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Bladder Function – 2 phases

 Storage/Filling  Accommodation of increasing volumes of at a Female 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  – 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  – complaint of any involuntary leakage of urine  Sympathetic inhibition –decreases detrusor inhibition

(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  – occurs when the bladder reaches the limit of it’s viscoelastic properties; occurs with  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 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 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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