Transcript Urology for Medical students

Urology for Medical students
Kieran Jefferson
Consultant Urological Surgeon
University Hospital, Coventry
Urinary Incontinence
‘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.’
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
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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
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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
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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
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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
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Pelvic floor exercises – 50% success
Topical oestrogens
Duloxetine
Surgery
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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