Urinary incontinence Flashcards
What are the clinical presentations associated with various types of incontinence?
only incontinence w/ stress: SUI
urge/frequency: urge incontinence (UI) or OAB w/ UI
incontinence during and after stress: mixed incontinence (SUI +UI)
continuous: fistula
frequent dribble: chronic urinary retention (aka overflow incontinence)
What is the workup of urinary incontinence?
- History & physical exam
- urinalysis: asymptomatic low-risk non smoker 35-50 ONLY get evaluation if >25 RBC per high power field. (AUA defines microscopic hematuria as >3 rBC per HPF).
- demonstration of stress incontinence: cough test (first supine and if neg, repeat standing w/ full bladder. if neg but pt has sx, do urodynamic testing).
- assessment of urethral mobility:
- measurement of post-void residual (abnormal >150. if incr PVR w/o prolapse, evaluate bladder emptying mechanism w/ pressure-flow urodynamic study
What to focus on in history for incontinence?
- Symptom severity: goals of tx, frequency (<8/day normal), nocturia (<1 night), dysuria, urgency
- aggravating factors (laugh, cough, jump, sneeze)
- Timing of leakage in relation to aggravating factors: immediate (genuine SUI), urgency/delayed + can’t stop=UI
- PMH (DM, MS, spinal cord, lung disease)
- PSH (spine, radiation, bladder surgery)
- Meds: diuretics, alcohol, narcotics, antihistamines, psychotropic (alpha agonists, alpha blockers, CCB, caffeine)
- bladder diary for 2-3 days.
What to focus on in physical exam for incontinence?
Weight (obesity)
Evidence of prolapse (assess all pelvic support compartments. prolapse can mask or decrease severity of incontinence symptoms
Degree of estrogenization of pelvic tissues.
Neuro exam:
- S2,3,4 contain important neurons controlling micturition/pudendal nerve: touch perineum and look for introital or anal contraction
- peripheral neuropathy (eg DM), lower limb reflexes
- Hyper-reflexic: if upper motor neuron lesion (spinal cord lesion)
What is the Q-tip test?
assess for urethral hyper mobility for SUI.
- at rest should be <0 degrees (below the horizontal)
- with valsalva should be < 30 degrees change (above horizontal)
Sterilize the swab cotton with 2% xylocaine jelly.
The swab cotton will be inserted gently and slowly into the urethra till no further resistance means the Q-tip has entered the bladder.
Then, gently pull back the cotton swab until increased resistance is met, indicating that the cotton tip is entering the urethra. at ureterovesical junction.
The first measure( resting angle) will be taken at this point related to the horizontal line it equals 0 when it is parallel to the ground in people with normal pelvic anatomy.
Ask the patient to cough, do Valsalva, or contract abdominal muscles to increase the intra-abdominal pressure.
Then the maximum deflection of Q- tip angle is measured. The normal angle from 10- 30, more than 30 considered hypermobility and means descent of the urethrovesical junction and may require surgery.
When do you need urodynamics?
rarely needed. only if:
- unclear diagnosis
- prior incontinence surgery
- persistent incontinence
- complex conditions present
What are the types of urodynamic studies?
- Cystometry/CMG: rule out OAB w/ UI: evaluate bladder and abdominal pressure relative to fluid volume during filling, storage, voiding to an assess bladder sensation, capacity and compliance.
- Uroflowmetry and pressure-flow studies (diagnose outflow tract problems): measure rate of urine flow and mechanism of bladder emptying. can eval voiding dysfunction.
Electromyography (clinically indicated): study neuromuscular activity. detect coordination between detrusor muscle contractions and simultaneous urethral sphincter relaxation.
Urethral pressure profile (clinically indicated): doesn’t reliably predict surgical outcomes.
What is the poor person’s CMG?
insert foley into bladder, connect to column of tubing elevated above patient.
- connect tubing to open 50cc syringe. gently fill bladder by adding water to open syringe.
- ask pt to cough, look for elevations in water column during and immediately after cough is over. if elevated after cough is over, UI.
- normal bladder capacity: 350cc
- should feel “something in bladder” at 100cc, full at 200cc, NEED to pee at 300cc.
- if pt has unprovoked detrusor contraction (OAB), would see rise in fluid level in syringe during contraction.
What are non-surgical treatments of urinary incontinence (OAB)?
- Anti-muscarinics: oxybutynin/tolterodine/solifenacin
- block parasympathetic M2/M3 receptors to inhibit involuntary detrusor contractions
- SE: dry mouth (most common), dry eyes, constipation.
- Contraindications: narrow-angle glaucoma, urinary retention, gastric retention - Beta-3 agonists: Mirabegron
- relaxes detrusor muscle and increases bladder capacity
- can cause tachycardia, HA, diarrhea
- C/I: severe HTN, severe renal/liver disease - Botulinum toxin A (100u intravesical q6 mo)
- more pts get complete relief of UI than with anti-muscarinics.
- SE: UTI, urinary detention.
topical estrogen MAY reduce incontinence episodes.
What are behavioral treatments for UI and SUI?
- pelvic floor exercises/PT
- weight loss
- dietary/fluid modification
- bladder training
-devices: pessaries, plugs.
What are surgical options for SUI and UI?
SUI:
- urethral bulking agents (great if lack of urethral mobility bc sling doesn’t work for these patients)
- surgery: mid-urethral slings w/ mesh=best choice. Also pubovaginal slings, Burch urethropexy.
- for SUI, can have urethral hyper mobility or intrinsic urethral sphincter weakness
UI:
- sacral neuromodulation for refractory urge incontinence.
What are complications of MUS, needle or suture suspensions?
UTI
worsening of urge incontinence
surgical site bleeding
urinary retention OR persistent SUI (if persistent, repeat urodynamic testing and cysto to exclude neuromuscular causes)
bladder perforation
mesh erosion
space of retzius hematoma
local anesthetic toxicity
injury to ureter or bowel (uncommon)
What are treatment options for urolithiasis?
antibiotics
anti-emetics
analgesics
- renal decompression w/ ureteric stent, ureteroscopic stone removal, percutaneous nephrostomy, lithotripsy (contraindicated in pregnancy).
What is a retropubic urethropexy/colposuspension (Burch)?
It restores the UVJ anatomy. surgically elevates and reinforces periurethral tissue. The Burch colposuspension procedure addresses SUI secondary to urethral hypermobility, but does not alleviate incontinence secondary to intrinsic sphincter deficiency
Differs from TVT/TOT because tVT/TOT is placed mid-uretethral and is a backstop for the urethra.
What are the advantages/disadvantages of a TVT (tension-free vaginal tape) vs a TOT?
Advantages:
- treats intrinsic sphincter deficiency
- less risk of dyspareunia
- no interruption of thigh muscles (athletes, equestrians)
- long term data
Disadvantages
- does NOT avoid retropubic space (prior surgery or large pants)
- technically more difficult
- higher complications (bowel/bladder injury)
- higher post-op voiding dysfunction and de novo detrusor instability
