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Reproduction > Week 4- Urinary incontinence > Flashcards

Week 4- Urinary incontinence Flashcards

1
Q

What urethral causes can cause urinary incontinence?

A

Detrusor overactivity
Urethral sphincter incompetence
Retention with overflow
Functional

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2
Q

What external causes to the urethra can cause urinary incontinence?

A

Congenital

Fistula

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3
Q

What are the types of urinary incontinence?

A

Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence

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4
Q

What are the risk factors for urinary incontinence?

A

Female sex- shorter urethra, pregnancy, childbirth and menopause are all RF’s.
Age- as you get older the muscles in your bladder and urethra lose some strength
Obesity- being overweight increases the pressure on your bladder
Smoking- risk of overactive bladder. Also chronic cough can cause episodes of incontinence.
Kidney disease or diabetes can increase risk of urinary incontinence.

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5
Q

What is meant by urgency?

A

The complaint of a sudden desire to pass urine which is difficult to defer.

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6
Q

What is meant by nocturia?

A

The complaint of having to wake up at night to void.

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7
Q

What is meant by frequency?

A

Patient voids too often per day.

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8
Q

What is urge urinary incontinence?

A

Involuntary urine leakage accompanied or preceded by the urge to urinate.

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9
Q

What is overactive bladder syndrome?

A

Urgency, with or without urge urinary incontinence, usually with frequency and nocturia in the absence of pathological or metabolic conditions that might explain these symptoms.

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10
Q

What is the difference between wet overactive bladder and dry overactive bladder?

A

Wet- is when there is urge urinary incontinence

Dry is when there isn’t.

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11
Q

What is mixed urinary incontinence?

A

Involuntary leakage associated with urge and also with sneezing, coughing and exertion (stress urinary incontinence)

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12
Q

What things in a history do you want to determine to get a good idea of what type of incontinence this is? Which tools can help with this?

A

Bladder diary for 3 days
Caffiene- important
Storage symptoms- frequency, nocturia, urgency, stress (e.g. cough, exertion).
Voiding symptoms- hesitancy, failure to void, poor flow
Postmicturition symptoms- incontinence, incomplete emptying.
Quantity of urine released.

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13
Q

On examination of urinary incontinence, what should you look for?

A

BMI
Abdominal exam- for pelvic masses
vaginal exam- prolapse, atrophy, SUI, fistula
PR- masses

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14
Q

How can urinary incontinence impact on quality of life?

A

Sexual- dont want to get into sexual interactions
Physicals- limit physical exercise
Psychological- guilt/depression. Loss of respect/dignity
Occupational- absence from work.
Domestic- requirements for specialised underwear/bedding.
Social- reduction in social interaction.

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15
Q

What occurs to the muscle in the bladder in overactive bladder?

A

It contracts frequently and involuntarily.

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16
Q

What occurs to the muscle in the bladder in stress incontinence?

A

Pressure on the muscle means the support muscles can’t remain closed, and therefore you get leakage of urine.

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17
Q

What tests on examination, and other investigations, can help diagnose a type of urinary incontinence?

A

Stress test- ask the patient to cough.
Post void residual- if more than 50mls is left- not good
Urinalysis- dipstick-
Bladder diary
Urodynamics- generally used in women who have had treatment but not got better.
Cystoscopy- maybe used in constant urine infections that aren’t treated.
Ultrasound- maybe for masses.

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18
Q

What is the normal voiding frequency and volume?

A

Normal is less than 8 times a day

Urine output of less than 2800.

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19
Q

How can you manage incontinence- go from least invasive to most invasive?

A 
Lifestyle factors- weight loss, dietary advice, avoidance of caffeine 
Bladder drill
Pelvic floor physiotherapy
Drugs
Botox
Neuromodulation
Reconstructive surgery.
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20
Q

What lifestyle measures can help with urinary incontinence?

A

Bladder retraining for a minimum of 6 weeks- aiming to increase bladder capacity and decrease frequency
Combination of bladder retraining and antimuscurinic if frequency is a problem
Sensible fluid intake
Caffeine reduction
Weight reduction

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21
Q

Which types of urinary incontinence do pelvic floor exercises benefit the patient?

A

Stress incontinence and mixed incontinence.

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22
Q

After lifestyle changes, what is the most common treatment for overactive bladder?
How do they work?

A

Anti-muscurinics.
They reduce intra-vesicle pressure, increase compliance, raise volume threshold for mictuiriton and reduce uninhibited contractions.

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23
Q

What side effects can you get from anti-muscarinics?

A

Dry mouth
Constipation
Blurred vision
Somnolence (strong desire to sleep)

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24
Q

If antimuscurinics fail, what other pharmacological treatment can be offered for overactive bladders?

A

beta 3 agonists- mirabegron

25
Q

How do beta-3 agonists work?

A

Relaxes the bladders smooth muscle by activating the beta 3 adrenoceptor.
They increase the voiding interval and inhibit spontaneous bladder contractions during filling.

26
Q

What are the conditions for using mirabegron?

A

Should only be used when anti-muscarinics are ineffective or contraindicated.

27
Q

What other non-pharmacological (random) therapies can be used for overactive bladder?
How does it work?

A

Posterior tibial nerve stimulation.

