Disorders of the Urinary Tract

Question 1

What occurs if there is increased uncontrolled detrusor pressure?

Answer 1

• Increases Bladder pressure beyond normal urethra → incontinence
• Most common cause: ‘Overactive bladder’ (OAB) AKA urinary urge incontinence (prev. called detrusor instability)

Question 2

What occurs if there is increased intra-abdominal pressure?

Answer 2

• Transmitted to bladder but not urethra, because upper urethra neck no longer in abdomen
• Bladder pressure > urethral pressure when → abdominal pressure e.g. coughing
• Most common cause: ‘Urinary stress incontinence’

Question 3

What are some rare causes of urinary incontinence?

Answer 3

Urine bypassing sphincter through fistula

Pressure of urine overwhelming the sphincter due to overfilling of bladder - neurogenic or outlet obstruction = Outflow Incontinence

Question 4

Define daytime frequency.

Answer 4

Number of voids during waking hours
Normally 4-7x daily
Defined as when patient perceives number of voids as too often

Question 5

Define nocturia.

Answer 5

Waking at night >1 time to void in those under 70

Question 6

Define urgency.

Answer 6

Sudden compelling desire to pass urine, which is difficult to defer
Most frequently secondary to detrusor overactivity
Inflammatory bladder conditions e.g. interstitial cystitis may present with urgency

Question 7

What are the investigations of the urinary tract?

Answer 7

• Urine dipstick
• Urinary diary
• Post-micturition USS or catheterisation - exclude chronic urine retention
• Urodynamic studies (cystometry)
• Ultrasonography - exclude incomplete emptying, also checks for congenital abnormalities, calculi, tumours and detects cortical scarring of kidneys
• Abdominal XR - foreign bodies and calculi
• CT urograms - integrity and route of ureter with contrast
• Methylene dye test - o Blue dye instilled into bladder
  o Leakage from places other than the urethra seen e.g. fistulae
• Cystoscopy - inspection of bladder cavity - exclude tumours, stones, fistulae and interstitial cystitis

Question 8

What is this cystometry showing?

Answer 8

Question 9

What are these showing?

Answer 9

Question 10

Define urinary stress incontinence.

Answer 10

Involuntary leakage of urine on effort or exertion, or on sneezing/coughing

Question 11

What are the risk factors of stress incontinence?

Answer 11

• Increasing age.
• Pregnancy and vaginal delivery — muscles and connective tissue can be weakened during delivery, and damage may occur to pudendal and pelvic nerves.
• Obesity — due to pressure on pelvic tissues and stretching and weakening of muscles and nerves from excess weight.
• Constipation — straining may weaken pelvic floor muscles.
• A deficiency in supporting tissues for example:
  
  • Prolapse — not a cause of stress urinary incontinence but may be caused by the same underlying deficiency of supporting tissues.
  • Hysterectomy — surgery may damage the pelvic floor muscles.
  • Lack of oestrogen at the menopause — oestrogens keep tissues that influence normal pressure transmission in the urethra healthy and maintain urethral secretions that help to create a ‘seal’.
• Family history — women whose mother or sisters are incontinent are more likely to develop stress urinary incontinence.
• Smoking — smoking is associated with chronic cough which may contribute to stress urinary incontinence.
• Drugs — for example angiotensin-converting enzyme (ACE) inhibitors (can cause cough and worsen stress incontinence).

Question 12

Describe the mechanism of stress urinary incontinence?

Answer 12

Increased Intra-adbominal pressure → compression of bladder → Increased bladder pressure → bladder > urethral pressure → incontinence

Question 13

What should you assess in stress urinary incontinence?

Answer 13

o Assess how life is disrupted
o Stress incontinence = major symptom
o Frequency, urgency or urge incontinence may also occur

o Faecal incontinence due to childbirth injury may coexist

Question 14

How should you investigate stress urinary incontinence?

Answer 14

• Urine testing → UTI
• Assessing residual urine - post micturition USS
• Urinary diary: frequent passage of small volumes of urine particularly at night
• Cystometry: demonstrates contractions on filling or provocation with detrusor overactivity

Question 15

How should we manage stress urinary incontinence?

Answer 15

• Note = stress incontinence is due to pelvic floor weakness / intrinsic sphincter deficiency
• Conservative:
  
  • avoid caffeinated drinks,
  • avoid drinking either excessive/reduced amounts of fluids daily,
  • weight loss if BMI > 30kg/m2
  • smoking cessation if applicable
  • Provide info on NHS.uk website
• 1st line: Offer referral for Pelvic floor muscle training to appropriate practitioner
  
  • Supervised training involving least 8 contractions performed 3 times per day for a minimum of 3 months
• 2nd line: Surgical procedures (only initiated by 2° services)
  
  • Colposuspension - sutures are used to lift the neck of the bladder and fix in place to Cooper’s ligaments
  • Autologous rectus fascial sling - elevate the urethra
  • Retropubic mid-urethral mesh sling - elevate the urethra
  • Intramural urethral bulking agents - injection of a bulking agent around the urethra
• 3rd line: Duloxetine (enhances sphincter contraction) then r/v in 2-4 weeks if unsuitable for surgery/prefer pharmacological to surgical Rx
  
  • SNRI - Enhances urethral striated sphincter activity via centrally mediated pathway

Question 16

Define overactive bladder syndrome. What causes it?

