TEALE FENNING

Nick Raine-Fenning

A 44-year woman undergoes urodynamic studies and is shown to have stress incontinence.

Outline the principles of urodynamics and how this diagnosis is made. (6 marks)

What are the non-surgical management options? (6 marks)

What are the surgical options? (8 marks)
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

my answer is ....

What I know -------

44 yrs old
UDS done
USI confirmed

What I don’t know -------

QOL issues
Symptoms – stress / urge / mixed
Assoc ano-rectal symp,
Comorbidities – constipation, cough, COPD
Treatments tried and successes with these
Obst h/o
Surg h/o
Medications – anti depressants, diuretics
Life style issues – coffee, alc,

Concept – understanding of USI, investigations, and treatment

Intro/ importance ----- common, underreported, chronic, no 100% cure available, psychosocial and sexual morbidity, great impact on QOL, cost implications

Bubble 1.

UDS – factual bubble.
It’s indication and use is controversial, views that not required pre op in presence of leak on stress with no symptoms of incomplete voiding or urge.

Where there is overlap in symptoms it provides accurate diagnosis, may predict cases that will have post op voiding difficulties.

USI is noted during filling cystometry and is defined as the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction.

Diagnosis bubble –

History –

Age
Symptoms – leak on cough/sneezing, positional?, associated mixed picture,
Chronic cough / constipation
Medications – diuretics = will worsen, antidepressants = care with duloxetine and amytryptaline for nocturia
Life style --- fluid intake, voiding frequency= long gaps, smoking, continence pads etc
Obstetric trauma
Menopausal – oe depletion
Prolapse – can ppt it also for mixed picture
Rx tried so far and their effects

Examination –

Gen – fitness for op
BMI – obesity is risk factor for GSI + complication with op
Chest – COPD
Abdo – masses, scars
Local vulva – excoriation, oedema, erythema = severity of leak,
Ps – prolapse
Ve, masses, prolapse, pelvic floor assessment
Cough = leak , confirms
Bonney’s test = full bladder leak documented, ve to support urethra stops leak.
PR if associated anoreactal symp

Investigations

Urine – infection
Fbc – preop investigation
CXR – chest symp
Freq – vol charts
USS – abdo masses, bladder vol
Video cystometry = funnelling of urethra, can be done as a part of UDS
UDS

Bubble 2—

Non Sx options

Medical =
duloxetine,
amitryptaline

Conservative =
pelvic floor exercises with or with out cones
if mixed - faradic stim, bio feed back
urethral plugs
urethral vaginal ring pessary
tampons

others=
fluid intake modification
change medication
avoid coffee/tea/alc
voiding – bladder training, avoid getting over full.

Bubble 3 –

Surgical

TVT/ TVTO / Mini TVT – newer, less complications, comparable to burch, long term effects still unclear,

Burch = gold std, good as both 1st line and rpt procedure

Needle suspensions = poor long term, need to rpt

Ant repair = 60% short term, pri for cystocoele not for USI, may worsen stress incontinence rarely.

Urethral bulking = good short term , in debilitated pts, can be repeated

Artificial sphincter= in very selected cases, research potential, high complication rate and morbidity.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Nick Raine-Fenning · Posted: Fri Mar 02, 2007 11:52 am Post subject:

Nice answer Raj and well bubbled Wink

I like the way you have tackled the second and third stems but you have gone into too much detail and lost your focus in section one.

The first part is really asking for a description of UDs - what is involved etc and then to define USI which afterall is how it is diagnosed.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

The Question says that she is diagnosed with stress incontinence already to save you from asking all about how many babies and how big they were! It's there already!

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I therefore think that for the first stem all you need to say is that:
UDS are indicated for women with mixed urinary symptomps or for those with failed treatments
They are laboratory tests trying to mimic physiological conditions and therefore they are liable to bias
They are performed by measuring the intraabdominal and intravescical pressures during the filling and voiding phases, providing valuable informations about bladder capacity, detrusor stability, stress incontinence, flow rates and residual volume.
The findings shouls always be interprated in relation to the patients symptomps.
The diagnosis of stress incontinence is made by evidence of involuntary loss of urine during increase of intraabdominal pressure in the abscense of detrusor contraction.

