Urogynaecology Flashcards
List six types of urinary incontinence
1) Stress urinary incontinence
2) Urge urinary incontinence
3) Mixed urinary incontinence
4) Overflow incontinence
5) Continuous incontinence
6) Others:
- Incontinence arising form UTI, medications, immobility or cognitive impairment
- Situational incontinence eg giggle incontinence
Which is the most common type of urinary incontinence? How common is it?
Stress urinary incontinence
1 in 10 will suffer it at some point in their lives
50% of incontinent women have purely stress incontinence
30-40% of incontinent women have mixed stress and urge incontinence
What is stress incontinence?
Involuntary leakage of urine on effort or exertion (eg sneezing or coughing)
It commonly arises as a result of urethral sphincter weakness
Increased intra-abdo pressure transmitted to the bladder but not to the urethra. Intravesical pressure exceeds the closing pressure on the urethra
May be associated with genitourinary prolapse
What are some causes of stress urinary incontinence?
Childbirth (most commonly) leading to denervation of pelvic floor, usually during delivery
Oestrogen deficiency during menopause leads to weakening of pelvic support and thinning of urothelium
Occasionally, weakness of the bladder neck occurs congenitally, or through trauma from radical pelvic surgery or radiation
What are the symptoms of stress urinary incontinence?
Complaints of urine leakage during coughing, sneezing, running, jumping or carrying heavy loads
Leakage usually small discrete amount, coinciding with physical activity
What are the signs of stress urinary incontinence?
Prolapse of urethra and anterior vaginal wall may be present
May be possible to demonstrate stress urinary incontinence by asking a woman to cough with a full bladder
What investigations are done for stress urinary incontinence?
MSU - exclude glycosuria
Freq/volume chart - usually shows a normal frequency and functional bladder capacity (or slightly raised)
Urodynamic studies
What factors does a frequency / volume chart? (7)
1) Functional bladder capacity
2) Volumetric summary of diurnal urinary frequency
3) Volumetric summary of nocturnal urinary frequency
4) Quantification of total fluid intake
5) Distribution of fluid intake throughout the day
6) Total voided volume and diurnal distribution of voiding
7) Evaluation of severity urinary incontinence
What does urodynamics involve?
A combination of tests that look at the ability of the bladder to store and void urine:
1) Cystometry
2) Ambulatory urodynamic monitoring
What is cystometry?
Involves measuring the pressure/volume relationship of the bladder during filling and voiding = useful measure of bladder function
The bladder is filled with saline via a catheter and the first sensation of filling, first desire to void and any strong desire to void are recorded
Electronic subtraction of the intra-abdo pressure from the intra-vesical pressure allows the detrusor pressure to be calculated
During filling the patient is asked to cough at regular intervals and to stand, in order to provoke the bladder
The presence of detrusor contractions and package through the urethra are noted
The woman is asked to void at the of the test for pressure / flow analysis
What is ambulatory urodynamic monitoring?
A small recording device is worn and information is later downloaded to a computer for analysis
The bladder is filled naturally and woman should carry out normal daily activities
Useful for investigating detrusor overactivity when standard laboratory urodynamics have failed to replicate symptoms experience (as not normal environment)
When are conservative managements indicated in stress urinary incontinence? (5)
1) Mild / easily manageable symptoms
2) Family incomplete
3) Symptoms manifest during pregnancy
4) Surgery CI by coexisting medical conditions
5) Surgery declined by pt
What are conservative management options for stress urinary incontinence?
