Sioned Griffiths Craig Dyson Urogynaecology Sioned Griffiths Craig Dyson

Contents Urogynaecology Cases Continence Micturition Stress incontinence Urge incontinence Management of urinary incontinence

What is Urogynaecology? Sub-specialty of urology and gynaecology. Specialising in urological problems of women. Prolapse and urinary incontinence.

Case 1 Mrs Evans, 32. History of involuntary loss of urine on exercise and coughing. Started shortly after the delivery of her last child, nearly 2 years ago. Forceps delivery followed by post partum haemorrhage. Can no longer go to the gym as she used to in order to keep her weight under control. Avoids carrying her son in public places as she is afraid to wet herself.

Case 2 Mrs Jones, 45. School teacher. 3 year history of running to the toilet frequently. Has been getting worse over the last few months. Passes urine 14 times a day and 4 times per night. On many occasions does not reach the toilet before wetting herself. Her symptoms are affecting her work significantly as she is sadly thinking of going into an early retirement.

Continence Normal bladder Bladder Pressure Detrusor contraction Intra abdominal pressure Urine Detrusor Pelvic floor Urethra Urethral pressure External sphincter Urethral muscle tone Pelvic floor Intra abdominal pressure

Micturition urethral pressure - pelvic floor relaxation bladder pressure –detrusor muscle contraction urethral pressure - pelvic floor relaxation

Urinary Incontinence ‘Involuntary urine loss that is objectively demonstrable, which is a social or hygienic problem’. Estimated 4 million women over 40 years are regularly incontinent in the UK.

Impact of Incontinence Embarrassment Distress Inconvenience Threat to self esteem Loss of personal control Desire for normalisation

Common Types of Incontinence in Women Genuine Stress incontinence. Over active bladder/Urge incontinence. Mixed Urge and stress incontinence. Rare: Fistula, neurogenic, overflow

Genuine Stress Incontinence Definition and mechanism involuntary urine leakage on effort or exertion and on sneezing or coughing. Usually due to weakened pelvic floor muscles. Normal Weak pelvic floor

Genuine Stress Incontinence Aetiology Obstetrics history: vaginal delivery, prolonged labour and forceps delivery. High BMI. Menopause: Thinning/drying of the skin in the vagina/urethra. Prolapse commonly co-exists. Previous hysterectomy.

Urge Incontinence/Overactive Bladder Definition and mechanism Involuntary urine leakage accompanied or immediately preceded by urgency. Most often caused by an 'overactive bladder‘. The detrusor muscle contracts suddenly and involuntarily increasing bladder pressure.

Urge Incontinence/Overactive Bladder Aetiology Idiopathic Neuropathy e.g. MS, spinal cord injury, Parkinson's disease, diabetes mellitus. Bladder irritation: UTI.

Urinary Incontinence Initial Assessment Thorough history: this alone may distinguish stress or urge incontinence. Examination: Digital exam of pelvic floor muscle strength Sims speculum examination: may reveal cystosele.

Further Investigations Urine dipstick: to exclude infection or diabetes. If symptoms suggest voiding dysfunction -> Assessment of residual urine with bladder scan or catheterization. Symptom scoring, QOL questionnaire and bladder diary for 3 days minimum.

Bladder Diary

Non-Invasive Management Advice on fluid intake – reduce volume, or increase volume in the case of UTI, reduce caffeine intake. Advice weight loss in high BMI Pelvic floor muscle training for stress incontinence.

Non-Invasive Management Behavioural therapies: Bladder retraining (gradually increasing time between toilet visits) for overactive bladder for ≥ 6 weeks. Overactive bladder drugs: If bladder training fails. Oxybutynin Tolterodine Darifenacin Block muscarinic acetylcholine receptors which decreases bladder contractions.

Invasive Management Stress incontinence Synthetic tapes: Placed under the urethra like a sling/hammock to keep the urethra in the correct position. Biological slings: Autologous rectus fascial sling (similar to the tape, but uses a piece of rectus fascia to form the sling). Colposuspension: Pulls the neck of the bladder into its rightful place. Stitch anterior vaginal wall to fascia of pubic bone. Intramural bulking agents: Silicone/collagen injected into urethral wall, causing it to tighten

Invasive Management Urge incontinence Botulinum toxin A injections to bladder: reduces detrusor activity. Percutaneous sacral nerve stimulation: Contracts urethral sphincter and pelvic floor muscles which in turn inhibits bladder contractions. Augmentation cystoplasty: reconstructive surgery to increase the size of the bladder Urinary diversion: ureters are redirected to the outside of the body.

Summary Incontinence is common Negative impact on QoL. Aetiology of stress and urge incontinence differ. Several invasive and non-invasive management options.

References Impey L, Child T, 2012. Obstetrics & Gynaecology. 4th Ed. Wiley-Blackwell. Common Urogynaecology problems and management. [http://www.wales.nhs.uk/sites3/Documents/767/WorkbookforUrogynaecology_ProblemsandManagement_DrManalElbadrawyNovember2010.pdf] accesses Oct 2013 NICE 2006, Urinary Incontinence, NICE clinical guideline 40 http://guidance.nice.org.uk/CG40/ QuickRefGuide/pdf/English] accessed Oct 2013.