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43 Cards in this Set
- Front
- Back
When a woman presents with urinary incontinence and all tests for UTI are negative, what is the next best step?
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Evaluate the incontinence including Cystometric exam to discern the etiology
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What is the best INITIAL treatment for urge incontinence?
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Anticholinergic meds
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What is the Cystometric exam able to do?
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Discern between STRESS and URGE incontinence.
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What would make you unable to diagnose GENUINE stress urinary incontinence definitively?
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-Time gap between valsalva and leakage
-URGE symptoms |
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What would a past medical history of DIABETES or NEUROPATHY lead you to think of?
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OVERFLOW incontinence
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What are 2 findings that would lead you to suspect pelvic relaxation and GSUI?
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-Cystocele
-Increased Urethral-Bladder angle |
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What is the anatomic defect in GSUI?
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The BLADDER NECK is below the abdominal cavity.
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What test would you order to differentiate between GSUI and Urge incontinence?
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Cystometrics
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Why is it important to distinguish the 2 entities?
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The therapies are very DIFFERENT and surgery can actually make URGE incontinence WORSE.
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If a patient's history and PE were consistent with pure GSUI, would you order cystometrics?
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NO - just order a Burch urethropexy automatically.
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What IS GSUI by definition then?
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Sudden leakage of urine through the urethra upon increased intrabdominal pressure, in the ABSENCE of bladder muscle spasm
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What is URGE incontinence by definition?
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Leakage of urine due to strong, uninhibited detrussor contraction.
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What is OVERFLOW incontinence?
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Overdistention of the bladder due to hypotonia and absence of detrusor CTX; leads to overflow leakage of urine.
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What are 3 conditions often associated with overflow incontinence?
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-Diabetes mellitus
-Spinal cord injuries -Lower motor neuropathies |
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What can cause overflow incontinence s/p pelvic surgeries?
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Urethral edema
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What is entailed in Cystometric evaluation?
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Measurement of volume and pressure changes within the bladder with the filling of known volumes.
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How is urinary continence normally maintained?
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Urethral pressure exceeds intravesicular (bladder) pressure.
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Where is the normal location of the bladder and proximal urethra?
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Intra-abdominal - above the pelvic diaphragm.
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What happens during Valsalva normally?
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Pressure is distributed to the bladder and proximal urethra equally, and bc urethral pressure normally exceeds vesicular, urine is not lost.
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What happens when the prox urethra slips below the pelvic diaphragm due to relaxation and Valsalva occurs?
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Now just the bladder squeezes, not the urethral sphincter; so urine leaks.
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What can CAUSE pelvic relaxation?
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-Trauma
-Childbearing |
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When does urine loss in GSUI occur wrt the valsalva?
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Simultaneously - without delay.
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What surgical procedure is done to fix GSUI due to pelvic relaxation?
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Burch urethropexy
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What is the Burch urethropexy?
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Replacement of the proximal urethra back into its intra-abdominal position.
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What is done in TVT procedures?
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Strips of tape suspend the MIDurethra
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What is the theoretical basis for doing a TVT?
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That urinary incontinence is due to Pubo-urethral ligament insufficiency
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What is the mechanism of OVERFLOW incontinence?
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Bladder hypotonia leads to overfilling and distention; upon valsalva, dribbling occurs.
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What are common causes of Overflow incontinence?
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Neuropathy
Diabetes Spinal cord injury |
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What is the diagnostic test for Overflow incontinence?
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Postvoid residual volume shows large amts (by catheterization)
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What is the TREATMENT for overflow incontinence?
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Self-catheterization
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What is the mechanism of URGE incontinence?
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Overactive bladder is contracting at random times; uninhibited; so you get this huge urge to pee.
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When does URGE incontinence occur wrt valsalva?
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DELAYED
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Common complaint in patients with URGE incontinence:
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I have to go and can't make it to the bathroom
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What is the diagnostic test for Urge incontinence?
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Cystometric exam - shows uninhibited bladder spasms.
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What is the treatment for Urge incontinence?
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Anticholinergic meds
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So what are the 4 pieces of info you should get in the INITIAL eval of incontinence?
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-History
-Physical exam -Urinalysis/culture -Postvoid residual volume |
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What is the first line of treatment for incontinence?
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BEHAVIORAL
-Timed voiding -Pelvic muscle exercises |
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What is the anticholinergic med that is used for treating Urge incontinence?
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Oxybutynin
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What is Oxybutynin aka?
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Ditropan
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What would you suspect in a patient that complains of constant leakage or urine from the vagina after surgery or prolonged labor?
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Vesicovaginal fistula
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What is the diagnostic test for Vesicovaginal fistula?
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Dye in the bladder shows discoloration of something inserted in the vagina.
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What is the treatment for a vesicovaginal fistula?
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Surgical repair
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And when do vesicovaginal fistulas most often develop?
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Following prolonged labor or pelvic surgery.
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