Obs&Gyn Urinary incontinence

Question 1

What problems does urogynecology deal with?

Answer 1

• urinary incontinence
• bladder-related problems
• prolapse

Question 2

What’s incontinence?

Answer 2

Incontinence is the involuntary loss of urine which is both a social and hygienic problem

Question 3

What’s required for continence?

Answer 3

Continence requires:

• normal anatomy
• good closure of the urethral sphincters/muscle

Question 4

Classifiction of incontinence (4)

Answer 4

• overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
• stress incontinence: leaking small amounts when coughing or laughing
• mixed incontinence: both urge and stress
• overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Question 5

Risk factors for urinary incontinence

Answer 5

• advancing age
• previous pregnancy and childbirth
• high body mass index
• hysterectomy
• family history

Question 6

Pathophysiology of stress incontinence

Answer 6

• Anatomy: decent of bladder neck & superior part of urethra outside of abdo cavity means increased abdo pressure (e.g. during sneezing) only exerted on bladder & not on neck & urethra so urine forced out of bladder
• Decent of bladder neck caused by: inc age, inc parity (especially prolonged 2nd stage of labour), postmenopausal women, chronic raised intra-abdo pressure: obesity, COPD, constipation
• Increased abdo pressure caused by: sneezing, coughing, laughing, activity

Question 7

Aetiology of urge incontinence

Answer 7

• largely idiopathic
• associated disease: MS, autonomic neuropathy, spinal lesions, pelvic surgery (damaging nerve connections)
• can be exacerbated (but not caused by): caffeine, alcohol & smoking
• urge incontinence can be caused by: infection, stones or tumours

Question 8

Signs and symptoms of stress incontinence

Answer 8

• Factors provoking leakage: coughing, sneezing, exertion

O/E:

• try to provoke incontinence
• speculum to look for prolapse
• assess severity and impact on daily life

Question 9

Signs and symptoms of urge incontinence

Answer 9

• frequency
• nocturia
• urgency

Important to assess severity and impact on daily life.

Question 10

Initial investigations for urinary incontinence

Answer 10

• bladder diary for minimum of 3 days
• urinalysis & mid stream sample to rule out UTI
• vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)

Question 11

Specialised investigations for urinary incontinence

Answer 11

Urodynamics:

• Uroflowmetery: measurement of flow rate (simple & non-inasive)
• Cystometry: Measures intra-abdominal & urethral pressure, can diagnose urge & stress by exclusion of urge
• Videocystourethrography (VCU): Bladder filled w/ dye then x-rays

Imaging:

• Cystoscopy-visualization of bladder (few indications) can show polyps, calculi and malignancy

Question 12

When to refer urgently with bladder problems?

Answer 12

Urgent Referral:

• microscopic haematuria (>50yo)
• visible haematuria
• recurrent & persistent UTI w/ hameaturia
• suspected malignancy

Question 13

Management of urge incontinence

Answer 13

• bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
• bladder stabilising drugs: antimuscarinics are first-line e.g. Oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)*
• Invasive: bladder wall injection w/ botulinum A toxin. Sacral nerve stimulation to reduce detrusor overactivity

* Immediate release oxybutynin should, however, be avoided in ‘frail older women’

*mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Question 14

Management of stress incontinence

Answer 14

• pelvic floor muscle training: at least 8 contractions performed 3 times per day for a minimum of 3 months
• Physiotherapy: to increase muscle tone and strength, & increase cortical connection to these muscles. 40-60% will need no further treatment than physio

*Bladder retraining should be used in conjunction

• Duloxetine as 2nd line
• surgical procedures: e.g. retropubic mid-urethral tape procedures

Question 15

Surgeries for stress incontinence

Answer 15

• 1st line surgery: Retropubic mid -urethral tape procedure (high efficacy, good recovery rate and decreased cost)
• 2nd line: Colposuspension
• 3rd Line: autologous rectus fascial sling

Question 16

Definition of vaginal prolapse

Answer 16

• Descent of a pelvic organ beyond its normal anatomical position.
• Descent is into the only potential space → the vagina
• Pressure can force wall of vagina, uterus or cervix through vaginal orifice

Question 17

Types of urogenital prolapse

Answer 17

Type of prolapse depends on organ which has descended:

1. Cystourethrocele: (most common) bladder or urethra descend
2. Uterine Prolapse: descent of uterus
3. Rectocele: prolapse of the front wall of rectum into posterior vaginal wall
4. Enterocele: prolapse of pouch of douglas with small intestine into the vagina
5. Vaginal Vault Prolapse: descent of vaginal vault (post hysterectomy) often with combination of above prolapses

Question 18

The classification system of urogenital prolapse (3)

Answer 18

Baden-Walker Classification

1st Degree: cervix visible when perineum depressed (w/in vagina)

