Urogynaecology Colm McAlinden
Definitions Urinary incontinence compliant of any involuntary leakage of urine with many different causes Two main types: Stress Urge
Definitions Nocturia: More than a single void at night is considered abnormal up to the age of 70 Dysuria: Pain when voiding, usually associated with UTIs
Classification Stress urinary incontinence: Involuntary leakage on effort or exertion (e.g. sneezing, coughing) Common cause: Urethral sphincter weakness Urge urinary incontinence: Involuntary leakage accompanying or immediately preceded by a strong desire to void. Nb - Urgency c/s urge urinary incontinence usually with frequency & nocturia is termed overactive bladder syndrome
Classification Mixed: Both urgency and stress, usually one is predominant Overflow incontinence Bladder becomes large and flaccid with minimal or no detrusor tone/function. Usually 2 to injury/insult e.g. surgery, childbirth. Simply, the bladder leaks when it becomes full
Classification Continuous urinary incontinence: Continuous leakage, usually associated with a fistula or congenital problem e.g. ectopic ureter Others: UTI, medications, immobility, cognitive impairment Situational: e.g. giggle
Assessment History: onset, duration, severity etc. QoL assessment: effect on daily life, social, personal and sexual relationships Frequency/volume chart: objective assessment of fluid intake and voiding
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Clinical examination General: BMI, BP, urinalysis, signs of systemic disease, mobility, mental state, manual dexterity Abdominal palpation: Abdo/pelvic mass (inc. pregnancy) Exclude a full bladder (i.e. obstruction / retention) Pelvic examination: Vulval disease Prolapse Urethral/bladder neck descent on straining Assessment of pelvic floor muscle strength (palpation)
Investigations Dipstick urine: leucocyte esterase, nitrites, protein, blood, and glucose If positive dipstick proceed to urine specimen for microscopy, culture and sensitivity Residual check: USS or catheterisation to exclude incomplete bladder emptying Pad test: simple test to detect & quantify leakage (weight of pads over test time period)
Cystourethroscopy Visualisation of: Urethra Bladder Mucosa Trigone Ureteric orifices Bladder biopsy http://www.laparoscopyhospital.com/picture/cystoscopy.jpg Indications: recurrent UTIs, haematuria, bladder pain, suspected injury/fistula, suspected bladder tumour/stone etc.
Imaging Not routine in all women presenting with urinary symptoms but targeted specific indications: USS incomplete bladder emptying, congenital abnormalities, tumours, stones, Abdominal radiograph FBs, calculi IV urography neuropathic bladder, fistulae etc. but contrast CT more accurate and rapid detection MRI renal or pelvic masses and tumour staging
Urodynamics Combination of tests to assess the ability of the bladder to store and void urine Indicated when surgery is planned to confirm dx, check for detrusor overactivity or voiding dysfunction http://gyne-am-see.ch/userfiles/image/abkl%c3%a4rungurodynamik.png
Stress incontinence 1 in 10 women Intravesical pressure exceeds closing pressure of urethra Most common cause is childbirth > denervation of pelvic floor Oestrogen deficiency at the time of menopause > weakening of pelvic support and thinning of urothelium Occasionally, weakness of bladder neck (congenital / trauma)
Symptoms & signs Symptoms: usually small discrete amount of leakage with cough, sneeze, exercise (heavy loads, running, jumping etc.) Signs: prolapse of urethra and anterior vaginal wall may be present. May be possible to demonstrate stress incontinence in clinic > cough with full bladder
Investigations Dipstick urine & MSU Frequency / volume chart Urodynamic studies
Management Conservative first: Weight reduction Stop smoking Tx chronic cough & constipation Pelvic floor muscle training (at least 3/12) Biofeedback (device which converts the effect of pelvic floor contraction to a visual/auditory signal to allow women objective assessment of improvement) Electrical stimulation (produces muscle contraction in those unable to do so) Vaginal cones (applying graded resistance against which the pelvic floor contract 15 mins BD)
Vaginal cones www.healthandcare.co.uk www.independentlivingconsultants.co.uk
Pharmacological management Duloxetine: only licensed drug SNRI that enhances urethral striated sphincter activity Mediocre efficacy Significant SEs, e.g. nausea, dyspepsia, dry mouth, insomina, drowiness, dizziness Not NICE recommended for first line
Surgery When conservative mx has failed and QoL compromised Peri-urethral injections: bulking agents, LA outpatient setting. Usually older frail unfit women Burch colposuspension: rarely performed, 2-3 sutures placed between paravaginal fascia and ipsilateral ileopectinal ligament (Cooper s ligament) Laproscropic colposuspension: similar to the open procedure but technically more difficult
Continued Tension-free vaginal tape (TVT): Most common procedure in UK Polpropylene tape place under mid-urethra via small vaginal incision (LA or GA) Cystourethroscopy is carried out to ensure no damage to bladder or urethra Transobturator tape (TOT): Similar to TVT but retropubic space not entered so less risk of bladder perforation but greater risk of nerve trauma
TVT http://www.bmihealthcare.co.uk/graphics/images/ftp-images/website-images/treatments/og19.jpg
Case 72 year old woman with a 2 year history of urine leakage when lifting grandchildren (twins) and occasionally when exercising in gym Happens approx. once a week Mild, small amount of urine No urgency symptoms, no nocturia, no colorectal symptoms, no neurological symptoms PMH: Hypertension well controlled with Ramipril Has 3 children (vaginal deliveries) Incontinence not interfering with QoL
Examination BMI in normal range Dipstick urine NAD Abdominal examination no masses VE: NAD, no incontinence demonstrated with cough Mx: reassurance, pelvic floor exercises
References Collins, S., Arulkumaran, S., Hayes, K., et al. Oxford Handbook of Obstetrics and Gynaecology. Third ed. Oxford: Oxford University Press; 2013. pp. 653-667