Urogynaecology

Question 1

What is urinary incontinence

Answer 1

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

Question 2

Describe the micturition cycle

Answer 2

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

Question 3

What interacts to allows the maintenance of continence

Answer 3

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

Question 4

Definition of dry overactive bladder

Answer 4

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

Question 5

Definition of wet overactive bladder

Answer 5

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

Question 6

Define urge incontinence

Answer 6

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

Question 7

Define stress urinary incontinence (SUI)

Answer 7

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

Question 8

Define urodynamic stress incontinence

Answer 8

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

Question 9

What is mixed incontinence

Answer 9

Co-existing SUI and OAB

- accounts for around 30% of incontinence cases in women

Question 10

Risk factors associated with OAB

Answer 10

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

Question 11

Aetiology of stress urinary incontinence

Answer 11

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

Question 12

Risk factors associated with urinary incontinence

Answer 12

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

Question 13

Implications of urinary incontinence on quality of life

Answer 13

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

Question 14

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

Answer 14

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

Question 15

Features of urinary incontinence on examination

Answer 15

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

Question 16

Investigations in a woman with ?urinary incontinence

Answer 16

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

Question 17

What are urodynamics and when are they performed

Answer 17

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

Question 18

Briefly describe the management for urinary incontinence

Answer 18

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

Question 19

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

Answer 19

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

Question 20

Conservative management of overactive bladder urinary incontinence

Answer 20

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)

Question 21

When is conservative management not suitable?

Answer 21

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

Question 22

Conservative management of urinary stress incontinence

Answer 22

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

Question 23

Medical management of overactive bladder

Answer 23

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

Question 24

Medical management of stress urinary incontinence

Answer 24

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

Question 25

Surgical management of overactive bladder

Answer 25

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

Question 26

Surgical management of stress urinary incontinence

Answer 26

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

Question 27

What are the problems with using anticholinergic medication

Answer 27

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

Question 28

What are the side effects of SNRIs

Answer 28

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