Urogynaecology

Essentially, this is about the symptoms of urinary incontinence in women although it can also be about voiding difficulty. There are 5 types:

Definition

The lack of voluntary control over micturition.

Classification

• Stress incontinence is the leakage of small quantities of urine when intra-abdominal pressure rises. This can be during exercise, exertion, sneezing, coughing etc.
• Urge incontinence is where the desire to urinate comes on suddenly and very strongly i.e. "if I've got to go, I've got to go now.
• Mixed incontinence is (as I'm sure you've figured out) a mixture of the above - both the feelings of urgency and leakage with rises in intra-abdominal pressure.

These two are the most common symptoms urogynaecology. There are, however, other types of incontinence: neuropathic incontinence which is due to a problem with the nerves; functional incontinence which occurs when the patient cannot reach the toilet due to other causes e.g. poor mobility; and overflow incontinence where there is an obstruction to outflow.

Epidemiology

15-30% of women over the age of 30 report some symptoms of urinary incontinence. A study in primary care sites across Britain showed that 21% had had stress incontinence, 3.5% urge incontinence and 21% mixed. 9% reported moderate or severe symptoms. 53% had not consulted a medical professional concerning the problem and of the 9% with moderate or severe symptoms, still only half had sought help. There are 3.5 million (men and women) suffering with incontinence in the UK.

Risk Factors

For women with urinary incontinence:

• Vaginal delivery
• Increasing age

Caesarean section was protective. Forceps and babies >4kg had not effect. Evidence on other obstetric risk factors is contradictory.

For all urinary incontinence:

• Cognitive disease
• Obstruction

Pathophysiology

Usually, there is no specific cause. However, the following are possible causes which need to be ruled out:

• Prolapse
• UTI
• Detrusor overactivity

Clinical Features

In terms of the history, these are areas you should ask about:

• Length of time with condition
• Cause of the loss of urine, e.g.:
  • On exertion
  • Coughing/sneezing/laughing
  • Functional (cannot reach toilet)
  • Walking/when getting out of bed and feet touch the floor
• Amount - small or large
• Nocturia - if so, number of episodes in a night
• Effect on quality of life: pads, restriction of fluids
• Obstetric history - particularly vaginal deliveries and instrumental devliery.

An abdominal examination and Sim's speculum examination (to rule out prolapse) are required.

Investigations

A woman should keep a bladder diary for 3 days over a mixture of working and resting days. MSU for microscropy, culture, sensitivity, glucose, albumin and blood.

Urodynamics (which includes filling cystometry) is used when the diagnosis is unclear or needs to be confirmed for potential surgery. This measures flow rate and the pressure during micturition. The test can differentiate between types of incontinence but also diagnose detrusor inactivity.

If there is a clear diagnosis of stress incontinence or it is urge/mixed incontinence but is to be managed conservatively, urodynamics is unecessary.

Other investigative issues

Findings suggesting malignancy:

• Haematuria which is
  • frank
  • micrscopic at >50 years old
  • caused by recurrent UTI >40 years old
• Suspected malignant mass of urinary tract.

Management

Conservative

• Pelvic floor exercises for 3 months
• Bladder training for 6 weeks
• Weight loss if BMI <30
• In OAB, caffeine reduction may help

Medical

Oxybutinin, an anticholinergic, is recommended by NICE as a first-line treatment. It reduces muscle spasm in the bladder. Other alternatives are darifenacin, solifenacin, tolterodine and trospium which are all also anticholinergics.

Desmopressin can be used to reduce nocturia in OAB.

Surgical

See prolapse for surgical techniques if prolapse is in fact the cause. Retropubic mid-urethral tape procedures can be used to treat stress incontinence if conservative measures fail. Colposuspension and autologous rectus fascial sling are also alternatives.