Urogynaecology Flashcards

1
Q

What is urinary incontinence

A

An involuntary loss of urine which can be objectively demonstrated
- social and hygiene problem

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2
Q

Describe the micturition cycle

A

1) Bladder fills
- detrusor muscle relaxes
- urethral sphincter contracts
- pelvic floor contracts
2) First sensation to void
- bladder is half full
- urination voluntarily inhibited until an appropriate time
3) Normal desire to void
4) Micturition
- detrusor muscle contracts
- pelvic floor relaxes

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3
Q

What interacts to allows the maintenance of continence

A
Brain
Spinal cord and nerves
- pelvic nerve
- pudendal nerve 
Bladder 
Urethral sphincter
Pelvic floor
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4
Q

Definition of dry overactive bladder

A

The symptoms of urgency, without urge incontinence, usually with frequency and nocturia

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5
Q

Definition of wet overactive bladder

A

The symptoms of urgency, with urge incontinence, usually with frequency and nocturia

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6
Q

Define urge incontinence

A

Leakage of urine in response to involuntary contraction of the detrusor muscle

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7
Q

Define stress urinary incontinence (SUI)

A

Leakage occurs with a rise in intra-abdominal pressure without a detrusor contraction (coughing, laughing, running and walking)
- sign or symptom of urinary leakage with increased intra- abdominal pressure

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8
Q

Define urodynamic stress incontinence

A

Urodynamic proven leakage of urine with an increase in intra-abdominal pressure
- old term = genuine stress incontinence

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9
Q

What is mixed incontinence

A

Co-existing SUI and OAB

- accounts for around 30% of incontinence cases in women

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10
Q

Risk factors associated with OAB

A
Neurological 
- MS
- Parkinsons
- Stroke
- Cognitive function
Mobility
Alcohol
Caffeine
Acute UTI
Constipation 
Previous surgery 
High urine production 
- medication 
- excess fluid intake
- diabetes
- poor kidney function
Bladder abnormalities 
- tumour 
- stones
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11
Q

Aetiology of stress urinary incontinence

A

Loss of suburethral support causing urethral mobility
Intrinsic sphincter deficiency/primary urethral weakness
Suburethral support may be sufficient
Defective function of the striated and smooth muscle and mucosal and submucosal cushions

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12
Q

Risk factors associated with urinary incontinence

A
Pregnancy
Childbirth
Pelvic surgery radiotherapy
Pelvic prolapse and repair 
Race
Family predisposition
Anatomical abnormalities 
Neurological abnormalities 
Drugs
Menopause
Cognitive impairment 
Increased intra-abdominal pressure 
Obesity 
Comorbidities 
Age
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13
Q

Implications of urinary incontinence on quality of life

A

Affects sleep, emotions, employment, exercise and sport, self-worth, relationships and socialising and travel and holidays

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14
Q

Questions in history that aid the diagnosis of type of urinary incontinence

A
Main symptoms 
- associated with increased intra-abdominal pressure
- frequency
- urgency 
- urge incontinence
- nocturia
- enuresis (bed wetting)
- haematuria 
- dysuria 
- voiding problems
- pain
- prolapse symptoms 
Risk factors
- mobility 
- mental agility
- renal system
- cardiac system
- chest problems 
- drug therapies 
- previous pelvic surgery
- obstetric history 
- menopausal status
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15
Q

Features of urinary incontinence on examination

A

Abdominal/bimanual examination
- pelvic masses
- palpable bladder
- impression of pelvic floor tone
Vaginal examination (bivalve/sims speculum, left lateral position)
- identify cervix or vaginal vault
- check walls in turn for prolapse, atrophy, fistulae and ulceration
- ask to cough and assess for urinary leakage

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16
Q

Investigations in a woman with ?urinary incontinence

A
Urinary dip +/- culture in EVERY WOMAN
- leukocytes & nitrates = UTI
- haematuria requires further investigation 
- glucose = ?DM
Bladder diary
- minimum 3 days
- input/output/times of leaking 
Cystoscopy & renal tract imaging indicated in
- haematuria
- recurrent UTIs
Urodynamic testing
17
Q

