Urogynaecology Flashcards
Describe the 2 main classes of urinary symptoms.
Storage symptoms: frequency, urgency, nocturia, dysuria, nocturnal enuresis
Voiding symptoms: hesistancy, intermittent stream, poor flow, splitting/spraying
Describe the symptoms of overactive bladder.
Frequency, urgency, nocturia, +/- urge incontinence
Describe the anatomy of the bladder in relation to the micturition cycle
- Bladder is a pyramidal organ, funneling into the urethra
- Detrusor muscle makes up the bladder wall, contracts to push out urine during voiding. Activated by parasympathetic nervous system
- Internal urethral sphincter at the neck of the bladder, relaxes to allow passage of urine. Controlled by sympathetic nervous system
- External urethral sphincter is group of muscles including pelvic floor muscles. Voluntarily controlled, relaxed to void
Define stress and urge incontinence.
Stress: involuntary loss of urine following activities that place pressure on the bladder eg. coughing, sneezing, laughing
Urge incontinence: involuntary loss of urine following a sudden, uncontrollable urge to urinate
Name the causes of stress incontinence and the risk factors.
Due to urethral sphincter incompetence:
- Hypermobility: urethra descends through urogenital hiatus with an increase in abdo pressure
- Intrinsic sphincter deficiency (ISD): due to weak sphincter muscles and loss of cushioning epithelia
RFs:
- Related to pregnancy: multiparity, vaginal delivery, instrumental (esp forceps), prolonged labour
- Non-obstetric: obesity, chronic cough, older age, postmenopausal
What is detrusor overactivity? What is the presentation?
- Involuntary contractions of the detrusor muscle during filling
- Symptoms of OAB but usually not incontinent unless there is sphincter incompetence also
Describe the neurological mechanism of bladder emptying
Nerves in S2-4 are responsible for the parasympathetic control of micturition.
Acetylcholine released binds to M2+3 receptors in the detrusor muscle to cause contraction
Sphincter relaxation is caused by inhibition of sympathetic input to the IUS
The EUS is under the control of the somatic nervous system
A 77 year old woman comes to the GP complaining that she is not able to control passing urine. What is important to know?
- What type of incontinence: stress, urge, mixed
- How severe: frequency, using pads/number, changing clothes, behaviour change
- Infection screen, DM screen
- Associated symptoms: faecal incontinence, prolapse, difficulties with sex, haematuria, pain
- Fluid intake: quantity, types
- PMH and DHx
- Obstetric history, menopause
- SHx: smoking, alcohol, caffeine, fluids
What type of examination do you want to do for incontinence?
- Abdo + pelvis exam, speculum and bimanual
- Valsalva with cough/bearing down, test sphincter tone
A 66 year old woman comes to the GP complaining that she is not able to control passing urine. The episodes of incontinence are preceded by feeling an extreme urge to go, and she is urinating at least 8-10 times through the day and night. She does not have any faecal incontinence or prolapse, and no dysuria or haematuria. She has had 4 children, all VDs. She does not take any medications and has no other medical problems.
On examination, the vaginal epithelium is light pink. There is no leakage of urine on cough test, and her pelvic floor tone is 3/5.
What would you like to do now?
- Investigations: urine dip, bladder diary for 3 days
- Conservative management: no caffeine and alcohol, aim for fluids intake about 1.5-2L a day
- Recommend bladder training for a 6 week course
- Follow up then
A 66 year old woman comes back to the GP complaining that she has not had much improvement in her incontinence symptoms after 6 weeks of bladder training. What would you do next?
Offer medical management: first line oxybutinin
Can consider mirabegron if cognitive impairment/dementia or frailty.
Describe the management options for urge incontinence.
-Conservative management: lifestyle advice, bladder training for 6 weeks
-Medical management:
1. Anticholinergics eg oxybutinin, propiverine, tolteridine.
2. B3 agonist eg. mirabegron
3. SNRI eg. duloxetine
Consider vaginal oestrogen creams eg. Vagifem
- Further medical management:
- Botulinum toxin A injections
- Sacral neuromodulation
A 66 year old woman comes back to the GP complaining that she has not had much improvement in her incontinence symptoms after 6 weeks of bladder training. You prescribe oxybutinin. What side effects do you need to inform her about?
- Dry mouth, blurry vision, constipation
- Symptoms should be improved by 4 weeks, follow up then
When is urodynamic testing indicated?
- In cases where it is difficult to determine the type of incontinence
- Incontinence refractory to medical management (OAB)
- Complex history
- Previous continence surgery
What are the management options for stress incontinence? And complications
Conservative:
- Lose weight, reduce caffeine, moderate fluid intake
- Pelvic floor muscle training: 3x/day, 8x/each, for 3 months minimum
Medical:
-Duloxetine: not used frequently. If Sx is unsuitable or not preferred
Surgical: NICE says offer colposuspension or rectus fascial sling
- Rectus fascial sling: uses fascia from the abdomen to create a sling to lift the neck of the bladder + urethra. Mesh free.
- Colposuspension: transabdo approach. Similar success and complications as tape, plus 10% risk of new posterior wall prolapse
- Tension-free vaginal tape, trans-obturator tape. 80-85% cure, low risk of erosion, new OAB symptoms, bladder perforation
- Intramural bulking agents: done under LA, better for frailty but may need repeating.
