5/5/2010
Bladder Function – 2 phases
Storage/Filling Accommodation of increasing volumes of urine at a Female Urology low pressure – elasticity of the bladder Symppppathetic stimulation and parasympathetic inhibition reduces detrusor tone Katie N. Ballert, MD Contraction of bladder neck/sphincter to prevent Assistant Professor of Surgery leakage Division of Urology Sympathetic stimulation increases smooth sphincter tone University of Kentucky Somatic pelvic nerve stimulation increases striated sphincter tone
Bladder Function – 2 phases Storage Symptoms
Frequency – complaint by the patient that she voids too often Emptying/Micturation during the day Lowering of smooth and striated sphincter resistance Nocturia – complaint that the patient has to wake at night one or Sympathetic and somatic pelvic nerve inhibition more times to void Relaxation of the striated sphincter is the 1 st event in normal micturition Urgency – complaint of a sudden compelling desire to pass urine Coordinated contraction of the detrusor muscle Parasympathetic stimulation –increases detrusor tone Urinary incontinence – complaint of any involuntary leakage of urine Sympathetic inhibition –decreases detrusor inhibition
Overactive Bladder (OAB) – urgency with or without urge incontinence and usually with frequency and nocturia
Urinary Incontinence Urinary Incontinence
Stress Urinary Incontinence (SUI) – complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Neurologic – CVA, MS, SCI, spina bifida Urge Urinary Incontinence (UUI) – complaint of involuntary leakage Inflammation/Infection –radiation, UTI accompanied by or immediately preceded by urgency Pharmacologic – diuretics,,v, sedatives, etc Mixed Urinary Incontinence – complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or Restricted Mobility coughing Obstruction –POP– POP Overflow Incontinence – occurs when the bladder reaches the limit of it’s viscoelastic properties; occurs with urinary retention Fistula – radiation, recent pelvic surgery
Unaware Incontinence – occurs without associated activity or urge and without the patient being aware of the leakage
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Voiding Symptoms Pelvic Organ Prolapse
Intermittency – urine flow stops and starts on more Descent of: than one occasions during micturition Anterior vaginal wall Apex of the vagina (cervix or vault) Hesitancy – difficulty in initiating micturition resulting Posterior vaginal wall in a delay in the onset of voiding Patients may present with: Straining – muscular effort is used to initiate, maintain, Vaginal bulge/pressure or improve the urinary stream Incontinence/Difficulty Voiding LUTS – frequency, urgency, UUI Sexual sxs - dyspareunia Slow Stream – patient’s perception of reduced urine Bowel sxs – constipation, splinting, fecal urgency flow, usually compared to previous performance
Additional History Physical Exam
Number of pads used Neurologic exam Abdominal exam Previous treatments and responses Pelvic exam History of UTIs Relaxed and with Valsalva Obstetrical history Urethral hypermobility – movement with straining or coughing Other medical problems/symptoms Pelvic organ prolapse –split speculum DM – neuropathy Assess patient’s ability to perform a Kegel Neurologic dz/sxs – weakness, numbness, visual changes Rectal exam Medications Sphincter tone Prior urologic or Gyn procedures/surgeries Perineal sensation
auanet.org – AUA website – video demonstration of female exam
Anterior Compartment Apical Compartment
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Posterior Compartment Further Evaluation
Urinalysis hematuria, pyuria, glucosuria, protienuria, nitrites
Urine Cx
Urine cytology Looks for malignant cells Indicated in patients with hematuria or storage symptoms not responding to treatment
Bladder US/PVR Measurement of residual urine after a patient has voided. (nml <50ml)
Management of OAB/Urge Further Evaluation Incontinence
Voiding diary Behavioral Therapy Record of fluid consumed, volume of each void, Timed voiding incontinence episodes, urinary symptoms Voiding every 11--22 hours; prior to urge to avoid leakage Urodynamics Reducing fluid intake QQ--tiptip test Avoid bladder irritants (caffeine, alcohol, acidic foods) Cystoscopy Bladder training Imaging Pt attempts to consciously delay voiding; Increase the interval between voids May help with frequency
Management of OAB/Urge Management of OAB/Urge Incontinence Incontinence
Behavioral Therapy Antimuscarinics Pelvic Floor Muscle Training (Kegel exercises) Mainstay of medical treatment Abort detrusor contraction Can be combined with behavioral therapy Pt should be assessed prior to make sure that they can voluntarily MOA – Competitive inhibition of muscarinic receptors on contract the pelvic floor the detrusor muscle 3 sets of 8-8-1212 slow velocity PFM contractions Side effects (caused my inhibition of muscarinic receptors Sustained for 6-6-88 seconds outside of the bladder) Performed at least 33--44 times/week Dry mouth For at least 1515--2020 weeks Constipation Biofeedback Blurred vision BFBF--assistedassisted PFMT is no more effective than PFMT alone Confusion/Cognitive effects (concern in the elderly) May be useful for purposes of teaching, motivation, compliance Urinary retention May be useful in women who cannot identify PFMs Tachycardia Contraindicated in patients with narrow angle glaucoma
