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