Urinary incontinence.txt

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kavinashah
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73572
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Urinary incontinence.txt
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2011-03-17 19:08:48
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incont
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  1. what is the definition of urinary incontinence?
    • involuntary loss of urine
    • that becomes a social problem
    • irrespective of amount
  2. which part of ANS helps voiding and which prevents?
    • parasympathetic aids voiding
    • sympathetic inhibits
  3. what does continence depend on in terms of pressure?
    pressure in urethra > pressure in bladder
  4. as the bladder fills with urine, what happens to the pressure inside it?
    no change as destrusor muscle is expandable
  5. why does coughing not usually cause incontinence?
    cough = increase IAP - transmitted equally to the bladder and upper urethra because both lie within the abdomen
  6. what are the 2 main types of incontinence?
    • stress incontinence
    • urge incontinence (destrusor overactivity)
  7. what is urge incontinence?
    • get an urgent desire to pass urine and sometimes urine leaks before you have time to get to toilet
    • due to overactive bladder
    • uncontrolled increases in detrusor pressure
    • so bladder pressure > normal urethra pressure
  8. what is the mechanism of stress incontinence?
    • upper urethra neck has slipped down from the abdomen
    • so when there is an incerase in IAP eg cough, the pressure is transmitted ot he bladder but not urethra
    • so bladder pressure > urethral pressure when coughing
  9. what are 2 other rarer causes of incontinence?
    • 1. FISTULA formation eg during labour so urine bypasses the sphincter through a fistula
    • 2. pressure in bladder overwhelming the sphincter due to OVERFILLING the bladder due to neurogenic causes (MS) or outlet obstruction
  10. why would you want to do urine dipstick?
    • UTI - leucocytes, nitrites
    • diabetes - glycosuria, protein
    • bladder cancer - haematuria, protein
    • stones - haematuria protein
  11. what can you ask the patient to do?
    • keep urinary diary
    • record for a week of the time and volume of fluid intake and micturition
  12. how can you exclude chronic retention of urine?
    • do post-micturition US or catheterisation
    • to check if retaining
  13. which is the single most important urodynamic study?
    cystometry (measure pressure in bladder)
  14. which 2 pressures are measured in cystometry and how?
    • bladder pressure: catheter into bladder and measure pressure when filling and see what happens when provoked with cough
    • intra abdo pressure: pressure transducer in rectum
  15. what is detrusor pressure and how is detrusor pressure calculated?
    • true detrusor pressure = pressure generated by true contraction of detrusor muscle
    • automatically calculated by: bladder pressure - IAP
  16. when would an IVP intravenous pyelogram be useful?
    assess and located fistulae and filling defects
  17. when would contrast CT be useful?
    • examine integrity and route of ureter
    • stones, strictures
  18. what is methylene dye test?
    • blue dye instilled into bladder
    • dye leakage from places other than urethra = fistula
  19. in a normal bladder, what happens to detrusor muscle when you cough?
    no contraction
  20. in stress incontinence, what happens to detrusor muscle when you cough?
    no contraction
  21. in detrusor overactivity, what happens to detrusor muscle when you cough?
    detrusor contraction after a cough
  22. in a normal bladder, what happens to urine flow with a cough?
    no urine flow
  23. in SUI, what happens to urine flow when cough?
    urine flow with cough
  24. in DO, what happens to urine flow when cough?
    urine flow happens with detrusor contraction IF the increase in bladder pressure is SUFFICIENT to overcome urethral pressure
  25. what can cystoscopy diagnose?
    • inspect anatomy of bladder and urethra
    • exclude mechanical causes of incontinence eg stones or cancer
    • but not assess bladder function
  26. what is stress incontinence?
    • involuntary loss of urine
    • bladder pressure > urethral pressure
    • in absence of detrusor contraction
  27. what are causes/RF for stress incontinence?
    • pregnancy
    • vaginal delivery
    • prolonged labour
    • forceps delivery
    • obesity
    • age
  28. what commonly co-exists with stress incontinence?
    prolapse
  29. what is the mechanism of incontinence in stress incontinence?
