous vaginal mesh or sling procedures

108
Q

can help assess changes in morphology of the urethra, bladder neck mobility, pelvic support structures at rest or with Valsalva, and to quantify these changes

A

Ultrasound

109
Q

used mostly in research to better understand the anatomy of the pelvis and the organs

A

MRI

110
Q

• to study the normal function and pathophysiology of the neuromuscular system:

A

Neurophysiologic testing

GYNE 4TH BI (14 decks)

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