2nd degree: cervix prolapsed through introitus (fundus remains in vagina)

3rd Degree: (procidentia) entire uterus outside introitus

Question 19

Epidemiology of urogenital prolapse

Answer 19

• 50% of parous women have some level of prolapse
• 10-20% seek medical help
• Leading cause of hysterectomy in women >50yo
• By age of 80 1 in 10 women will have had surgery for prolapse

Question 20

Aetiology of urogenital prolapse

Answer 20

• Defect of ligaments & muscles (or no nerve connection) of pelvic floor
• 2% in nulliparous women (? congenital cause: ?connective tissue disease)

Question 21

Risk factors for urogenital prolapse

Answer 21

• Childbirth (leading cause): parity, instrumental delivery, delayed 2nd stage
• Ageing: post-menopausal atrophy
• Chronic conditions: cough, constipation, masses (inc abdo pressures e.g. obesity)
• Previous pelvic surgery

Question 22

General signs and symptoms of urogenital prolapse

Answer 22

• local discomfort
• awareness of “something coming down”
• difficulty retaining tampon
• spotting
• dysparaeunia/loss of sensation
• can be exacerbated by coughing, sneezing & straining

Question 23

Signs and symptoms of cystourethrocele

Answer 23

• incontinence
• frequency
• urgency
• poor stream
• may require manipulation of prolapse to micturate

Question 24

Symptoms of rectocele

Answer 24

• constipation
• urgency to pass stool
• tenesmus
• may require manipulation to defecate

Question 25

What to examine in suspected urogenital prolapse?

Answer 25

Assess vagina using a sims speculum, observing movement of prolapse and urinary incontinence on straining

Question 26

Investigations in suspected urogenital prolapse

Answer 26

* Clinical diagnosis * Swabs/urinalysis/MSSU → if infection suspected * Referral for urodynamics if associated incontinence

Question 27

Management of urogenital prolapse

Answer 27

* **Conservative:** weight loss, stop smoking, treat chronic cough/constipation, avoid lifting and high impact physical exercise * **Pelvic floor exercises**: referral to specialist physiotherapy * HRT replacement (topical or oral) → improve collagen content * **Vaginal pessaries:** simple measure, difficulty finding correct size initially, may occasionally cause local irritation. Sex possible w/ pessary * **Surgery**

Question 28

Types of surgery for urogenital prolapse

Answer 28

* anterior/posterior colporrhaphy * hysterectomy * Manchester repair * Fothergill procedure * sacrospinous fixation * sacral colpopexy

Question 29

Questions in history for suspected urinary incontinence

Answer 29

* Daytime frequency and nocturia * Presence of urgency * Any leakage and when this occurs * Any feeling of incomplete bladder emptying * Presence of bladder pain/symptoms of cystitis * Any haematuria * Presence of recurrent proven urine infections * Symptoms of a bulge/discomfort within the vagina * Need to assess length and severity of symptoms * Ask about any previous treatment * Establish usual fluid intake and what this comprises * Ask about potential co-morbidities, eg chronic cough, constipation * Ask about whether a patient is sexually active and if there are any complications * Ensure full medical, surgical and medication history is taken

Question 30

What information 'Bladder dairy' should include?

Answer 30

* Fluid input * Type of fluid * Volume voided * Day * Night * Episodes of leakage

Question 31

How does a urodynamic assessment look like? (1 stage)

Answer 31

•Involves a measurement of pressures and flow It's comprised of two stages: 1.Storage/Filling phase * Bladder filled at a pre-determined rate * Patient is asked to describe bladder sensations such as: first and normal desire to void, urgency, bladder pain * Patient is asked to cough, listen to taps or perform other activities that may cause leakage Information is gained as to: actual bladder capacity, presence of detrusor contractions, type of leakage

Question 32

How does detrusor overactivity look on cystometry?

Answer 32

Question 33

How does stress incontinence look on cystometry?

Answer 33

Question 35

2nd stage of urodynamic assessment

Answer 35

**Voiding phase** * starts when the patient is given permission to void It gives information about: * Flow rates and stream * Complete/Incomplete bladder emptying * Detrusor muscle pressure required to empty bladder i.e. if the patient strains to void

Question 36

Mirabegron - class - use - caution - SEs

Answer 36

**Class**: b3 receptor agonist and activates b3 adrenoreceptors in the bladder causing * Relaxation of the bladder * Improved filling and storage of urine **Use if**: * Antimuscarinics are contra-indicated or clinically ineffective * In patients who cannot tolerate the side effects of antimuscarinics **Caution**: Lower doses should be used if renal or hepatic impairment **Common side effects:** UTIs, palpitations and increase in blood pressure (hence do not used if severe or uncontrolled hypertension