    • as bladder neck has SLIPPED BELOW PELVIC FLOOR (because its supports are weak)
    • then there is increased IAP, the bladder neck is not compressed together with the bladder
    • so only bladder is compressed and its neck is open - so urine will come out
  30. if stress incontinence is due to childbirth injury, what else may exist?
    faecal incontinence
  31. why do you have to palpate abdomen if thinking SI?
    exclude distended bladder
  32. what may you see on sims speculum in SI?
    cystocele or urethrocele
  33. what lifestyle changes can be made to help with SI?
    • lose weight if obese
    • stop smoking - cause chronic cough
    • reduce xs fluid intake
  34. what is the conservative Rx of Stress incontinence? and this is first line Rx
    • pelvic floor muscle training for 3 months taught by physiotherapist
    • 8 contractions, tds
    • vaginal cones are inserted into vagina and held in position by voluntary muscle contraction
  35. what are 2 drug Rx for stress incontinence?
    • 1. duloxetine (SNRI) can enhance pudendal nerve stimulation of pelvic floor
    • give after PFMT failed. it can increase tone of urethral sphincter
    • SE: headache and gastric problems
    • 2. oestrogen HRT
  36. which Rx can cure the majority of women with SUI?
    surgery
  37. what needs to be done before any surgery for SUI? why?
    • cystometry
    • exclude overactive bladder
  38. what is the main aim of surgery for Rx of SUI?
    allow transmission of raised IAP to bladder neck as well as the bladder
  39. what is the traditional gold standard surgical Rx of SUI called?
    • Burch colposuspension
    • bladder neck is lifted using sutures placed via abdominal incision
  40. what is the new, surgical procedure of choice for SUI which is 1st line?
    • TVT = Tension free Vaginal Tape
    • inserted through a small vaginal incision over the mid urethra
    • TVT compresses the urethra when you cough to stop leakage
  41. what are 3 advantages of TVT > colposuspension
    • 1. less invasive
    • 2. can do under spinal or local anaesthetic
    • 3. shorter hospital stay
  42. what are risks of all the operations for SUI?
    • bleeding
    • infection
    • voiding difficulty & retention
    • de novo overactive bladder!
    • bladder perforation
  43. what is overactive bladder?
    • urgency
    • with or without urge incontinence
    • usually with frequency, nocturne
    • in absence of proven infection
  44. how can destrusor overactivity be diagnosed in urodynamics?
    • by involuntary detrusor contractions during the filling phase
    • which may be spontaneous or provoked by eg coughing
    • (get increase in detrusor pressure which you dont with SUI)
  45. what is cause of overactive bladder?
    • idiopathic
    • after operation for SI
    • neuropathy eg MS causing detrusor overactivity
    • spinal cord injury
  46. why may you think its stress incontinence when its actually overactive bladder?
    • as coughing can lead to provocation of destrusor contraction
    • which is overactive bladder
  47. what is different about the symptoms in OAB compared to SUI?
    • get urgency, urge incontinence
    • frequency
    • nocturia
    • hx of childhood enuresis is common
  48. what do you see on examination of OAB?
    normal usually!
  49. what may urinary diary show in OAB?
    • passage of small vol of urine
    • esp at night
    • and when take caffeine
  50. what would cystometry show in detrusor overactivity?
    detrusor contractions on filling or provocation
  51. what is Rx of OAB?
    • 1. caffeine and fluid reduction if xs
    • 2. bladder training: void by the clock at increasing intervals
    • 3. antimuscarinic eg tolterodine or oxybutynin, solifenacin - relax smooth muscle in bladder
  52. how may you treat OAB in post menopausal women?
    • if also have vaginal atrophy then give
    • intravaginal oestrogens
  53. if medical/conservative Rx failed for OAB, what is next step - 2 options?
    • botulinum toxin A (botox)
    • sacral nerve stimulation
  54. where is botox given? and MOA?
    • into detrusor muscle with a needle cystoscopically
    • MOA: blocks NMJ so relax detrusor contraction
  55. what is risk of botox?
    • risk of total bladder paralysis
    • so need self catheterisation
  56. how long can botox Rx last for?
    6 months
  57. how does sacral nerve stimulation work?
    • like a pacemaker - causes contraction of external sphincter and pelvic floor muscle
    • causes inhibition of bladder contractions
  58. if there is very severe OAB, what is surgical option?
    clam augmentation ileo cystoplasty
  59. what is frequency?
    >7/8 times a day
  60. what is nocturne?
    > twice

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