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Urogynaecology > Urinary incontinence/frequency > Flashcards

Urinary incontinence/frequency Flashcards

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1
Q

How is urinary continency maintained in women?

A

At urethra via external sphincter + pelvic floor muslces maintaining urethral pressure greater than bladder pressure
Micturition occurs on relaxation of these muscles and detrusor contraction

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2
Q

What is normal bladder storage capacity?

A

500ml (but urge to void usually occurs at 200ml)

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3
Q

What are the forms of incontinence?

A

Involuntary leakage of urine, divided (in urogynae) into:
Stress (49%)
Urge (22%)
Mixed (29%)

Many other forms exist (nocturnal enuresis, postural, coital etc)

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4
Q

Where is the micturition reflex controlled?

A

Pons (mainly parasympathetic for voiding)

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5
Q

What common symptoms are seen in incontinence?

A 
Daytime frequency (normal 4-7)
Nocturia (up to 70y with >1 void abnormal)
Nocturnal enuresis (occurs during sleep)
Urgency
Voiding difficulties (hesitancy, straining, slow/intermittent stream; commonly seen in neurological abnormalities)
Incomplete emptying
Bladder pain (common in interstitial cystitis)
Dysuria
Haematuria
Recurrent UTI
Prolapse, bowel symptoms?
Check PMHx
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6
Q

What should be asked in a urogynae history?

A 
Fluid intake (what, when, volume)
Toileting habits
Hesitancy
Flow
Dysuria (before, during, after)
Urgency ('key in lock')
Sensation of incomplete emptying
Accidents
Flooding
Urine leakage on coughing/straining
Neurological deficits (esp post op/spinal damage)
Haematuria
Sensation of 'lump in vagina'
Psychosocial impact
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7
Q

What storage symptoms may be elicited?

A

Frequency
Nocturia
Urgency
Urinary incontinence

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8
Q

What voiding symptoms may be elicited?

A 
Hesitancy
Slow stream
Straining
Spraying splitting of urine
Double void/immediate re-void
Incomplete emptying
Position dependent emptying
Retention
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9
Q

What is continuous urine leakage associated with?

A

Vesicovaginal fistula

Congenital abnormality e.g. ectopic ureter

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10
Q

What is stress urinary incontinence?

A

Involuntary leakage of urine on effort or exertion, sneezing, coughing, laughing (increased intrabdominal pressure

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11
Q

What may cause stress UI?

A

Childbirth (any weakening of pelvic floor)

Menopause

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12
Q

What is urge urinary incontinence?

A

Involuntary leakage of urine with a strong desire to pass urine (urgency); commonly coexists with frequency and nocturia, forms part of overactive bladder syndrome

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13
Q

What can cause urge UI?

A

Infection
Stones
Idiopathic detrusor overactivity (DO)

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14
Q

What is mixed urinary incontinence?

A

Involuntary leakage of urine associated with both urgency and exertion (usually one symptom will predominate - treat this first)

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15
Q

What is overflow incontinence?

A

Usually due to injury or insult e.g. postpartum.

Treat with catheter

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16
Q

What can cause UI?

A 
Parity
Increasing age
Raised BMI
Recurrent straining (heavy lifting, chronic constipation, chronic cough)
Pregnancy
Medication
Connective tissue disorder
Neurological condition
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17
Q

What examinations can be performed in UI?

A

Abdominal exam (tenderness, palpable masses)
Speculum
VE (assess for prolapse, pelvic floor strength)

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18
Q

What Ix are available for UI?

A 
Bladder diary
Urinalysis
Imaging
Cystoscopy
Urodynamics
Quality of life assessment
USS (pelvis and bladder); check for residual volume
Specific examination (stress test, pad test, Q-tip test)
Prolapse assessment
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19
Q

Why is urinalysis useful in assessing UI?

A

Check for UTI (along with MSU and MC&S)

OGTT if diabetes suspected

20
Q

Why is imaging useful in assessing UI?

A

Exclude incomplete emptying and define any pelvic mass

21
Q

Why is cystoscopy useful in assessing UI?

A

Visualise urethra, bladder mucosa, trigone and ureteric orifices
Biopsies can be taken
Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour or interstitial cystitis

22
Q

Why are urodynamics useful in assessing UI?

A

Uroflowmetry screening for voiding difficulty (pt voids into commode with urinary flow meter, measuring voided volume over time)
Cystometry involves measuring pressure and volume within the bladder during filling and voiding to test bladder function. (bladder filled with saline and intravesical and rectal probes measure difference in pressure) Pt asked for first desire to void, strong desire to void and cough (results plotted on graph and any detrusor contractions and/or leakage noted)

23
Q

What is stress incontinence (SUI)?

A

Detrusor pressure > urethral closing pressure (e.g. raised intra-abdominal pressure)
Most common form of urinary incontinence

24
Q

What are risk factors for stress incontinence?

A

Pregnancy (mode of delivery irrelevant)
Menopause (oestrogen deficiency - thinning of urothelium/weakening of pelvic support)
Radiotherapy
Congenital weakness
Trauma from radical surgery (e.g. gynae cancer)

25
Q

What Ix would be indicated in SUI?

A

Urine dip for infection
Urodynamics (esp when surgery considered)
Check for detrusor dysfunction (e.g. consequence of surgery)
Check for voiding dysfunction (low flow rate = inc risk of urinary retention)

26
Q

What conservative management is used in SUI?