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Management of OAB/Urge Management of Stress Incontinence Incontinence
Pelvic Floor Muscle Training Intradetrusor injection of botulinum toxin Not FDA approved Pt should be assessed prior to make sure that they can Inhibits muscle contraction by blocking release of acetylcholine voluntarily contract the pelvic floor Repeat injections required 3 sets of 8-8-1212 slow velocity PFM contractions Sacral Neuromodulation Stidf6Sustained for 6-8d8 seconds Stimulation of S3 nerve root by implanted electrical pulse generator Performed at least 3-3-44 times/week 2 stage procedure For at least 1515--2020 weeks Contraindication for MRI Biofeedback Augmentation Cystoplasty BFBF--assistedassisted PFMT is no more effective than PFMT alone Increases bladder capacity and decreases intravesical pressure during contraction May be useful for purpose of teaching, motivation, compliance Pts may require CIC May be useful in women who cannot identify PFMs
Management of Stress Incontinence Management of Stress Incontinence
Pessary –device inserted into the vagina; used to Medications compress the urethra AlphaAlpha--adrenergicadrenergic drugs (pseudoephedrine, ephedrine) Inconsistent results and high rate of AE’s Duloxetine (serotonin and NE reuptake inhibitor) Available in Europe Withdrawn from FDA consideration for approval in US
Surgical Management of SUI Surgical Management of SUI
Bulking Agents – Injection of a substance to augment the urethra and increase the compressive force inward toward the urethral lumen Not permanent; repeat procedures necessary
Slings – placed under urethra to improve support PVS with Autologous fascia Midurethral Synthetic Sling
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Management of Pelvic Organ Management of Pelvic Organ Prolapse Prolapse Pessary Maintenance Pessaries Vaginal estrogen If possible teach pt to remove and reinsert device Symptomatic patients who Preferably leave out overnight at least once weekly do not want surgical ReRe--examineexamine within 1 week of insertion intervention Patients that are not good Issues/Complications with pessary use: surgical candidates Vaginal discharge SUI Temporary use until Vaginal erosion/ulceration surgery is performed Fistula Voiding or defacatory difficulties
Surgical Management of POP Urinary Tract Infections
Transvaginal Approaches Contamination – organisms are introduced during collection or processing of urine Abdominal/Laparoscopic Approaches
Colonization (asymptomatic bacteriuria) – organisms are present in the urine, but are not causing symptoms or illness
Infection (UTI) – combination of pathogen(s) in the urine and symptoms or inflammatory response
Recurrent UTIs Recurrent UTIs
Symptomatic infection which follows the Urinary tract obstruction or retention of urine resolution of a previous UTI Urolithiasis UreaUrea--splittingsplitting organisms -Proteus, Klebsiella, Providentia, Pseudomonas, Staphylococcus Intravesical stone or foreign body Three or more symptomat ic UTIs in 1 yr or 2 or Surgical clip, mesh, stone more in 6 months Fistula Vesicoenteric –pneumaturia, fecaluria Anatomic abnormalities May be due to relapse of original organism or Infected parurethral glands infection with a different organism Urethral diverticula
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Evaluation of Recurrent UTIs Management of Recurrent UTIs
Avoidance of spermacides and diaphragms PVR NonoxynolNonoxynol--99 has bactericidal effect on normal Imaging vaginal flora Renal US Vaginal Estrogen Pelvic MRI Lowers vaginal pH and restores lactobacilli CT scan Postcoital Antibiotics Cystoscopy LowLow--DoseDose Prophylactic Antibiotics TMP, TMP-TMP-SMX,SMX, nitrofurantoin
Indications for Referral Questions
Hematuria The first event during normal micturation is: Complicated/Refractory Incontinence Overflow Incontinence a) Detrusor contraction b) Detrusor relaxation Recurrent UTIs c) Relaxation of the external striated sphincter Symptomatic POP d) Contraction of bladder neck e) Relaxation of the bladder neck
Questions Questions
Anticholinergics are contraindicated in patients Which of the following is not a ureaurea--splitting with: organism?
a) Diabetes a) E. Coli b) Hypertension b) Proteus c) Narrow angle glaucoma c) Klebsiella d) Cataracts d) Pseudomonas e) COPD e) Staphylococcus
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Questions Questions
A 57 year-year-oldold female with history of diverticulitis A common side effect of anticholinergic presents with a chief complaint of chronic frequency, urgency and dysuria that has not resolved despite medications is: multiple courses of antibiotics. She has multiple urine cultures documenting >100, 000 E coli. She also complai ns o f pneumaturi a. Th e most likel y di agnosi s a) Tremor is: b) Glaucoma a) Vesicovaginal fistula b) Staghorn calculus c) Bradycardia c) Vesicoureteral reflux d) Dry mouth d) Vesicoenteric fistula e) e) Intravesical foreign body Diarrhea
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