Urology for Medical students Kieran Jefferson Consultant 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 cc First urge to void cc 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