Unknown mechanism of action but effective in the short and medium term.

28
Q

What are the first line choices for women with overactive bladder or mixed urinary incontinence?

A

Oxybutylin (immediate release)
or - tolterodine (immediate release)
or propiverine (immediate release)

29
Q

What are the second line choices for women with overactive bladder or mixed urinary incontinence?

A

Tropsium (immediate release) or
Oxybutylin (extended release)
Darifenacin

30
Q

What is uroflowmetry?

A

Measurement of volume of urine expelled from the bladder each second.

31
Q

When is uroflowmetry indicated?

A 
Hesitancy
Voiding difficulty
Neuropathy
History of urine retention
Post op follow up
32
Q

When is multichannel urodynamics indicated?

A

Uncertain diagnosis
Failure to respond to treatment
Prior surgery

33
Q

What is cystometry?

A

A measure by which the pressure/volume relationship of the bladder is measured during filling, provocation and during voiding.

34
Q

When is post-residual volume considered abnormal?

A

greater than 100-150

35
Q

What is overflow incontinence?

A

When there is obstruction of the urethra.

Poor contractile bladder muscle.

36
Q

What must you stop in overflow incontinence?

A

Must stop anticholinergics.

37
Q

How do you treat stress urinary incontinence conservatively?

A

Lifestyle- lose weight, less caffeine, stop smoking, avoid excessive fluid intake.
Physiotherapy- pelvic floor muscle retraining, biofeedback, electrical stimulation
Drugs- duloxetine
Others- incontinence pads, vaginal pessaries

38
Q

How does duloxetine work?

A

Its a combined serotonin and noradrenaline reuptake inhibitor (increased intraurethral closure pressure)

39
Q

What surgical methods can treat stress incontinence?

A

Low tension vaginal tape
Intraurethral injection
Artificial sphincters
Colposuspension

40
Q

What surgical methods can treat overactive bladder?

A 
Augmentation cystoplasty
Sacral nerve modulation
Tibial nerve stimulation
Bladder overdistension
Botox injections
41
Q

What are the three compartments of prolapse?

A

Anterior
Middle or apical
Posterior

42
Q

How is uterovaginal prolapse classified?

A

1st degree- into the vagina
2nd degree- at interiotus
3rd degree- outside vagina
Procidentia- entirely outside the vagina

43
Q

What compartment does a cystocele occur in?

A

Anterior

44
Q

What is a cystocele?

A

Occurs when the wall between the vagina and bladder are weakened and allows the bladder to droop into the vagina.

45
Q

What are the symptoms of a cystocele?

A 
Bulging pressure
Mass felt
Difficulty voiding
Incomplete voiding
Difficulty inserting tampon
Pain with intercourse.
46
Q

What compartment does an enterocele occur in?

A

Middle/apical compartment.

47
Q

What is an enterocele?

A

The peritoneal sac containing bowel droops posterior to the vagina into the rectovaginal space between the posterior surface of the vagina and anterior surface of the rectum.

48
Q

What are the symptoms of an enterocele?

A 
Same symptoms as cystocele:
Bulging pressure
Mass felt
Difficulty voiding
Incomplete voiding
Difficulty inserting tampon
Pain with intercourse.
49
Q

What compartment does a rectocele occur in?

A

Posterior

50
Q

What is a rectocele?

A

Herniation of the anterior wall of the rectum into the vagina.

51
Q

What are the symptoms of a rectocele?

A 
Bulging pressure
Mass felt
Incomplete defecation 
Difficulty inserting tampon
Pain with intercourse.
52
Q

In taking a history of someone with prolapse, what headings do you need to cover?

A

Urinary symptoms
Bowel symptoms
Sexual history/dysfunction

53
Q

How is prolapse diagnosed?

Which tests may benefit?

A 
Clinical diagnosis
Could perform:
USS
MRI
Anorectal manometry
Endoanal USS
54
Q

What is complete eversion?

A

All compartments-
Uterine providentia (completely outside the body)
Complete uterine prolapse

55
Q

What is the pelvic organ prolapse quantifications system (POP QS)

A

Patient is straining while 6 specific sites are evaluated.
Measure each site to the hymenal ring- which is fixed.
If the site is above the hymen- negative number
If below- positive number.

56
Q

What are the risk factors for vaginal prolapse?

A 
Ageing
Pelvic surgery
Menopause
Loss of muscle tone
Multiple vaginal births
Obesity
Chronic constipation, coughing or heavy lifting 
Uterine fibroids
Family history
Connective tissue disorders e.g. marfans.
57
Q

How do you manage uterovaginal prolapse?

A

Reassure
Avoid heavy lifting, lose weight, stop smoking
Vaginal oestrogens- if atrophic vaginitis.

58
Q

What are the treatment options for prolapse?

A 
Expectant Management
Physiotherapy
Pessary
Surgery (Many!!)
-Abdominal 
-Vaginal 
-Laparoscopic
-Robotic assisted Laparoscopy
-Mesh kits
59
Q

Who is suitable for a pessary?

A 
Women unfit for surgery
Relief symptoms whilst awaiting surgery
Further pregnancies planned or pregnant
As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI
Patient request

Reproduction (34 decks)

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