A

Control of other medical problems e.g. diabetes, treatment of chronic cough, constipation
Weight loss
Smoking cessation
Pelvic floor exercises (3m and continued long-term - ref to physio)
Vaginal cones/sponges can be considered (held in place by voluntary muscle tone); also intramural bulking agents e.g silicone

27
Q

What medical management is used in SUI?

A

Pharmacological treatment not recommended for first line treatment
Topical HRT may be used to increase oestrogen
Duloxetine can be used (SNRI, associated with nausea, dyspepsia, dry mouth, dizziness, insomnia) but not recommended by NICE

28
Q

What surgical management is used in SUI?

A 
Urethral bulking (60-70% cure rate; pain/difficulty in passing urine may result, 1 in 3 requests top up)
Peri-urethral injections (bulking agents - see above, low cure rates but useful in women who have not completed childbirth, frail elderly pts and if prev surgery failed)
TVT (tension-free vaginal tape) - most common, 80-90% cured, mesh (some controversy); risks include bladder injury, voiding difficulty, tape erosion (and exposure)
TOT (trans-obturator tape) - Same as for TVT, but lower chance bladder injury  (as retropubic space not entered); higher postop groin pain
Colposuspension (Bursch procedure, 80-90% success rate; but associated with failure to work, OAB symptoms, rectocele, dyspareunia, difficulty passing urine)
29
Q

What mid urethral slings are available?

A

TVT

TOT

30
Q

What is the difference between urodynamic stress incontinence and stress incontinence?

A

USI is a disorder diagnosed by cystometry, where SI is a major symptom
SI is a symptom (but may be due to USI)

31
Q

What is the principle for TVT?

A

Synthetic tape placed in U shape under mid-urethra via small vaginal anterior wall incision
Tension adjusted to prevent leakage as woman coughs
Cystourethography performed to ensure no damage to bladder/urethra

32
Q

What is the principle for TOT?

A

Similar to TVT but tape inserted via transobturator foramen, through transobturator and puborectalis muscles (avoiding retropubic cavity)

33
Q

What is overactive bladder syndrome?

A

Chronic condition with underlying detrusor overactivity (DO), but not necessaryily present
Defined as urgency (+/- urge incontinence) usually with frequency or nocturia, in the absence of proven infection

34
Q

How can DO be diagnosed?

A

Urodynamic testing

35
Q

How common is OAB?

A

Up to 35% of UI in women, 1 in 6 women will be affected by it

36
Q

What is the cause OAB?

A

Most commonly idiopathic
MS
Spina bifida
Secondary to pelvic/incontinence surgery

37
Q

What may provoke symptoms in OAB?

A

Cold weather
Opening door (‘key in lock’)
Coughing/sneezing (hence confusion with SI)

38
Q

What symptoms give a classical Hx of OAB?

A 
Urgency and urge incontinence
Frequency
Nocturia
SI also common
Childhood Hx of enuresis common, as is faecal urgency
39
Q

What may be found on examination for OAB?

A

Typically normal examination

Cystocele may be present incidentally

40
Q

What Ix should be performed in OAB?

A 
Exclude UTI
Urinary diary (e.g. frequency/volume chart showing increased diurnal frequency and nocturia)
Urodynamics (e.g. cystometry) only considered if doubt surrounding diagnosis, complex symptoms or drug treatment failure
41
Q

What conservative management methods can be used in OAB (and urge incontinence/mixed UI)?

A

Avoid excessive fluid intake (esp caffeinated/carbonated drinks and alcohol)
Bladder retraining for 6w minimum (encourage voiding at set times - suppress urinary urge and extend intervoiding intervals)
Catheters (intermittent self-catheterisation, permanent - urethral, suprapubic)

42
Q

What medical management methods can be used in OAB (and urge incontinence/mixed UI)?

A
  • Anticholinergics (antimuscarinics) - blocking parasympathetic nerves and relaxing detrusor e.g. oxybutynin 2.5mg 1-4 times/day (alternatives: solifenacin 5-10mg OD, tolterodine 2mg BD). Note side effects include dry mouth, constipation and nausea; oxybutynin should not be used in elderly/frail.
  • Intravaginal oestrogen cream ( alsohelps in vaginal atrophy)
  • Sympathomimetics (Mirabegron) - Bladder antispasmodics without anticholinergic side effects (so useful second line to antimuscarinics). Note association with hypertension (so BP monitoring indicated)
43
Q

What invasive procedures are available for OAB?

A
  • Botulinum A injections (intramural, in cases of proven DO resistant to conservative/medical Rx; may have to perform intermittent self-cathaterisation after)
  • Percutaneous sacral nerve stimulation (If other treatment fails; electrodes placed SC around sacrum, to stimulate S2-4 supply to bladder)
  • Augmentation cystoplasty (re-fashioning/enlargement of bladder using bowel)
  • Urinary diversion (e.g. nephrostomy, urostomy)
44
Q

What should a GP do to a patient with overactive bladder?

A

Start conservative (lifestyle changes, bladder retraining, pelvic floor exercises, leaflets)
Start on antimuscarinics (tolteradine 4mg OD, solifenacin 5mg-10mg OD, trospium 60mg OD)
Mirabegron 50mg PO OD
Refer

45
Q

What surgical procedures are available for UUI?

A 
Cystoscopy (e.g. for stones)
Botox intravesical injection
Neuromodulation (sacral, tibial)
Bladder distention
Detrusor myomectomy
Augmentation cystoplasty
46
Q

What can cause urgency and frequency?

A 
UTI
Bladder pathology
Pelvic mass compressing bladder
OAB
USI

Urogynaecology (4 decks)

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