URINARY INCONTINENCE CHAPTER 35 PAGE 461

LUTZ UTI Cystoscopy

- Urgency - Dysuria - Initial testing suggests other pathologies

o Involuntary leakage ass with urgency
- Stress urinary incontinence
o Involuntary leakage on effort or
exertion
- Mixed urinary incontinence
- Nocturnal enuresis
o Involuntary loss of urine occurring
during sleep
- Insensible urinary incontinence
o Unaware of how it occurred
- Coital incontinence
o Loss of urine with coitus
- Overactive bladder
o Urgency, frequency and nocturia
History
- Bowel or prolapse sx
- Sexual function
- Previous treatment
- Environmental and mental status
- Physical activities
- Coexisting disease
- Pain
sx of voiding dysfunx
- Sensory → reduced sensation of filling
- Hesitancy → delay in initiating void
- Straining to void → poor or intermittent
stream
- Postmicturition leakage → continuing loss of
small volumes of urine after voiding
- Incomplete voiding → sensation of urine in
bladder after voiding or having to void
immediately after
- Normal residual urine is <50ml in pre-
menopausal women and <100 in PM women
- Retention → cannot pass urine at all
- Hematuria - Pain or discomfort in LUTS
- Recurrent UTI → 3 infections in past 12 - Fistula evaluation
months proven by blood cultures
Renal function assessment
Gynae
- Pts with renal impairment
- Sexual, vaginal discharge, prolapse
Uroflowmetry
Neuro, psychiatric, obstetric, medical, surgical hx
- Screening test for sx of voiding dysfunction
Exam
Urodynamic testing
- Abdomen
- Performance of bladder function
- Neuro
- Fill bladder with saline and recording the
- Genitalia
pressure in the bladder and abdomen
Special investigations simultaneously
- Recommended in
Urinalysis o Prior to invasive procedures
- Dipstick and MC&S o After treatment failure if more info is
needed to plan further therapy
PVR (estimation of post void residual urine) o Long term surveillance programme
in neurogenic lower urinary tract
- By U/S or sterile catherization dysfunx
Imaging o Young women
o Sudden onset of sx
- Xray or U/S o Poor response to therapy
o Mixed incontinence
Upper tract imagining done for:
Frequency volume chart (bladder diary)
- Neurogenic urinary incontinence
- Significant PVR - Over a period of 3 days patient must fill in
- Kidney/loin pain an a prepared chart the time of every
daytime void, volume and pad usage
- POP
- Fistula
Review nerve supply to bladder and micturition cycle
- Children with incontinence
- Urodynamic studies which show raised
intravesical pressure on bladder filling
Stress urinary incontinence Overactive bladder and urgency incontinence Overflow incontinence