Answer 16

OAB is defined as urgency, with or without urge incontinence, usually with frequency or nocturia, in absence of proven infection

• Symptom combinations are suggestive of detrusor overactivity
• Can be due to other form of urinary tract dysfunction. It is a urodynamic diagnosis for the former and characterised by involuntary detrusor contractions during the filling phase (either spontaneous or provoked for instance coughing)

Question 17

Define urgency urinary incontinence.

Answer 17

Involuntary leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine which is difficult to defer (urgency). UUI is part of a larger symptom complex known as overactive bladder (OAB) syndrome

Question 18

Describe the aetiology of overactive bladder syndrome.

Answer 18

• Idiopathic in most women
  
  • In some cases, it can be associated with systemic neurological conditions such as Parkinson’s disease, multiple sclerosis, or injury to pelvic or spinal nerves
  • Comorbidities such as obesity, type 2 diabetes, and chronic urinary tract infection can increase urgency symptoms.
• In addition, the adverse effects of some drugs may also cause detrusor overactivity, such as parasympathomimetics, antidepressants, and hormone replacement
• Diuretics can also increase urinary frequency
• Urinary urgency can be exacerbated by caffeinated, acidic, or alcoholic drinks

Question 19

How does overactive bladder syndrome present?

Answer 19

o Urgency and urge incontinence

o Frequency and nocturia
o Leak at night or at orgasm
o Hx childhood enuresis

o Faecal urgency

Question 20

What are the investigations for overactive badder syndrome

Answer 20

• Urine testing
• Post-void residual urine volume
• Urinary diary: frequent passage of small volumes of urine particularly at night for 3 days
• Cystometry: demonstrates contractions on filling or provocation with detrusor overactivity
• DDx
  
  • Urinary infection
  • Bladder pathology
  • Pelvic mass compressing the bladder

Question 21

What is the management of urge incontinence?

Answer 21

• Conservative:
  
  • avoid caffeinated drinks,
  • avoid drinking either excessive/reduced amounts of fluids daily
  • weight loss if BMI > 30kg/m2
  • Self help on NHS website
• 1st Line: Bladder retraining for 6 weeks
  
  • Aim is to gradually increase the intervals between voiding
  • This may be available from the local continence nurse, continence physiotherapist, or urology clinic.
• 2nd Line: Continue bladder training and add Bladder stabilising drugs - antimuscarinics
  
  • NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation).
  • Immediate release oxybutynin should, however, be avoided in ‘frail older women’
• 3rd Line: Mirabegron (beta-3 agonist)
  
  • May be useful if there is concern about anticholinergic side-effects in frail elderly patients
• Before starting meds explain:
  
  • that it may take time to work (at least 4 weeks) and symptoms may continue to improve.
  • Likely adverse effects: (such as dry mouth and constipation) may indicate that anticholinergic medicine is starting to work.
  • Review 4 weeks later, if works 12 mostly review
• 4th Line: Referral to secondary care - Surgical Procedures
  
  • Botox injection
    
    • Percutaneous tibial nerve stimulation (PTNS) or sacral nerve stimulation (SNS)

Question 22

When would you consider the 2 week referral in response to incontinence?

Answer 22

• Refer urgently (within 2 weeks) using a suspected cancer pathway referral for bladder cancer if the woman:
  
  • Is aged 45 years and over with:
    
    • Unexplained visible haematuria without urinary tract infection, or
    • Visible haematuria that is persistent or recurrent after successful treatment of urinary tract infection, or
  • Is aged 60 and over with unexplained non-visible haematuria and dysuria or a raised white cell count on a blood test.

Question 23

Define mixed incontinence.

Answer 23

Mixed incontinence: both urge and stress

o Overflow incontinence: can be due to detrusor underactivity or bladder outlet obstruction causing urinary retention and leakage of urine

o Continuous: can either indicate severity or due to a fistula

Treat the most predominant type.

Question 24

Define acute urinary retention.

Answer 24

Unable to pass urine for 12h or more

Question 25

What causes acute urinary retention?

Answer 25

o Childbirth
o Perineal or vulval pain
o Surgery
o Anticholinergics
o Retroverted gravid uterus
o Pelvic passes
o Neurological disease (e.g.MS or CVA)

Question 26

How should you initially manage acute urinary retention?

Answer 26

 Catheterisation → as much or more urine than normal bladder

 48h catheterisation whilst cause is treated

Question 27

What causes chronic retention and urinary outflow?

Answer 27

Bladder overdistension → overflow

o Urethral obstruction

o Detrusor inactivity

Question 28

How do patients with chronic retention present? How should it be diagnosed and treated?

Answer 28

• Presentation may mimic stress incontinence or urinary loss may be continuous
• Examination: distended, non-tender bladder
• Diagnosis confirmed by ultrasound or catheterisation after micturition Intermittent self-catheterisation is commonly required

Question 29

define painful bladder syndrome. How does it present and diagnosed? How is it managed?

Answer 29

 Suprapubic pain related to bladder filling

 Other sx include frequency in absence of UTI

 Diagnosis confined to patient with painful bladder symptoms and characteristic cystoscopic and histological features

 Aetiology unknown

 Tx

o Dietary changes

o Bladder training

o TCAs
o Analgesics

o Intravesical infusion of various drugs

Question 30

What are fistulae? What are the most common types? How is it investigated and managed?