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OBGYN 4MB > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

What guideline is used in the management of urinary incontinence?

A

NICE guideline - Management of Urinary Incontinence in Women 2006

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2
Q

Define urinary incontinence

A

The complaint of involuntary leakage of urine

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3
Q

List the types of urinary incontinence

A
  1. Stress
  2. Urge
  3. Mixed
  4. Overactive bladder
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4
Q

Define stress incontinence

A

Involuntary urine leakage on effort or exertion or on sneezing or coughing

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5
Q

Define urge incontinence

A

Involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to defer)

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6
Q

Define mixed incontinence

A

Involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing

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7
Q

Define overactive bladder (OAB)

A

Urgency that occurs with or without urge incontinence and usually with frequency and nocturia
Suggestive of urodynamic finding of detrusor overactivity, but can be result of other urethrovesical dysfunction

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8
Q

List the risk factors for urinary incontinence

A
  1. Family hx
  2. Chronic constipation
  3. Cognitive impairment
  4. Vaginal/forceps/C-section delivery
  5. Obesity
  6. Pregnancy
  7. Previous gynaecological surgery
  8. Female
  9. Diabetes
  10. Increasing age
  11. Neurological disease
  12. Hysterectomy
  13. Chronic cough
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9
Q

What should we enquire about in the history?

A

Questions about incontinence:

  1. Frequency
  2. Urgency
  3. Estimated volume leakage
  4. Timing
  5. Precipitating/relieving factors

Symptoms of UTI:

  1. Nocturia
  2. Haematuria
  3. Dysuria
  4. Cloudy urine
  5. Any obstructive symptoms
  6. Previous hx of UTI

Obstetrics hx:

  1. Previous pregnancies
  2. Mode of delivery
  3. Length of labour
  4. Weight of baby
  5. Any complications
  6. Previous incontinence associated with pregnancy

Other:

  1. Menstrual history
  2. Previous surgery esp pelvis/ spinal
  3. Bowel habits
  4. Medications
  5. Lifestyle
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10
Q

What could you find on examination of a woman with incontinence?

A
  1. Abdo exam - enlarged bladder or masses
  2. V/E - ?pelvic organ prolapse, ?masses, irritation or inflammation
  3. DRE - ?posterior wall prolapse, ?constipation)
  4. Digital evaluation of pelvic floor muscles
  5. Perineal sensation
  6. ?cognitive assessment by MMSE if >75
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11
Q

What investigations should be done in urinary incontinence?

A 
Bloods:
1. U&E - renal function baseline 
Urine:
1. Dipstick 
2. MC&S ? infection 
Urinary diary:
- Diary of fluid intake and output, incontinence
Urodynamic studies 
Cystoscopy 
Others:
1. IVP (Intravenous pyelogram) 
2. Methylene blue test
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12
Q

What is the mechanism behind stress incontinence?

A

The rise in intra-abdominal pressure is transmitted to the bladder and causes pressure within the bladder to exceed pressure within the urethra so leakage or urine occurs

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13
Q

What is the conservative management of stress incontinence?

A
  1. Weight loss
  2. Stop smoking
  3. Reduce fluid intake
  4. Review medication (e.g. stop diuretics)
  5. Pelvic floor muscle training - >3/12 trial, contract pelvic floor muscles (Set of 8 contractions 3 times a day)
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14
Q

What is the medical management of stress incontinence?

A
  1. Duloxetine (SNRI) - enhances pudendal nerve stimulation so increase urethral sphincter closure
    * Not first line but can be used as alternative to surgery
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15
Q

What is the surgical management of stress incontinence?

A
  1. Tension free vaginal tape (TVT):
    - Mesh like tape passes through both sides of the endopelvic fascia and behaves like a sling
    - Placed around the urethra to create support without obstruction
  2. Transobturator Tape (TOT):
    - Version of TVT where tape is passed through obturator canal
  3. Colposuspension:
    - Vaginal wall on either side of bladder neck is hitched up to the ileopectineal ligament on either side of the symphysis pubis with non-absorbable sutures
    - Stabilises position of bladder
    - Tenses urethra, making leakage of urine more difficult
  4. Peri-urethral bulking agents:
    - Collagen/silicon/Teflon can be injected around the urethra to bulk the tissue
    - Creates narrower passage for the urine to flow
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16
Q

What is the pathophysiology behind urge incontinence?

A

Instability within the detrusor muscle leading to involuntary contractions
Accompanied by involuntary relaxation of urethra

17
Q

What is the conservative management of urge incontinence?

A
  1. Fluid modification
  2. Lose weight (if BMI >30)
  3. Bladder training
18
Q

What is bladder training?

A

Scheduled voiding intervals with stepped increases and suppression of urge with distraction or relaxation techniques

19
Q

What is the medical management of urge incontinence?

A
  1. Anti-muscarinics
  2. Intravaginal oestrogens
  3. Mirabegron
  4. Desmopressin
20
Q

How do anti-muscarinics work to treat urge incontinence?

A
  • Relaxant effect on urinary smooth muscle, reduce involuntary detrusor contractions and increase bladder capacity
  • Oxybutyrin = first line for OAB or mixed if bladder training ineffective
  • Alternatives = Darifenacin, Solifenacin, Tolterodine, Trospium
21
Q

List the side effects of anti-muscarinic medications

A
  1. Dry mouth
  2. Dry skin
  3. Blurred vision
  4. Tachycardia
  5. GI upset (constipation)
  6. Hyperthermia
  7. Confusion
22
Q

How do intravaginal oestrogens work to treat urge incontinence?

A

If vaginal atrophy in postmenopausal women

23
Q

How does Mirabegron work to treat urge incontinence?

A
  • Agonist of beta-3 receptors in detrusor smooth muscle , cause relaxation
  • Used if anti-muscarinics CI or effects not tolerated
24
Q

When is Desmopressin used?

A

Nocturia

25
Q

What is the surgical management of urge incontinence?

A
  1. Botulinum toxin A
  2. Nerve stimulation
  3. Augmentation cystoplasty
  4. Urinary diversion
26
Q

How does botox treat urge incontinence?

A
  • Injected directly into bladder
  • Cases muscle to relax and increase its ability to hold more urine before you feel need to empty bladder
  • Needs to be repeated every 6-12mths usually
27
Q

How does nerve stimulation treat urge incontinence?

A
  1. Sacral nerve stimulation:
    - Small device implanted under skin
    - Mild electrical impulses to stimulate sacral nerves of lower back
    - Corrects misfiring signals between brain and bladder
  2. Posterior Tibial Nerve Stimulation:
    - Less invasive
    - Place needle through skin near the ankle
    - Electrical stimulation flows through needle along tibial nerve to spine
    - Connects with nerves that control bladder
    - 30 min procedure, once a week for 12wks
    - Many experience improvement by week 6
    - May need to have occasional treatment to sustain improvement (once every 3wks)
28
Q

How does augmentation cystoplasty treat urge incontinence?

A
  • Uses patch of own tissue (intestinal) to make your bladder bigger
  • Divide dome of bladder and insert tissue between
  • Need yearly cystoscopy to monitor for malignancy as increased risk
29
Q

How does urinary diversion treat urge incontinence?

A
  • Reroutes ureters so that bladder is bypassed and tubes lead directly to outside of the body through abdominal wall
  • Urine does not flow into bladder
  • Collected in small bag on abdominal wall (ostomy bag)

OBGYN 4MB (25 decks)

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