Urology

Question 1

List six types of urinary incontinence

Answer 1

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

Question 2

Which is the most common type of urinary incontinence? How common is it?

Answer 2

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

Question 3

What is stress incontinence?

Answer 3

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

Question 4

What are some causes of stress urinary incontinence?

Answer 4

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

Question 5

What are the symptoms of stress urinary incontinence?

Answer 5

Complaints of urine leakage during coughing, sneezing, running, jumping or carrying heavy loads

Leakage usually small discrete amount, coinciding with physical activity

Question 6

What are the signs of stress urinary incontinence?

Answer 6

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

Question 7

What investigations are done for stress urinary incontinence?

Answer 7

MSU - exclude glycosuria

Freq/volume chart - usually shows a normal frequency and functional bladder capacity (or slightly raised)

Urodynamic studies

Question 8

What factors does a frequency / volume chart? (7)

Answer 8

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

Question 9

What does urodynamics involve?

Answer 9

A combination of tests that look at the ability of the bladder to store and void urine:

1) Cystometry
2) Ambulatory urodynamic monitoring

Question 10

What is cystometry?

Answer 10

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

Question 11

What is ambulatory urodynamic monitoring?

Answer 11

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)

Question 12

When are conservative managements indicated in stress urinary incontinence? (5)

Answer 12

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

Question 13

What are conservative management options for stress urinary incontinence?

Answer 13

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

Question 14

When is surgical management of stress urinary incontinence?

Answer 14

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

Question 15

What are some surgical options for the management of stress urinary incontinence? (5)

Answer 15

1) Periurethral injections
2) Burch colposuspension
3) Laparoscopic colposuspension
4) Tension-free vaginal tape (TVT)
5) Transobturator tape (TOT)

Question 16

What are periurethral injections?

Answer 16

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

Question 17

What is burch colposuspension?

Answer 17

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)

Question 18

What is tension-free vaginal tape (TVT)?

Answer 18

= 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%

Question 19

What is transobturator tape (TOT)?

Answer 19

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

Question 20

MOVE THESE = Classic incontinence symptoms

What is daytime frequency? What is the normal range?

Answer 20

The number for times a woman voids during her waking hours

Usually 4-7 voids / day

Question 21

What is nocturia?

Answer 21

Having to wake at night one or more times to void

Up to 70yr, more than a single void is considered abnormal

Question 22

What is nocturnal enuresis?

Answer 22

Urinary incontinence occurring during sleep

Question 23

What is urgency?

Answer 23

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

Question 24

What are some potential voiding difficulties?

Answer 24

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

Question 25

What is postmicturation?

Answer 25

Feeling of incomplete bladder emptying

Terminal dribble = a prolonged final part of micturition

Postmicturitional dribble = the involuntary loss of urine immediately after passing urine

Question 26

When does absent or reduced bladder sensation occur? What does it lead to?

Answer 26

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

Question 27

Where is bladder pain felt? What is it often relieved / exacerbated by?

Answer 27

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

Question 28

Where is dysuria felt? What is it most commonly associated with?

Answer 28

Pain experienced in the bladder or urethra on passing urine

Most commonly associated with UTIs

Question 29

What is haematuria?

Answer 29

The presence of blood in the urine

Can either be microscopic or macroscopic (frank)

It is always significant and always warrants further investigation

Question 30

STOP MOVE

How common is urge urinary incontinence?

Answer 30

Urge urinary incontinence = Overactive bladder syndrome (OAB)

Common - affects 1 in 6 women

Second most common cause of urinary incontinence

Most common cause of urinary incontinence in older women

Question 31

What is the pathophysiology of OAB?

Answer 31

Chronic condition defined as urgency, with or without urge incontinencce, usually with freq or nocturia

Involuntary detrusor contractions (detrusor overactivity = DO) during the filling phase, which may be spontaneous or provoked by increased abdo pressure - this is a diagnosis made on urodynamic testing

Detrusor contraction is normally felt as urgency - if strong enough, it causes the bladder pressure to overcome the urethral pressure and the pt leaks urge incontinence

Question 32

What is the aetiology of OAB?

