Urogynaecology Flashcards
What are the different types of incontinence?
Urgency - overactive bladder.
Stress incontinence - anatomical defect in urethral support or sphincter muscle weakness.
Mixed stress and urgency.
Explain the micturition cycle
- Bladder fills, the detrusor muscle relaxes and urethral sphincter relaxes while pelvic floor contracts.
- First sensation to void - urination voluntarily inhibited
- Normal desire to void
- Micturition - detrusor muscle contracts while pelvic floor relaxes.
What is the presentation of urge incontinence and overactive bladder
Overactive bladder - frequency and nocturia
Urge incontinence - leakage of urine in response to involuntary contraction of detrusor muscle
What is the presentation of stress incontinence?
Signs and symptoms of urinary leakage with increased intra-abdominal pressure without detrusor contraction (coughing, laughing, running or walking).
What are potential causes of an overactive bladder?
Neurological - Parkinson’s, stroke, MS
Mobility,
Constipation/previous surgery,
Acute UTI,
Caffeine
Alcohol,
Bladder abnormalities - tumours or stones,
High urine production - meds, excess fluids, diabetes
What is the difference between stress incontinence and urodynamic stress incontinencce?
Stress - Clinical diagnosis.
Urodynamic stress - Stress incontinence proven by urodynamic studies
What are the main risk factors for urinary incontinence?
Pelvic prolapse and repair,
Pelvic surgery radiotherapy,
Menopause,
Family history,
Anatomical abnormalities
Pregnancy,
Cognitive impairment,
Medications,
UTIs,
Obesity,
Increased intra-abdo pressure
What are the main symptoms of incontinence?
Stress incontinence, frequency, urgency, nocturia, enuresis, haematuira, dysuria,
explain the examination process when patient presents with incontinence
Abdominal/bimanual exam - look for pelvic masses/palpable bladder.
Vaginal exam - speculum exam, ask to cough to look for urine leakage
What are the investigations for incontinence?
Urinary dip +/- culture
Bladder diary - minimum of three days (input, output)
Cystoscopy and renal tract imaging,
Urodynamic testing (measures pressure in bladder and rectum by putting catheters in)
What is the management of incontinence?
Conservative - lifestyle changes, physiotherapy and bladder retraining.
Medical - Abx, anticholinergics, B3 agonists, duloxetine.
What is the medical management of an overactive bladder?
1st line - Antimuscarinics eg, Tolterodine, solfenacin. However side effects include dry mouth, dry eyes or constipation. Must use for 3 months to see if there has been effect
2nd line - B3 adrenoreceptor agonists eg, mirabegron (relaxes bladder)
What is the medical management of stress incontinence?
Vaginal oestrogen if post menopausal.
Duloxetine - only if declined surgery. Not very effective and has high side effect profile (GI disturbance, dry mouth, headaches)
What is the surgical management of an overactive bladder?
If medical management hasn’t worked.
1. Botox injections into detrusor muscle - effects last from 3-13 months. Patients should be able to perform self catheterisation.
2. Percutaneous sacral nerve stimulation.
3. Augmentation cystoplasty.
Urinary diversion.
What is the surgical management of stress incontinence?
Synthetic tapes,
Colposuspension,
Biological slings,
Intramural bulking agents
