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what is the definition of urinary incontinence?
- involuntary loss of urine
- that becomes a social problem
- irrespective of amount
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which part of ANS helps voiding and which prevents?
- parasympathetic aids voiding
- sympathetic inhibits
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what does continence depend on in terms of pressure?
pressure in urethra > pressure in bladder
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as the bladder fills with urine, what happens to the pressure inside it?
no change as destrusor muscle is expandable
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why does coughing not usually cause incontinence?
cough = increase IAP - transmitted equally to the bladder and upper urethra because both lie within the abdomen
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what are the 2 main types of incontinence?
- stress incontinence
- urge incontinence (destrusor overactivity)
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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
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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
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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
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why would you want to do urine dipstick?
- UTI - leucocytes, nitrites
- diabetes - glycosuria, protein
- bladder cancer - haematuria, protein
- stones - haematuria protein
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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
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how can you exclude chronic retention of urine?
- do post-micturition US or catheterisation
- to check if retaining
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which is the single most important urodynamic study?
cystometry (measure pressure in bladder)
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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
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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
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when would an IVP intravenous pyelogram be useful?
assess and located fistulae and filling defects
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when would contrast CT be useful?
- examine integrity and route of ureter
- stones, strictures
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what is methylene dye test?
- blue dye instilled into bladder
- dye leakage from places other than urethra = fistula
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in a normal bladder, what happens to detrusor muscle when you cough?
no contraction
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in stress incontinence, what happens to detrusor muscle when you cough?
no contraction
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in detrusor overactivity, what happens to detrusor muscle when you cough?
detrusor contraction after a cough
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in a normal bladder, what happens to urine flow with a cough?
no urine flow
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in SUI, what happens to urine flow when cough?
urine flow with cough
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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
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what can cystoscopy diagnose?
- inspect anatomy of bladder and urethra
- exclude mechanical causes of incontinence eg stones or cancer
- but not assess bladder function
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what is stress incontinence?
- involuntary loss of urine
- bladder pressure > urethral pressure
- in absence of detrusor contraction
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what are causes/RF for stress incontinence?
- pregnancy
- vaginal delivery
- prolonged labour
- forceps delivery
- obesity
- age
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what commonly co-exists with stress incontinence?
prolapse
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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
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if stress incontinence is due to childbirth injury, what else may exist?
faecal incontinence
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why do you have to palpate abdomen if thinking SI?
exclude distended bladder
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what may you see on sims speculum in SI?
cystocele or urethrocele
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what lifestyle changes can be made to help with SI?
- lose weight if obese
- stop smoking - cause chronic cough
- reduce xs fluid intake
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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
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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
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which Rx can cure the majority of women with SUI?
surgery
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what needs to be done before any surgery for SUI? why?
- cystometry
- exclude overactive bladder
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what is the main aim of surgery for Rx of SUI?
allow transmission of raised IAP to bladder neck as well as the bladder
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what is the traditional gold standard surgical Rx of SUI called?
- Burch colposuspension
- bladder neck is lifted using sutures placed via abdominal incision
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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
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what are 3 advantages of TVT > colposuspension
- 1. less invasive
- 2. can do under spinal or local anaesthetic
- 3. shorter hospital stay
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what are risks of all the operations for SUI?
- bleeding
- infection
- voiding difficulty & retention
- de novo overactive bladder!
- bladder perforation
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what is overactive bladder?
- urgency
- with or without urge incontinence
- usually with frequency, nocturne
- in absence of proven infection
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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)
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what is cause of overactive bladder?
- idiopathic
- after operation for SI
- neuropathy eg MS causing detrusor overactivity
- spinal cord injury
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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
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what is different about the symptoms in OAB compared to SUI?
- get urgency, urge incontinence
- frequency
- nocturia
- hx of childhood enuresis is common
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what do you see on examination of OAB?
normal usually!
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what may urinary diary show in OAB?
- passage of small vol of urine
- esp at night
- and when take caffeine
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what would cystometry show in detrusor overactivity?
detrusor contractions on filling or provocation
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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
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how may you treat OAB in post menopausal women?
- if also have vaginal atrophy then give
- intravaginal oestrogens
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if medical/conservative Rx failed for OAB, what is next step - 2 options?
- botulinum toxin A (botox)
- sacral nerve stimulation
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where is botox given? and MOA?
- into detrusor muscle with a needle cystoscopically
- MOA: blocks NMJ so relax detrusor contraction
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what is risk of botox?
- risk of total bladder paralysis
- so need self catheterisation
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how long can botox Rx last for?
6 months
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how does sacral nerve stimulation work?
- like a pacemaker - causes contraction of external sphincter and pelvic floor muscle
- causes inhibition of bladder contractions
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if there is very severe OAB, what is surgical option?
clam augmentation ileo cystoplasty
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what is frequency?
>7/8 times a day
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what is nocturne?
> twice
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