- Defective urethral closure → maximal Uncontrolled contractions of the bladder muscle Detrusor function deteriorates → women unable to
urethral closure may be exceeded during during filling phase. Contractions are mediated by void to completion → reduced or absent bladder
activities that raise intra-abdominal pressure muscarinic receptors sensation
- Caused by anatomical defect
Sx Dx
- Spontaneous bladder contraction is absent
- Urgency - Post voidal residue estimation which is
Mx
- Frequency <100ml
- Normal voiding habits - Nocturia
Mx
- Physiotherapy
Mx
- Pessaries Intermittent self-catheterization on a daily basis to
Pharmacotherapy keep residual volumes low
Pharmacotherapy: Duloxetine
- Antimuscarinic drugs Continuous urinary incontinence
- Serotonin and NA reuptake inhibitor
- Oxybutynin
- Enhances urethral rhabdosphincter muscle Any fistula that results in continuous leaking needs
o Reduces frequency and intensity of
contraction referral to urologist
involuntary contractions → increase
Surgical in functional bladder capacity Causes
o Side effects: dry mouth, constipation
- Burch colposuspension: suspension of and palpitations - Congenital abnormalities
vaginal fascia from iliopectineal ligament o 2.5mg bd - Obstetric fistulae – pressure necrosis caused
- Tension free vaginal tape: reinforce poorly - Tolterodine is safe and less side effects by fetal head = vesicovaginal fistula. Next
functioning fascial background and secure o 2mg/4mg SR births = C/S
support of mid urethra to maintain - Neoplastic fistulae – carcinoma of the cervix
incontinence Bladder training may erode into bladder
- Record in the frequency – volume chart - Iatrogenic fistulae – most common. After
Prevention
- Increase the intervals between voiding pelvic surgery (hysterectomy). Watery
- Elective C/S? - First to void one hourly the intervals vaginal effluent occurs a few days after
- Modify risk factors increased by 15 minutes until interval is surgery
o Obesity between 2-4 hours Mx
o Lung disease
o Smoking Surgical - Clinical exam
- Neurostimulation of S3 or pelvic floor - Speculum exam
electrostimulation - 3 – swab – test: placing 3 cotton balls in the
- Stimulator is connected to the electrode vagina + infusing 200ml of dilute methylene
placed in S3 spinal foramina and is blue into the bladder via a plastic feeding
implanted tube. Patient walks around for a few minutes
→ swabs removed. Blue staining on swabs =
leakage through fistula.
- Cystogram, IVP, X - ray
OTHER CONDITIONS AFFECTING THE Voiding difficulty and retention Mx
BLADDER
Acute – cannot pass urine at all - Double voiding technique: Patient voids,
UTI gets up and sits down again to attempt to
Chronic - >50% bladder contents retained after void once more
Definitions micturition - Self-catheterization if detrusor hypotonia or
Causes neurogenic bladders
1. Asym bacteriuria: >100 000 bacteria per ml of
urine with no sx Acute
- Post op pain or spasm
- Denervation of bladder after extensive pelvic - Transurethral/ suprapubic catheterization for
2. Urinary tract infection: bacteriuria >100 000 surgery a few days
CFU/ml on voided specimen, with pyuria >10 - Kinking of urethra due to POP - Pain relief and rx of local conditions
WBC/mm3 with LUTZ - Severe pain due to herpes genitalis infection
- Obstruction Chronic
- Atonic bladder
- Catheterization esp post op
3. Complicated urinary tract infection: infection in - Neuro damage
- Retention with urine volumes ≥1000ml for
catheterized patients, immunosuppressed - Impaction Pelvic mass / retro converted preg
more than 6 hours= permanent neuro
patients, abnormality in urinary tract, systemic uterus of early gestation
disease (DM), pregnant women and young girls damage to the bladder
- Malig infiltration
NOCTURNAL ENURESIS
Sx sy
4. Recurrent urinary tract infection: relapse - Review in paeds book
Voiding sx
(infection with same organism within 2 weeks).
URINARY TRACT AND PREGNANCY
Synthetic penicillin, quinolones and - Poor stream
cephalosporins must be given. Follow up culture - Delayed initiation of micturition
is NB within 2 weeks of completion of treatment - Feeling of incomplete emptying
to confirm cure. Recurrent UTI → 3 infections in - Straining
past 12 months proven by blood cultures. - Postmicturition dribbling
Causes include a congenital abnormality.
Acute

- LAP: cramping or dull

- Tender suprapubic mass

Chronic

- Frequency
- Lower abdom discomfort
- Overflow incontinence
- Recurrent urinary tract infections
- Suprapubic mass
- Renal impairment
URINARY TRACT AND ELDERLY Urethral caruncles

- More common - Common in elderly

- Test for UTI - Red mass of urethral mucosa is visible at
- Detrusor function is compromised urethral meatus
- Dysuria, minor bleeding
Mx - Due to oestrogen deficiency
- Treat UTI, constipation, mobility, toilet - Rx = topical oestrogen therapy
access, current meds, fluid intake and - Resistant cases need biopsy
regular toileting Congenital abnorm
- TVT – type operation: minimally invasive
and easily tolerated - Bladder extrophy
- Postvoid residue >100ml = clean intermittent o Absence of anterior abdominal wall,
self-catheterization anterior bladder wall and divergence
of pubic bones
MISCELLANEOUS PROBLEMS - Epispadias
Urethral diverticula o Deficient dorsal aspect of urethra
and absence of sphincter
Sx sy - Both are treated by surgical repair and
reconstruction by urologist in tertiary hosp
- Recurrent cystitis
- Frequency
- Dysuria
- Post micturition dribble
- Dyspareunia
- Incontinence
- Voiding difficulty

Exam

- Tender lump over urethra

- Stone in diverticulum

Causes

- Infection
- Birth trauma or instrumentation

SI

- Voiding cystogram
- Vaginal U/S

Rx

- Asym = leave alone

- Diverticulectomy or marsupialization
 Innervation of bladder

Normal micturition cycle