Urinary incontinence and pelvic organ prolapse - NICE 2019 Flashcards
3 main types of incontience
Stress UI
Mixes
Urgency/Overreactive bladder OAB
History for urinary incontience
- Frequency/nocturia
- Urgency, urge UI
- Stress UI, ?continous (fistula)
- Voiding - hesitant, poor stream, intermittent stream
- Post-micturation - incomplete empty, dribbling
- Haematuria, pain (bladder/urethral)
- Bowel Sx
- medical Hx
- Surgical Hx
- O&G Hx - ?completed family, sexual dysfunction
- Drug Hx
Examination
AMTS
Abdo examination (masses
Bimanual +/- PR
Investigations for incontience
MSU
Residual volume - USS or catheter post void
Bladder diary for 3/7
Symptom score
If urinalysis shows leukocytes and nitrites +ve
Await MSU, if +ve treat
When to perform urodynamic testing?
Do not perform for primary stress incontinence before surgery
Perform if stress and :
- Urge-predominant, or unclear
- Voiding dysfunction
- Anterior or apical prolapse
- Hx of previous surgery for SUI
Lifestyle advice to give for urinary incontience
Less caffeine
Drink 1-2 L fluid/day
If BMI >30 lose weight
How long and how often should pelvic floor muscle training for stress/mixed UI
3 months
8 contractions at least TDS
4 months if POP
For how long should bladder retraining take place for OAB or mixed
Minimum 6 weeks
2 terms used with overactive bladder if accompanied with incontinece or not
OAB dry or wet
If urodynamic being used how is detrusor overactivity diagnosed?
Diagnosis is therefore made at filling cystometry:
a) Rise in detrusor pressure of >15cm H2O
b) Rise in detrusor pressure of <15cm H2O in the presence of urgency or urge incontinence
What drugs are offered 1st line in OAB
Oxybutynin
Tolteradone
Solifenacin/Darifenacine
What proportion of women have improve symptoms after anticholinergics?
57-71% of women,
Side effects of anti-cholinergics
Nausea, constipation, diarrhoea and abdominal discomfort
Dry mouth (88%)
Blurred vision
Voiding difficulties
Headache, dizziness, drowsiness, restlessness and disorientation
Rash, dry skin, photosensitivity
Arrhythmia
Angioedema
When are anticholinergics contraindicated?
Glaucoma
Ulcerative colitis
Myasthenia gravis
Intestinal obtruciton
When should you not given oxybutynin
Avoid if >80yrs or frail
Can consider transdermal
Which anticholinergic has the least confusion side effects and can be consider in women with dementia
Darifenacin
When to review after start anticholinergic
4 weeks
Long term & >75 review every 6 months
When to consider desmopressin
nocturia and nocturnal enuresis.
When is desmopressin contraindicated and side effects
Congestive heart failure, caution if 65+ with CVD or HTN
Side-effects include fluid retention with hyponatraemia, epistaxis, nasal congestion and rhinitis with nasal spray
If antimuscarinic contraindicated, what medication to consider?
Mirabegron
What type of drug is mirabegron
Selective B-3 adrenergic agonist
If medication not controlling overactive bladder symptoms what is the next step?
Refer to MDT to discuss
What ti explain to patient before Bladder wall injection with botox A
- the likelihood of complete or partial symptom relief
- clean intermittent catheterisation, the risks, and how long it might need to be continued
- the risk of adverse effects, including an increased risk of urinary tract infection
- Not much evidence about how long the injections work for, how well they work in the long term and their long-term risks*
How much botox to give at initially, when to review
100 units botox A
Review in 12 months
Can increase two 200 if limited response
Whe to offer posterior sacral nerve stimulation
Declined or no response to botox
What very rare surgical options can be considered for OAB
Augmentation cystoplasty - surgery to enlarge bladder
Urinary diversion
What proportion of stress incontience can be managed with conservative measures
50%
When should be referred to MDT
When conservative measures fail to work
Main surgical treatments of stress incontience
- Open/Lap Burch Colposuspension
- Autologous recurs fascial sling/Retropubuic mid-urethral mesh sling
Bulking agents
Deloxetine
Conservative treatments of prolapse
losing weight, if the woman has a BMI greater than 30 kg/m2
minimising heavy lifting
preventing or treating constipation
Topical oestrogen - if signs of atrophy or consider oestrogen ring
Pelvic floor training - 4months
Pessaries
How often should pessaries be removed and inspected
6 months
For prolapse and does not mind if retains uterus, what surgeries can be offered?
vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or
vaginal sacrospinous hysteropexy with sutures or
Manchester repair.
For prolapse would like to retain uterus, what surgeries can be offered?
vaginal sacrospinous hysteropexy with sutures or
Manchester repair (unless want children)
What is a Manchester repair?
excision of the elongated cervix and approximation of the cardinal ligaments anterior to the cervix to elevate and retract it so that the uterus is both anteverted and supported
What surgery can be offered to anterior or posterior repair?
Anterior: Anterior repair without mesh
Posterior: Posterior repair without mesh
Review in 6 months
If women has mesh complication what can offer as management
Consider topical oestrogen cream if exposed area <1cm, FU 3 months
removal has limited benefits, may worsen pain, UI or prolapse may recur
Consider partial/complete removal if
- Does not want topical oestrogen, area of exposure >1cm, gainful mesh extrusion, no response in 3 months
Sacrocolpopexy
Surgery to treat vault prolapse, plastic mesh used to attach vagina to sacrum
Sacro-hysteropexy
Uterine prolapse, plastic mesh from womb to sacrum
Vaginal sacrospinous fixation
Vaginal vault or uterine prolapse - top of vagin stitched to sacrospinous ligament
Vaginal sacrospinous hysteropexy
Used to treat uterine prolapse - cervix stitched to sacrospinous ligament
