Medical Archive

Physiology of Micturition

Normal urethral closure

The bladder

Innervation

Micturition

Normal postvoid residual volume
<150mL in women
<50mL in men

Urinary Incontinence

Definitions

Types of disorders

Stress urinary incontinence (SUI)

• Pathophysiology
  • Leakage due to abdominal pressure
  • Weakening of pelvic floor muscles ? urethral hypermobility (urethra abnormally moves with increased ?abdominal pressure
  • Urogenital mucosal atrophy from decreased estrogen levels.
  • Stretch injury to the pudendal nerve (main sensory nerve of the pelvis, voluntary contraction of external urethral sphincter)
• Diagnosis
  • ??
  • Q-tip test; ? vesicourethral angle
  • ????, ???? (??? ??? ??)
• Treatment
  1. Kegel exercise (?????? ??)
  2. Drug therapy
     1. Alpha adrenergics
     2. TCA (imipramine): detrusor ?? ??.
     3. Estrogen (?? ?)
  3. Midurethral sling
  4. Electrical stimulation
  5. Tension free tapes (TVT, TOT)
• Postpartum SUI
  • In the immediate postpartum period (ie, <6 weeks after delivery) are managed with observation and reassurance (typically self-limited)

Urgency urinary incontinence and overactive bladder

Diagnostic w/u

• ?????? using cystometrogram
• ??? >50mL

• Treatment
  1. Behavioral Tx
     • ?? ?? – resisting the urge
  2. Anticholinergics
     • eg, Oxybutynin
     • Relaxes the detrusor muscle and reduces spasm
  3. ?3 adrenergic agonist
     • eg, Mirabegron
     • Relaxes the detrusor muscle. Can be offered to patients who cannot take antimuscarinic drugs.
  4. Functional electrical stimulation

Mixed incontinence

• Evaluation
  • Voiding diary: in order to classify the predominant type and determine optimal treatment
• Treatment
  • Bladder training & lifestyle change

Functional and transient incontinence

Extraurethral incontinence

Fistula 

• Causes of fistula
  • After Gynecologic surgery (75%) : 7-10days after TAH
  • 18 month after Radiation
  • M/c type: vesicovaginal
• Diagnosis
  • Vesicovaginal filstula: ?? cotton tampon ??, transurethral cath. ? ??? ???? tampon? ?????? ??.
  • Ureterovaginal fistula: IV indigocarmine ? ? ? tampon?? ????? ??? ?? ?? ? ??? methylene blue??? ??? ???? ??.
• Treatment
  • Foley cath. ???? drain. 15%? 4-6? ? ?? ??.
  • ?? ??? ?? ?? ???? ? ?? ?? 3-4?? ??? ? ??
  • ??? ?? ???? ??? ???? ?????!
• ? ????? 5~10%?? ????. ??? CT urogram, ???? ??. IVP? ??.

Nocturia

Risk factors for urinary incontinence

Cystourethrocele indicates urethral hyper motility -> stress incontinence.

Initial evaluation

History
QOL measures
Physical examination

Simple(primary care level) tests

Voiding diary
Urinalysis
Postvoid residual volume
Cough stress test
Pad tests

Advanced testing

• Urodynamics
  • For patients with complicated urinary incontinence (ie, those who do not respond to treatment)
• Imaging tests
• Neurophysiologic tests

Nonsurgical treatment

Lifestyle changes
Physical therapy
Behavioraltherapy and bladder training
Vaginal and urethral devices
Medications

Surgical treatment for stress incontinence

Historical Perspective
Retropubic Urethropexy (Colposuspension)
Traditional Pubovaginal Sling
Minimally Invasive Sling
Bulking Agents
Complications

Procedures for urgency urinary incontinence

Neuromodulation
Botox Injections
Augmentation Cystoplasty and Urinary Diversion

Surgical treatment of fistulae

Cystoscopy

Voiding Dysfunction and Bladder Pain Syndromes

Voiding dysfunction

Causes
Evaluation
Treatment

• Treatment of overflow incontinence
  • Cholinergic agents (eg, bethanechol)
  • If severe, intermittent self-catheterization or indwelling catheter.

Bladder Pain Syndromes

Terminology and prevalence
Diagnosis
Treatment