Urogynaecology Flashcards
What is urinary incontinence
An involuntary loss of urine which can be objectively demonstrated
- social and hygiene problem
Describe the micturition cycle
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
What interacts to allows the maintenance of continence
Brain Spinal cord and nerves - pelvic nerve - pudendal nerve Bladder Urethral sphincter Pelvic floor
Definition of dry overactive bladder
The symptoms of urgency, without urge incontinence, usually with frequency and nocturia
Definition of wet overactive bladder
The symptoms of urgency, with urge incontinence, usually with frequency and nocturia
Define urge incontinence
Leakage of urine in response to involuntary contraction of the detrusor muscle
Define stress urinary incontinence (SUI)
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
Define urodynamic stress incontinence
Urodynamic proven leakage of urine with an increase in intra-abdominal pressure
- old term = genuine stress incontinence
What is mixed incontinence
Co-existing SUI and OAB
- accounts for around 30% of incontinence cases in women
Risk factors associated with OAB
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
Aetiology of stress urinary incontinence
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
Risk factors associated with urinary incontinence
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
Implications of urinary incontinence on quality of life
Affects sleep, emotions, employment, exercise and sport, self-worth, relationships and socialising and travel and holidays
Questions in history that aid the diagnosis of type of urinary incontinence
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
Features of urinary incontinence on examination
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
Investigations in a woman with ?urinary incontinence
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
What are urodynamics and when are they performed
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
Briefly describe the management for urinary incontinence
Conservative - continence advice and lifestyle changes - physiotherapy - bladder retraining Medical - antibiotics - anticholinergics - B3 agonists - duloxetine Surgical
Describe the continence advice and lifestyle changes recommended in management of urinary incontinence
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
Conservative management of overactive bladder urinary incontinence
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)
When is conservative management not suitable?
Haematuria, infection, pain or voiding difficulty not yet investigated
Previously tried and failed
Patient unable/unwilling to engage in therapy
No facilities
Conservative management of urinary stress incontinence
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
Medical management of overactive bladder
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
Medical management of stress urinary incontinence
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
Surgical management of overactive bladder
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
Surgical management of stress urinary incontinence
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
What are the problems with using anticholinergic medication
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
What are the side effects of SNRIs
GI disturbance (n/v) Dry mouth Headache Suicidal ideology SSRI withdrawal effects