What are urodynamics and when are they performed

A

Dynamic study of bladder function
- uroflowmetry (measuring flow)
- filling and voiding cystometry (measuring pressures in the bladder and abdomen and calculating detrusor pressure)
Why
- obtain a diagnosis, chose correct operation, predict complications and/or understand why treatments have failed
Who
- in those with failed conservative management, prior to surgery, previous failed surgery, treatment complications and with a suspected voiding problem

18
Q

Briefly describe the management for urinary incontinence

A
Conservative
- continence advice and lifestyle changes 
- physiotherapy 
- bladder retraining 
Medical 
- antibiotics 
- anticholinergics
- B3 agonists
- duloxetine 
Surgical
19
Q

Describe the continence advice and lifestyle changes recommended in management of urinary incontinence

A
Education 
- how the bladder works 
Good habits 
- start bladder retraining 
Fluids
- normalise intake (at least 1.5 litres/day, but no excess)
- avoid caffeine, alcohol and carbonated drinks 
Lifestyle
- diet
- weight loss
- smoking cessation 
- treat chronic cough
- treat chronic constipation
20
Q

Conservative management of overactive bladder urinary incontinence

A

Small role for physiotherapy
- pelvic floor exercises with voluntary contraction and relaxation of pelvic floor muscles
- instructor follow-up more successful than patient led therapy
- biofeedback (digital palpation or vaginal electrodes)
- use of weighted cones as adjunct
Bladder retraining
- relearning higher cortical control of the detrusor muscle
- patient empties bladder to strict time schedule (hourly), gradually increasing the time between voids
- techniques to aid retraining (distraction, sitting on a hard seat and pelvic floor squeezes)

21
Q

When is conservative management not suitable?

A

Haematuria, infection, pain or voiding difficulty not yet investigated
Previously tried and failed
Patient unable/unwilling to engage in therapy
No facilities

22
Q

Conservative management of urinary stress incontinence

A

Physiotherapy is 1st line
- pelvic floor exercises with voluntary contraction and relaxation of pelvic floor muscles
- instructor follow-up more successful than patient led therapy
- biofeedback (digital palpation or vaginal electrodes)
- use of weighted cones as adjunct
Urethral and vaginal inserts
- adjunct during times of increased intra-abdominal pressure e.g. exercise
- occasional use only

23
Q

Medical management of overactive bladder

A

Anticholinergic drugs (1st line)
- oxybutynin, tolterodine and solifenacin
- inhibits involuntary contractions
B3 adrenoceptor agonist
- increases detrusor relaxation
- only if antimuscarinic contraindicated, clinically ineffective or SE unacceptable

24
Q

Medical management of stress urinary incontinence

A
Vaginal oestrogen if post-menopausal
- pessaries 
Duloxetine 
- SNRI
- stimulates pudendal motor neurones, increasing contraction or urethral striated muscle of sphincter, increasing urethral closure pressure 
- high side effect profile
25
Q

Surgical management of overactive bladder

A
Botox injections to detrusor muscle 
- effects last 3 to 12 months 
- needs to be able to self catheterised 
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
26
Q

Surgical management of stress urinary incontinence

A
Patient selection 
- fit for surgery?
- do they want an operation?
- is SUI main symptom?
- understand and accept potential complications?
- conservative management been attempted?
- urodynamically proven SUI?
Synthetic tapes
- TVT and TVT-O
Colposuspension
Biological slings 
Intramural bulking agents 
- repeat injections
- efficacy lower with time
- increases the force with which the urethra closes
27
Q

What are the problems with using anticholinergic medication

A

Use is limited by side effects in most patients
- dry mouth
- dry eyes
- constipation
Efficacy differs between types of preparations
- SEs from one type of preparation doesn’t exclude a trial of another anticholinergic
4-6 weeks of treatment to assess response
If patient well-established, trial withdrawal of treatment every 3-4 months

28
Q

What are the side effects of SNRIs

A
GI disturbance (n/v)
Dry mouth
Headache 
Suicidal ideology 
SSRI withdrawal effects