urology Flashcards
urinary incontinence
- impact on physical, psychological & socio-economical aspects of life
- high prevalence in women due to multifactorial reasons
- high in men after prostatectomy
UI urinary incontinence def & symptoms
a condition in which involuntary loss of urine through the urethral meatus constitutes a social or hygiene problem and can be objectively demonstrated
- Complaint of involuntary loss of urine.
SUI stress urinary incontinence def & symptoms
involuntary leakage on effort or exertion, or on sneezing or coughing
- relaxed pelvic floor
- increased abdominal pressure
- Complaint of involuntary loss of urine on effort or physical exertion (e.g., sporting activities), or on sneezing or coughing. N.B.: ‘‘activity related incontinence’’ might be preferred in some languages to avoid confusion with psychological stress.
UUI urge urinary incontinence def & symptoms
involuntary leakage accompanied by or immediately proceeded by urgency
- bladder oversensitivity from infection
- Complaint of involuntary loss of urine associated with urgency.
MUI mixed urinary incontinence def & symptoms
involuntary leakage associated with urgency and with exertion, effort, sneezing, coughing
- Complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing.
overflow urinary incontinence def
- urethral blockage
- bladder unable to empty properly
postural urinary incontinence symptoms
Complaint of involuntary loss of urine associated with change of body position, for example, rising from a seated or lying position.
nocturnal enuresis symptoms
Complaint of involuntary urinary loss of urine which occurs during sleep.
continuous urinary incontinence symptoms
Complaint of continuous involuntary loss of urine.
insensible urinary incontinence symptoms
Complaint of urinary incontinence where the woman has been unaware of how it occurred.
coital incontinence
Complaint of involuntary loss of urine with coitus. This symptom might be further divided into that occurring with penetration or intromission and that occurring at orgasm
bladder storage symptoms
- Increased daytime urinary frequency: Complaint that micturition occurs more frequently during waking hours than previously deemed normal by the woman.
- Nocturia: Complaint of interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep.
- Urgency: Complaint of a sudden, compelling desire to pass urine which is difficult to defer.
- Overactive bladder (OAB, Urgency) syndrome: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology.
sensory symptoms - bladder filling
A departure from normal sensation or function, experienced by the woman during bladder filling. Normally, the individual is aware of increasing sensation with bladder filling up to a strong desire to void.
- Increased bladder sensation: Complaint that the desire to void during bladder filling occurs earlier or is more persistent to that previous experienced. N.B.: This differs from urgency by the fact that micturition can be postponed despite the desire to void.
- Reduced bladder sensation: Complaint that the definite desire to void occurs later to that previously experienced despite an awareness that the bladder is filling.
- Absent bladder sensation: Complaint of both the absence of the sensation of bladder filling and a definite desire to void.
voiding & post-micturition symptoms
SSSPPIN HUFD
A departure from normal sensation or function, experienced by the woman during or following the act of micturition.
- Hesitancy: Complaint of a delay in initiating micturition.
- Slow stream: Complaint of a urinary stream perceived as slower compared to previous performance or in comparison with others.
- Intermittency: Complaint of urine flow that stops and starts on one or more occasions during voiding.
- Straining to void: Complaint of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain, or improve the urinary stream.
- Spraying (splitting) of urinary stream: Complaint that the urine passage is a spray or split rather than a single discrete stream.
- Feeling of incomplete (bladder) emptying: Complaint that the bladder does not feel empty after micturition.
- Need to immediately re-void: Complaint that further micturition is necessary soon after passing urine.
- Post micturition leakage: Complaint of a further involuntary passage of urine following the completion of micturition.
- Position-dependent micturition: (NEW) Complaint of having to take specific positions to be able to micturate spontaneously or to improve bladder emptying, for example, leaning forwards or backwards on the toilet seat or voiding in the semi-standing position.
- Dysuria: Complaint of burning or other discomfort during micturition. Discomfort may be intrinsic to the lower urinary tract or external (vulvar dysuria).
- (Urinary) retention: (NEW) Complaint of the inability to pass urine despite persistent effort.
