Urogynaecology Flashcards
Red flag symptoms
- Visible haematuria (bladder cancer)
- Pain associated with bladder filling (bladder cancer)
- Abdominal swelling (pelvic mass)
Following presentation of incontinence - carry out the following:
- Urine analysis to exclude infection
- Examine to exclude pelvic mass
- Review medication (alpha blockers can cause incontienence)
- Give lifestyle advice (e.g. stopping smoking)
- Refer to community physiotherapy or community continence team for pelvic floor muscle training
Normal bladder diary values
- Intake
- Voided volumes
- Capacity
- Frequency
- Output
- Intake: 1500-2000 mls
- Voided volumes: 250-500 mls
- Capacity: up to 500 mls
- Frequency: 3-7 voids per day
- Output: 1000-2800 ml per 24 hours
Classification of URINARY incontinence
- Stress incontinence
- Urge incontinence
- Mixed incontinence
- Overflow incontinence
- Continuous incontinence
- Incontinence arising from UTIs, medications, immobility, cognitive impairment
- Situational incontinence e.g. giggle incontinence
Stress incontinence: Definition
The involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Commonly arises from urethral sphincter weakness.
Urge incontinence: Definition
The involuntary leakage of urine accompanied by, or immediatly preceded by, a strong desire to pass urine (void).
Urgency, with or without urge urinary incontinence, usually with frequency and nocturia is also defined as overactive bladder (OAB) syndrome
Mixed incontinence: Definition
The involuntary leakage of urine associated both with urgency and with exertion, effort, sneezing or coughing.
Usually, one of these is predominant i.e. either the symptoms of urge incontinence, or those of stress incontinence, are most bothersome.
Overflow incontinence: Definition
Occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function.
Urinary symptoms
- Urinary incontinence
- Daytime frequency
- Nocturia
- Nocturnal enuresis
- Urgency
- Voiding difficulties
- Post-micturition symptoms
- Absent/reduced bladder sensation
- Bladder pain
- Urethral pain
- Dysuria
- Haematuria
Assessment of lower urinary tract: Hx + examination
- History
- Quality of life assessment
- Frequency/volume chart
- Physical exam (General, abdo + pelvic)
INFO obtainable from a Frequency/volume chart
- Functional bladder capacity
- Volumetric summary of diurnal urinary frequency
- Volumetric summary of nocturnal urinary frequency
- Quantification of total fluid intake
- Distribution of fluid intake throughout the day
- Total voided volume
- Diurnal distribution of voiding
- Evaluation of the severity of urinary incontinence.
Assessment of the lower urinary tract: Investigations
- Basic (4)
- Advanced (1)
Basic:
- Urinalysis
- Urine specimen (MC&S)
- Post-void residual check
- Pad test
Advanced:
- Cystourethroscopy
Urinalysis: Definition
Cheap and sensitive, tests for the following:
- Leucocyte esterase
- Nitrites
- Protein
- Blood
- Glucose
Urine specimen: Definition
Bacteriological analysis of a midstream urine specimen for microscopy, culture and sensitivity (MC&S)
Post-void residual check: Definition
A post-void residual check should be carried out, either by USS or by catheterization to exclude incomplete bladder emptying.
Pad test: Definition
This is a simple method of detecting and quatifying urinary leakage based on weight gain of absorbant pads during a set period of time.
Cystourethroscopy: Definition
Allows visualization of all the lower urinary tract: urethra, bladder, trigone and ureteric orifices.
Can be performed using rigid or flexible cytoscope, with or without anaeasthesia.
Bladder biopsies can be taken to obtain histological diagnosis and exclude malignancy.
Indications for cystourethroscopy
- Recurrent UTIs
- Haematuria
- Bladder pain
- Suspected urinary tract injury or fistula
- To exclude bladder tumour or stones
- If interstitial cystitis is suspected
Assessment of the lower urinary tract: Imaging
- Ultrasonography
- Plain abdominal radiograph
- Contract-enhanced CT
- IV urography
- Micturating cystourethroscopy
- MRI
Urodynamics: Definition
Urodynamics describes a combination of tests that look at the ability of the bladder to store and void urine. The tests include:
- Uroflowmetry
- Post-void residual measurement
- Cystometry
Additional tests:
- Urethral pressure profilometry
- Video-urodynamic investigations
Incontinence: Initial investigations
- Bladder diaries should be completed for a minimum of 3 days
- Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- Urine dipstick and culture
- Urodynamic studies
Management: URGE incontinence
If urge incontinence is predominant:
- Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- Bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
- Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management: STRESS incontinence
If stress incontinence is predominant:
- Pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- Surgical procedures: e.g. retropubic mid-urethral tape procedures
SURGICAL interventions for SUI: Mid- urethral slings (MUS)
- Tension free tapes made of polypropylene mesh.
- Inserted via a vaginal incision.
- They work by supporting the mid-urethra during times of raised intra-abdominal pressure.
- They are most commonly inserted by the retropubic route but may also be inserted by a transobturator technique.
- There have been concerns raised about long term complications such as pain.
- Other risks include damage to the urinary tract, voiding dysfunction, overactive bladder symptoms and exposure of the mesh in the vagina or urinary tract.