Answer 32

Idiopathic in most cases

Neurogenic DO found in the presence of conditions such as MS, spina bifida or UMN lesions

Secondary to pelvic or incontinence surgery (if already have urge incontinence, surgery for stress incontinence can worsen it)

OAB due to outflow obstruction is uncommon in women

Question 33

What are some signs/symptoms of OAB?

Answer 33

1) Frequency
2) Urgency
3) Urge incontinence
4) Nocturia
5) Nocturnal enuresis
6) Provocative factors often trigger it eg hearing running water
7) Bladder contractions may be provoked by increasing intra-abdo pressure (eg coughing or sneezing) leading to a complaint of stress incontinence which can be misleading

QOL can be significantly affected

Question 34

What investigations should be done for OAB?

Answer 34

Urine culture - exclude infection

Freq/volume chart

• Typical features are inc diurnal freq associated with urgency and episodes of urge incontinence
• Nocturia common feature of OAB

Urodynamics

• Characterised by involuntary detrusor contractions during the filling phase of the micturition cycle, which may be spontaneous or provoked
• Video-urodynamic testing more appropriate in women with neurological diseases
• Urodynamic assessment is essential for the diagnosis of OAB in women with multiple / complex symptoms

Question 35

What are some ddx for OAB?

Answer 35

Metabolic abnormalities:
- DM / hypercalcaemia

Physical causes:
- Prolapse or faecal impaction

Urinary pathology:
- UTI or interstitial cystitis

Question 36

What are some conservative management options for OAB?

Answer 36

Behavioural therapy:

• Consume 1-1.5L of liquid a day
• Avoid caffeine and alcohol
• Review drugs which may alter bladder function eg diuretics and antipsychotics

Bladder retraining:

• Based on ability to suppress urinary urge and extend intervals between voiding
• Cure rates = 44-90%

Question 37

What are some pharmacological interventions for OAB?

Answer 37

1) Anticholinergic (antimuscarinic) agents:
- 1st line = block the sympathetic nerve thereby relaxing the detrusor muscle
SE = dry mouth (30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias
CI = acute (narrow angle) glaucoma, myasthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction

2) Antidepressants
- Imipramine has marked systematic and anticholinergic effects

3) Oestrogens
- Can try intravaginal oestrogen can be tried in women with vaginal atrophy

Question 38

What are the surgical managements of OAB?

Answer 38

Reserved for those with debilitating symptoms, and who have failed to benefit from medical and behaviour therapy

Procedures such as bladder distension, sacral neuromodulation, detrusor myomectomy, and augmentation cystoplasty have limited efficacy and complication rates are high

Permanent urinary diversion occasionally indicated in women with intractable incontinence

Question 39

How do botulinum toxin A help OAB?

Answer 39

Blocks neuromuscular transmission causing the muscle to become weak

Injected cystoscopically into detrusor, usually under LA

Can cause urinary retention in 5-20% of cases, in which intermittent self catheterisation may be required

Repeat injections required every 6-12 months

Long term effects of repeat injections unknown

Question 40

What general investigations are useful to

Answer 40

Residual check
- Postvoid either via USSS or catheter to exclude incomplete bladder emptying

Pad test
- Simple method of detecting and quantifying urinary leakage based on weight gain of absorbent pads during a set period of time (not helpful in identifying cause)

Neurological examination
- if symptoms point to a neurological cause

Sims speculum examination for prolapse

Assessment of urethral and bladder neck descent on straining

Assessment of pelvic floor muscle strength (0-5)

Cystourethroscopy

• Allows visualisation of all of the lower urinary tract
• Allows bladder biopsies to be taken to rule out cancer

Question 41

What imaging is performed to investigate urinary incontinence?

Answer 41

Ultrasonography
- Used to exclude incomplete bladder emptying

Intravenous urography
- Indicated