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

And now you have plenty of time to develop your second and third stem which you have done nicely. I although disagree about amitryptiline which is treatment for enurisis, not for USI. (again waste of time)
Also cones ant tampons are rarely used now days. What they really want to read is Physiotherapy (taught by appropriate physiotherapist), restriction in fluid intake to 1-1.5 litres a day, weight loss if applicable, stop smoking (always good...) and duloxetine (good results, not liscenced, second line Tx but good idea for young with uncompleted families or the very frail, side effects). Bang!

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Oh I also liked the modification of medications (diuretics etc).
Advice to use proper pads may score as well! (or may not..)

Nick Raine-Fenning · Posted: Fri Mar 02, 2007 3:39 pm Post subject:

I think you are right wolverine and this shows how important it is to read the question fully.

However, Raj's bubbling for parts 2 and 3 got her loads of good points (and we know what points translate into = prizes i.e. marks).

You have actually hit the nail on the head regarding part 1 and the word principles. We have discussed this on several courses now when we have gone through the last exam and the retained placenta question which contained the same word.

"Principles" asks for you to discuss the operation / process / procedure and to outline the indications, advantages and risks, consent issues and so on.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

bubble 1 --- oophs!!!!
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Abik · Posted: Sat Mar 03, 2007 10:13 am Post subject:

Principles of UDS;

Process;
Measurement of detrusor pressure with intravesical pressure catheter and intra-abdominal pressure catheter (actual positioning is rectum due to access) IAP - IVP = detrusor pressure.
Measure during filling and voiding to look for overactivity of detrusor muscle. Also can incorporate flowmetry and residual measuring to assess voiding function.

Indications;
OAB symptoms non-responsive to bladder drilling and empirical treatment with anti-muscarinics. (Pure OAB or mixed symptoms)
Any symptoms of voiding dysfunction.
Stress incontinence as a symptom which has not responded to treatment.

Results allow diagnosis of OAB syndrome, non-compliant bladder, voiding dysfunction, USI and can be helpful in planning treatment and counselling for risks of surgery (eg worsening of OAB, or voiding dysfunction)
Risks of infection therefore MSU first and dipstick on the day. Consent not a big issue.

Anything else?

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

It's IVP- IAP=detrusor I think. Otherwise I'll give you 6 marks

Abik · Posted: Sat Mar 03, 2007 11:06 am Post subject:

Could you mark my essays for me in the exam Wolverine - much more generous than your marker (SF!)
Laughing

Nick Raine-Fenning · Posted: Sat Mar 03, 2007 12:10 pm Post subject:

Abik · Posted: Sun Mar 04, 2007 10:14 am Post subject:

Yes - brilliant, thanks Nick!

sens/spec for UDS? - crap?
anyone know?

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I don't know the exact figures but is definetely higher than the 60-65% of the clinical examination

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

i think the values are as follows -----

stress incontinence -- sensitivity 60-70% and specificity is more than 80%

urge incontinence 50 - 60% and around 90%

for mixed incontinence 80-85% and 60-70%

i have these values written at the back of my book, can't remember where they are from.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Abik · Posted: Sun Mar 04, 2007 11:41 am Post subject:

Tell me - diagnosis of stress incontinence by UDS is just seeing them leak?

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Correct! But don't go very close! Laughing

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

diagnosis is

1. filling phase = ask to cough,

leak with no detrusor activity

2. if video component in use = watch funneling of the bladder neck = USI with bladder neck hpermobility + all imp leak with out det contraction

depends on which set up u have.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Abik · Posted: Sun Mar 04, 2007 2:08 pm Post subject:

when is video-urodynamics used?