UTI urinary tract infection def & symptoms
Bacteria purifier
BUFD UP
- finding of microbiological evidence of significant bacteriuria and pyuriaxii usually accompanied by
- symptoms such as increased bladder sensation, urgency, frequency, dysuria, urgency urinary incontinence, and/or pain in the lower urinary tract.
Recurrent urinary tract infections UTI
At least three symptomatic and medically diagnosed UTI in the previous 12 months.
UTI examination
IF U POo
- Internal examination
- Other general examination findings
- Pad tests
- Frequency volume chart
- Urodynamic investigations and pelvic imaging
UTI tests
MUURC
- Uroflowmetryl
- Cystometry
- Ultrasound
- Radiological imaging
- Magnetic resonance imaging
SUI types & pathophysiology
- Urethral hypermobility: loss of ligamentous support of urethra to be pressed against
- Intrinsic sphincter deficiency (ISD): vascular plexus (under urethral urothelium) sensitive to abnormal hormonal levels
UI pathophysiology
- Chronic, progressive disease with or without symptoms
- Disease, trauma, fatigue, ageing may contribute
- Disturbed balance between closing and opening, storage & emptying functions
- Urethral overactivity & insufficiency are shared features of all UI
- Similar patterns of functional disorder – differences in disease due to difference in degree
- Impaired pelvic structure & function
- Urethral smooth muscle relaxation can trigger overactivity
- Relaxatory mechanism of urethra with faster opening function
- Unintentional opening with pressure drop
- More pronounced stress component → larger risk of urgency
- Faster opening mechanism → greater probability of urgency
UI causes
CIA AgEnt
- Congenital anomalies
- Injuries and disease of nervous system
- Anomalies of detrusor and innervation
- Ageing
- Effect of pregnancy and delivery
i. Injury to CT
ii. Vascular damage
iii. Pelvic nerve/ muscle damage (PR)
iv. Direct injury to urinary tract
surgical management of UI
overactive bladder OAB def
= Functional disorder of LUT
= urgency with or without frequency and/ or UUI
= nocturia often associated
OAB - neurogenic pathophysiology
Disturbed balance between filling and voiding
OAB - myogenic pathophysiology
Increased irritability of detrusor muscle e.g. hypersensitivity
OAB pathophysiology
- Hypoxia & bladder wall thickening + decreased blood flow during detrusor contractions
- Primary changes in CNS
- Non-neurogenic release from urothelium
- Higher degree of nerve stimulation and/ or lower threshold for outflow of signals → ↑ voiding activity
- Increased afferent activity from bladder to CNS → increase activation of striated muscle in urethral sphincter and pelvic floor → generates afferent input
= Inhibition of voiding-promoting nerves
OAB PFM pathophysiology
role of PFM pelvic floor muscle
Relaxation of striated muscles in urethra → pressure drop → starts micturition = premature micturition reflex
normal bladder VS OAB
normal: detrusor muscle contracting when bladder is full
OAB: detrusor muscle contracting before bladder is full
OAB conservative management
- PFM training
- NES
- Bladder training
- Medication
- Physiotherapeutic treatment modalities should be based on the underlying pathology causing OAB
bladder training management hypotheses
- Improved cortical inhibition over involuntary detrusor contractions
- Improved cortical facilitation over urethral closure during bladder filling
- Improved central modulation of afferent sensory impulses
- Individual become more knowledgeable and aware of circumstances that cause incontinence and so changing behaviour in ways that increase the ‘reverse capacity’ of the lower urinary tract system
bladder training management
- Patient education on bladder, incontinence, and urgency control strategies
- Scheduled voiding regime – 1 hour interval (shorter times may be indicated) during waking hours
- Increase schedule 15-30 minutes per week
- Positive reinforcement techniques – use of social media
- Interdisciplinary approach – address diet
- Re-assess after 3 weeks
PFMT management hypotheses
- Intentional contraction during urgency, and holding of contraction till urge to void disappears
- Strength training of the PFM with longlasting changes in muscle morphology, which may stabilize neurogenic activity
NES management hypotheses
- Change in PFM activity during nervous excitation that automatically inhibit/ prevent detrusor activity
- Learning process that make patient aware of contracting the PFM during urgency to inhibit involuntary detrusor contraction
- Increase in strength of PFM that provide more inhibition of overactivity of bladder
