Urinary tract Flashcards
What type of nerves aid voiding? And what type prevent it?
Parasympathetic aid (increase detrusor tone), sympathetic prevent (decrease detrusor tone).
What are the two main causes of incontinence?
Uncontrolled increases in detrusor pressure: Urge incontinence / overactive bladder
Increased intra-abdominal pressure: transmitted to bladder, but not urethra due to urethra slipping out of the abdomen. Stress incontinence.
What is urinary stress incontinence?
Involuntary leakage of urine on effort / exertion / sneezing / coughing.
What is the normal mechanism of urinary stress incontinence?
Urethral sphincter weakness - pelvic floor weakness allows the urethra to slip out of the abdomen. This causes a higher pressure in the bladder than the urethra, hence leakage.
What is the aetiology of urinary stress incontinence?
Pregnancy.
Vaginal delivery (+ prolonged labour, forceps delivery).
Obesity.
Age.
Previous hysterectomy.
How does stress incontinence present?
Urination on sneezing / coughing / lifting.
May also have frequency / urgency.
Need to understand primary concern.
O/E: Sims speculum often shows cystocoele / urethrocoele.
How would you investigate stress incontinence?
Urine Dip - exclude infection.
Cystometry to exclude overactive bladder if considering surgery or OAB symptoms fail to respond to medicine.
How would you treat stress incontinence?
Weight loss, address chronic cough, reduce fluid intake.
First line = pelvic floor muscle training - 8 contractions, TDS.
Second line = duloxetine (SNRI) - enhances sphincter activity. S/E = nausea (also dyspepsia, dry mouth, insomnia, drowsiness)
Surgery - mid-urethral sling (tension free vaginal tape and trans-obturator tape). Complications - bladder perforation, voiding difficulty, bleeding, infection, mesh erosions.
What is an overactive bladder?
Urgency, +- urge incontinence, usually with frequency and nocturia; without infection. Due to involuntary detrusor contractions, often stimulated by a cough or similar.
What causes an overactive bladder? What is the aetiology?
Normally caused by detrusor overactivity.
Typically idiopathic. Can be due to surgery for stress incontinence or rarely neuropathy.
How does an overactive bladder present?
History and urge incontinence (feel the need to go, then leakage), frequency and nocturia. Also +- stress incontinence, leaking at night or orgasm.
O/E: often normal, sometimes incidental cystocoele seen.
How would you investigate an overactive bladder?
Urinary diary: frequent, small volumes of urine, esp at night.
After failure of lifestyle change: Cystometry: contractions on filling / provocation.
How would you treat an overactive bladder?
Conservative: Reduce fluid and caffeine intake; review medications.
Bladder training: education, timed voiding, positive reinforcement.
Drugs: Antimuscarinics to suppress the detrusor. S/E: dry mouth. Oestrogen if post-menopausal. Botulinum if antimuscarinics fail.
What are the causes of acute urinary retention?
Childbirth, vulval / perineal pain, surgery, anticholinergics, retroverted uterus, pelvic masses, neurological disease.
What causes chronic urinary retention?
Urethral obstruction: pelvic masses, incontinence surgery.
Detrusor inactivitiy: autonomic neuropathies (DM), previous overdistension.
