Case Files 1 - Incontinence

Front 1

When a woman presents with urinary incontinence and all tests for UTI are negative, what is the next best step?

Back 1

Evaluate the incontinence including Cystometric exam to discern the etiology

Front 2

What is the best INITIAL treatment for urge incontinence?

Back 2

Anticholinergic meds

Front 3

What is the Cystometric exam able to do?

Back 3

Discern between STRESS and URGE incontinence.

Front 4

What would make you unable to diagnose GENUINE stress urinary incontinence definitively?

Back 4

-Time gap between valsalva and leakage
-URGE symptoms

Front 5

What would a past medical history of DIABETES or NEUROPATHY lead you to think of?

Back 5

OVERFLOW incontinence

Front 6

What are 2 findings that would lead you to suspect pelvic relaxation and GSUI?

Back 6

-Cystocele
-Increased Urethral-Bladder angle

Front 7

What is the anatomic defect in GSUI?

Back 7

The BLADDER NECK is below the abdominal cavity.

Front 8

What test would you order to differentiate between GSUI and Urge incontinence?

Back 8

Cystometrics

Front 9

Why is it important to distinguish the 2 entities?

Back 9

The therapies are very DIFFERENT and surgery can actually make URGE incontinence WORSE.

Front 10

If a patient's history and PE were consistent with pure GSUI, would you order cystometrics?

Back 10

NO - just order a Burch urethropexy automatically.

Front 11

What IS GSUI by definition then?

Back 11

Sudden leakage of urine through the urethra upon increased intrabdominal pressure, in the ABSENCE of bladder muscle spasm

Front 12

What is URGE incontinence by definition?

Back 12

Leakage of urine due to strong, uninhibited detrussor contraction.

Front 13

What is OVERFLOW incontinence?

Back 13

Overdistention of the bladder due to hypotonia and absence of detrusor CTX; leads to overflow leakage of urine.

Front 14

What are 3 conditions often associated with overflow incontinence?

Back 14

-Diabetes mellitus
-Spinal cord injuries
-Lower motor neuropathies

Front 15

What can cause overflow incontinence s/p pelvic surgeries?

Back 15

Urethral edema

Front 16

What is entailed in Cystometric evaluation?

Back 16

Measurement of volume and pressure changes within the bladder with the filling of known volumes.

Front 17

How is urinary continence normally maintained?

Back 17

Urethral pressure exceeds intravesicular (bladder) pressure.

Front 18

Where is the normal location of the bladder and proximal urethra?

Back 18

Intra-abdominal - above the pelvic diaphragm.

Front 19

What happens during Valsalva normally?

Back 19

Pressure is distributed to the bladder and proximal urethra equally, and bc urethral pressure normally exceeds vesicular, urine is not lost.

Front 20

What happens when the prox urethra slips below the pelvic diaphragm due to relaxation and Valsalva occurs?

Back 20

Now just the bladder squeezes, not the urethral sphincter; so urine leaks.

Front 21

What can CAUSE pelvic relaxation?

Back 21

-Trauma
-Childbearing

Front 22

When does urine loss in GSUI occur wrt the valsalva?

Back 22

Simultaneously - without delay.

Front 23

What surgical procedure is done to fix GSUI due to pelvic relaxation?

Back 23

Burch urethropexy

Front 24

What is the Burch urethropexy?

Back 24

Replacement of the proximal urethra back into its intra-abdominal position.

Front 25

What is done in TVT procedures?

Back 25

Strips of tape suspend the MIDurethra

Front 26

What is the theoretical basis for doing a TVT?

Back 26

That urinary incontinence is due to Pubo-urethral ligament insufficiency

Front 27

What is the mechanism of OVERFLOW incontinence?

Back 27

Bladder hypotonia leads to overfilling and distention; upon valsalva, dribbling occurs.

Front 28

What are common causes of Overflow incontinence?

Back 28

Neuropathy
Diabetes
Spinal cord injury

Front 29

What is the diagnostic test for Overflow incontinence?

Back 29

Postvoid residual volume shows large amts (by catheterization)

Front 30

What is the TREATMENT for overflow incontinence?

Back 30

Self-catheterization

Front 31

What is the mechanism of URGE incontinence?

Back 31

Overactive bladder is contracting at random times; uninhibited; so you get this huge urge to pee.

Front 32

When does URGE incontinence occur wrt valsalva?

Back 32

DELAYED

Front 33

Common complaint in patients with URGE incontinence:

Back 33

I have to go and can't make it to the bathroom

Front 34

What is the diagnostic test for Urge incontinence?

Back 34

Cystometric exam - shows uninhibited bladder spasms.

Front 35

What is the treatment for Urge incontinence?

Back 35

Anticholinergic meds

Front 36

So what are the 4 pieces of info you should get in the INITIAL eval of incontinence?

Back 36

-History
-Physical exam
-Urinalysis/culture
-Postvoid residual volume

Front 37

What is the first line of treatment for incontinence?

Back 37

BEHAVIORAL
-Timed voiding
-Pelvic muscle exercises

Front 38

What is the anticholinergic med that is used for treating Urge incontinence?

Back 38

Oxybutynin

Front 39

What is Oxybutynin aka?

Back 39

Ditropan

Front 40

What would you suspect in a patient that complains of constant leakage or urine from the vagina after surgery or prolonged labor?

Back 40

Vesicovaginal fistula

Front 41

What is the diagnostic test for Vesicovaginal fistula?

Back 41

Dye in the bladder shows discoloration of something inserted in the vagina.

Front 42

What is the treatment for a vesicovaginal fistula?

Back 42

Surgical repair

Front 43

And when do vesicovaginal fistulas most often develop?

Back 43

Following prolonged labor or pelvic surgery.