1) Lifestyle interventions
- Weight reduction if BMI >30
- Smoking cessation
- Treatment of chronic cough and constipation
2) Pelvic floor muscle training (1st line)
- For at least 3 months but must be continued long term
- Subsequent to digital assessment of pelvic muscle contraction
- Common regimen = 8-12 slow maximal contractions sustained for 6-8s each per day
- Continue if successful
- Consider biofeedback and/or electrical stimulation in women who cannot actively contract pelvic floor muscles
Biofeedback:
- Use of a devise to convert the effect of pelvic floor contraction into a visual or auditory signal to allow objective assessment of improvement
Electrical stimulation:
- Can assist in the production of muscle contractions in women who are unable to produce muscle contraction
3) Vaginal cones
- A way of applying graded resistance against which the pelvic floor muscles contract
- The cones are inserted into the vagina and held in position by voluntary contraction
4) Duloxetine (2nd line)
- A SNRI (serotonin and noradrenalin reuptake inhibitor) that enhances urethral striated sphincter activity via a centrally mediated pathway
- Associated with significant and dose-dependent decreases in frequency of incontinence episodes
- Nausea = most frequently reported SE (25%
= Other SE inc dyspepsia, dry mouth, insomnia, drowsiness and dizziness
When is surgical management of stress urinary incontinence?
When conservative measures have failed and the woman’s (WO??) compromised
NB very important before attempting surgical repair to be clear about the underlying cause of the incontinence = stress incontinence may be successfully treated surgically but detrusor over-activity may be made worse
What are some surgical options for the management of stress urinary incontinence? (5)
1) Periurethral injections
2) Burch colposuspension
3) Laparoscopic colposuspension
4) Tension-free vaginal tape (TVT)
5) Transobturator tape (TOT)
What are periurethral injections?
Mainly for women who are fail, elderly, unfit or have had multiple failed procedures
- Intramural bulking agents (eg glutaraldehyde cross-linked collagen or silicone)
- Lower immediate success rate (not as effective as other treatments)
- Low morbidity
What is burch colposuspension?
Two or three stitches are used to attach the anterior wall of the vagina to Cooper’s ligament at the level of the bladder to add support = the neck of the bladder is ‘lifted’
- Complications include haemorrhage, bladder/ureter injury, detrusor overactivity, enterocele or rectocele formation
VS laparoscopic colposuspension (quicker recovery)
What is tension-free vaginal tape (TVT)?
= Most commonly performed procedure for stress incontinence
- A polypropylene tape is placed underneath the middle of the urethra via a small vaginal incision lift up bladder
- Cystourethroscopy is carried out to ensure there is no damage to the bladder or urethra
- Minimally invasive
- Most women return to normal activities within 2 weeks
- Complications = bladder injury, bleeding into retropubic space, infection, voiding difficulties and table erosion into vagina / urethra
- Cure rate = 82-99%
What is transobturator tape (TOT)?
Polypropylene tape is passed via transobturator foramen through the transobturator and puborectalis muscles
The main difference is that the retropubic space is not entered and the risk of bladder perforation is low
What is daytime frequency? What is the normal range?
The number for times a woman voids during her waking hours
Usually 4-7 voids / day
What is nocturia?
Having to wake at night one or more times to void
Up to 70yr, more than a single void is considered abnormal
What is nocturnal enuresis?
Urinary incontinence occurring during sleep
What is urgency?
The sudden compelling desire to pass urine, which is difficult to defer
Urgency is more commonly secondary to detrusor overactivity, although can occur with inflammatory bladder conditions such as interstitial cystitis
What are some potential voiding difficulties?
Hesitancy - difficulty initiating micturition
Straining to void
Slow or intermittent urinary stream
= all suggestive of urethral obstruction, an underachieve detrusor muscle, or loss of coordination between detrusor construction and urethral relaxation
Intermittency is seen with neurological disease
What is postmicturation?
Feeling of incomplete bladder emptying
Terminal dribble = a prolonged final part of micturition
Postmicturitional dribble = the involuntary loss of urine immediately after passing urine
When does absent or reduced bladder sensation occur? What does it lead to?
Usually due to denervation caused by spinal cord injuries or pelvic surgery
Leads to infrequent micturition and large capacity bladder
Often associated with overflow incontinence
Where is bladder pain felt? What is it often relieved / exacerbated by?
Felt suprapublically or retropubically
Typically occurs with bladder filling and is relieved by emptying
Indicative of an intravesical pathology such as interstitial cystitis or malignancy - warrants further investigation