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Urology for Medical students
Kieran JeffersonConsultant Urological Surgeon
University Hospital, Coventry
‘Involuntary loss of urine in sufficient amount or frequency to constitute a social and/or health
problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine
to continuous urinary incontinence with concomitant fecal incontinence.’
Urinary Incontinence
Prevalence
• Increases with age (but not normal at any age)
• 25-30% of community dwelling older women
• 10-15% of community dwelling older men
• 50% of nursing home residents; associated with dementia, faecal incontinence, immobility
Importance
• Major cause of morbidity and institutionalisation
• Not life-threatening
• Bladder pressure exceeds urethral resistance
Normal bladder
• Detrusor muscle
• External and Internal sphincter
• Normal capacity 300-600cc
• First urge to void 150-300cc
• Sacral reflexes modified by CNS
Pressure/volume curve
Innervation
Types of Incontinence
• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Functional incontinence
• Continuous incontinence
Stress Incontinence
• Common in middle aged females
• Raised intra-pelvic pressure leads to leakage due to poor sphincter resistance
– Cough, sneeze, straining…..
• Females after child bearing with bladder neck hypermobility
• Males rare except post-surgery
Urge Incontinence
• Commonest cause of UI >75 years of age
• Abrupt, uncontrollable desire to void
• Usually idiopathic
• Consider: – infection, tumor, stones, atrophic vaginitis, stroke, Parkinson’s
Disease, dementia
Overflow Incontinence
• Prolonged problems with bladder emptying lead to detrusor failure and chronic retention
• Pressure eventually rises due to tissue overdistension, causing leakage
• Classically occurs at night
Functional Incontinence
• Manifestation of systemic disease which does not involve lower urinary tract
• Result of psychological, cognitive or physical impairment
Continuous incontinence
• Leakage occurs continuously, not related to bladder sensation or other events
• Due to fistula between urinary tract and skin, or duplex kidney in female, where upper moiety ureter inserts below rhabdosphincter
Management
• History and examination
• Investigations
• Treatment
History
• Precipitating events, duration
• Pad usage & bother
• Parity
• Medical/surgical history– Pelvic surgery– Diabetes, CVA, other neuro disorder
• Medications
Examination
• Mental status & Mobility
• Abdomen inc VE/DRE
• Neurologic exam
Investigations
• MSU dipstix, M,C&S, cytology
• FBC, U&Es, Glucose
• Frequency-volume chart
• Flows & Post-void residuals
• Urodynamics (cystometry)
Treatments
• Most patients will respond to conservative treatments
– Reduce fluid/caffeine intake
– Pelvic floor exercises
– Bladder training protocols
• Other treatments as per type/aetiology
Treatments for SI
• Pelvic floor exercises – 50% success
• Topical oestrogens
• Duloxetine
• Surgery– Tapes – TVT/TOT
– Urethral bulking agents
– Colposuspension
– Artificial urinary sphincter/diversion
Treatments for SI
Treatments for UI
• Bladder retraining, avoid stimulants
• Anticholinergic medication– Oxybutynin, tolterodine, darifenacin, solifenacin
– Tablets vs patches
• Botox intravesically
• Surgery– Clam cystoplasty, detrusor myomectomy
– Urinary diversion
Botox
Overflow incontinence
• Restore bladder emptying
• Intermittent self-catheterisation
• Surgical treatment of bladder outflow obstruction
• Long-term catheter
Continuous incontinence
• Usually requires surgical treatment of underlying anatomical disorder
– Hemi-nephrectomy
– Ureteric reimplantation
– Repair of fistula
Summary
• Incontinence rarely shortens lives but has a huge effect on QoL
• Most patients can be (cost) effectively treated at low risk