Urinary incontinence

Question 1

what is the cotton swab test?

Answer 1

insert a lube’d cotton swab into urethra to the level of the urethrovesical junction. Ask pt to strain as if urinating. Should see a change in cotton swab angle < 30 degrees, but if bladder neck is hypermobile, it will be more than this.

Question 2

what are the 4 types of incontinence?

Answer 2

stress
urge
total
overflow

Question 3

what is total incontinence?

Answer 3

continuous urine leakage due to urinary fistula

Question 4

what is overflow incontinence?

Answer 4

overdistension of bladder 2/2 poor detrusor ctr’ns => leaking

Question 5

RFs for stress incontinence?

Answer 5

conditions causing pelvic relaxation
(vaginal births, aging, genetics)
Conditions causing chronic increases in intraab’l P
(constipation, chronic cough, chronic heavy lifting, ob)
Conditions that weaken the urethral closing mechanism
(ES def’y, scarring, meds, denervation)

Question 6

tx for stress incontinence?

Answer 6

Kegel exercises
Pessaries
d/c’ing certain meds, regulating fluid intake, bladder training/biofeedback
topical ES
surgery - urethropexy, suburethral sling

Question 7

what is detrusor instability?

Answer 7

urge incontinence. Involuntary detrusor contractions, usually idiopathic, can be 2/2 neurologic disorders, infection, bladder stones, suburethral diverticulum

Question 8

CP of detrusor instability

Answer 8

urgency
frequency
stress incontinence
nocturia

Question 9

tx of detrusor instability:

Answer 9

Kegels
bladder tr (regular voiding schedule), biofdbk
hypnosis, psychotherapy
oxybutinin (anti-ACh)
tolterodine (SMC relaxant)
imipramine
**medical therapy, not surgical**

Question 10

what is most common cause of urinary fistulas?

Answer 10

ob trauma  (seen more in developing countries)
pelvic radiation or surgery (in dvp'd countries)

Question 11

which surgeries account for most of vesicovaginal fistula formation?

Answer 11

simple ab’l hysterectomy

vag hyst

Question 12

how to eval for vesicovaginal fistula?

Answer 12

instill methylene blue dye into bladder, see if it comes out onto tampon or pad.

Question 13

how to eval for utererovaginal fistula?

Answer 13

inject indigo carmine IV. It will be filtered by kidneys, and if fistula is present, it will be on tampon or pad. But methylene blue test will be negative.

Question 14

tx of urinary fistula?

Answer 14

surgery

Question 15

causes of overflow incontinence?

Answer 15

fecal compaction
meds
neuro'c disorders
post-op bladder distension 2/2 epidural anesth 
post-op urethral obstruction

Question 16

tx of overflow incontinence

Answer 16

prazosin, terazosin (relax urethra)
diazepam, dantrolene (striated m. relaxant)
bethanechol (ACh agonist)
intermittent self-cath
surgical correction if obstruction is cause
foley catheter for 24-48h if post-op urinary retention