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Hi, everyone. I'm just gonna give it a couple of minutes. So that wrong conjoined, and then we'll go ahead and start, right. So I think we'll go ahead and start then. So, um, thank you. Have room for joining us again today for one of our from the urologist sessions with Mind The bleep today's subjects gonna be You're on urinary incontinence and it's going to be presented by sin. And so let him introduce himself in a second. But I'm gonna be keeping my eye on the chat box store of the session. So if anyone has any questions or anything, feel free to drop about the drop in the box, and I'll be happy to relate them to send an to go ahead exact. So, uh, my name is Seneca Dorrie. I'm a uro gyn registrar in Abdeen Rolling Family Onda. I'll be doing a quick whistle stop tour through urinary incontinence today. So and the objectives of the stalk is to go through the classification of your incontinence. Um, look a briefly. The cause is of urine incontinence. How we evaluate patients with incontinence on what the various treatments el. So we're going to go through those. So to start with classification, I'm sure you'll have heard of some of these. At least the most common classifications are stress. Urinary incontinence on urgency or urgent continence stress. Incontinence is the involuntary urinary leakage on effort. Exertion, sneezing or coughing. Herget see incontinence and urge incontinence is leakage accompanied by our immediately proceeded by urgency. You can course get a mixture of those two, and that's called mixed urinary incontinence. There are other types of incontinence is, well, there's overflow incontinence that's typically seen in people with a full bladder on urine overflows out of the urethra On this is typically in men with chronic retention, but can also happen in women. Nocturnal enuresis is incontinent of urine occurring during sleep. Often the person is unaware of this and will wake up in a pool of urine on. This tends to happen in men with chronic high pressure retention. It's a big, telltale sign sign of that, Um, and then you can have, um, post micturition dribble, which is also kind of incontinence. This's happened test happen in people with benign in large prostates that have outflow obstruction. Uh, so what are the causes off urine retention where we can think of them with regards to bladder abnormalities on your throne. Strict abnormalities. So the bladder is a muscle. It stores urine, but it's a muscle eso If that muscle is overactive, then it can cause incontinence. Um, or if the bladder has a low compliance, compliance is basically the ability off the bladder to stretch on accommodate urine. So if if the compliance is poor or low, then it can't stretch and accommodate urine as well. So it will. It will leak. Um, and then we can think of urethral and spincter abnormalities. So if the urethra is hoping mobile so typically in ladies with pelvic with week, tell the floor after, you know, multiple vaginal deliveries. Um, Andi, you can have an intrinsic sphincter deficiency. So the sphincter itself is deficient and doesn't close shut. So you get incontinence. So those are the two kind of broad that causes in terms of what you need to do if you, uh, Clarkin or meet a patient with the contents, like with anything, you take a history. So you're assess what type of incontinence it is based on the classifications we've just gone through. So you ask things like, you know, Does it leak? When you cough sneeze, do you get any urgency associated with it? Lutzes Lower urinary tract symptoms. So any other symptoms that are associated with it frequency on, but also how severe your symptoms are? Um, there are certain risk factors that you should ask which contribute to incontinence. So grader therapy, as you know radiotherapy to any tissue, makes it slowly stiff on fibrotic, so that can affect both the bladder, but also the sphincter. Because it doesn't it loses that elasticity and it can't close shut fully. Um, obviously neurological disorders. If the nerves are talking to the bladder or the sphincter, then they won't be doing their job properly. Obstetrics and gynecology history For the reasons I've indicated earlier, especially regarding spontaneous vaginal deliveries, any complications such as tears, etcetera Onda. Uh, obviously you need to ask about medications on so especially things like diuretics, um, which will cause our increase in urine output on that can exacerbate symptoms. Um, as with any condition, there are always red flags you need to ask about, um, incontinence with pain. Hematuria's any blood in the urine on recurrent you ties, they could all be associated with bladder cancer. Um, then there are some useful ways of assessing incontinence. There's a questionnaire called the I See I Q, which assesses specifically urinary incontinence. You can also ask the patient to keep a bladder diary. Um, so on the left here is 30 questionnaire, and it just goes through things like, How often do you leak urine, etcetera? Um, on then the blood. The diaries useful because you can assess, uh, usually are you give this to the patient, asked them to fill it. And, um, normally over three days on, you can assess sort of what, what their intake is, how much it is, what their output is on, what the pattern with when they drink fluids, especially things like coffee, caffeine in to drink so stupid are a stimulant. Um, so if you see a pattern where they're drinking, lots of you know, stimulants on bear peeing lots, then you can tell that that's associative. But also look at the amount they pee on. Then finally, what What makes a bladder diary different from a frequency volume chart is that you have this comment bit on the side where it talks about how urgent the need to void was at the time at what they were doing on gather, they leaked it all. So that's obviously very informed, informative carrying on with the evaluation After your history, you can examine the patient. So you're gonna do abdominal exam in ladies. It's more imperative to do a pelvic PBX, Sam. Um, on dimen, you're going to want to assess the prostate and do a digital rectal examination. It be good to get their body mass index So that heightened weight because high, high, high B m I r o B city, it's associated with incontinence. Um, a common test we do in clinic is the urinary flow rate, where you get the patient to pee in a bucket that measures your flow rate. You also measures the total volume they've peed on. Go over how long, And then after that, you can measure their post void residual to check if they empty their bladder. Uh, well enough. So you know, in somewhat in a man with bladder outflow obstruction, If they're not emptying their bladder and they're always a full capacity, then that's probably the reason they're leaking because they're always for, um the blood test might be helpful, especially in chronic retention to assess renal function. Uh, same indication for imaging on. Sometimes you'd want to, um, assess the bladder and the urethra with the cystoscopy. Urodynamics is a more invasive investigation that's safe for selected patients. Really? On what your A dynamic saw is it a test to assess the, uh, basically the dynamics of the bladder? So commonly, you put it, you pass a a wire catheter with a pressure transducer of the end into the bladder. Wanted to the rectum, the bladder one measures the detrusor pressure on the rectal. One measures intraabdominal pressure Onda through these, you can look at what's happening when the bladder fills. When the patient gets a sensation to pee, does the bladder twitch and is overactive on board? Does it stretch nicely and fill on? Then, uh, you know when when the patients ask to avoid What kind of pressures is the bladder? Is the detrusor muscle putting and how does that compare to that intractable pressure? So all these different, uh, data points you get from this test are very useful to to determine exactly what's going on and why they might have incontinence. So, um, moving on to treatment, uh, will talk about stress. Urinary incontinence festival. Um, as with as with anything, there's always a conservative treatment on. So we spoke about how, uh, this could be caused by week, Alec. Floor muscles. So you can do pelvic floor muscle training. Um, and that's sort of least eight contractions three times a day. You can also refer them to physical therapy for pelvic floor training. That's that's been shown to have slightly better outcomes. There are even devices that, um, you know, with all that absent things that we have devices that help you remember to do your pelvic girdle muscle training. Um uh, Septra eso that can be very effective by self and then stopping continents. Lifestyle modification is a huge thing. Weight loss, stop smoking void. Constipation on. Make sure your fluid intake is It's good, um, moving on from conservative treatment medication therapy. Duloxetine is the main treatment of choice for stress incontinence. Um, if that doesn't work on lifestyle measures haven't worked. Then you can consider sir surgical treatment. So there's a number of different options. Um, there are urethra bulking agents on. Basically, you just inject this bulking agent, which is an inert substance into the urethra. This is commonly for women who have a short urethra and leak. Um, basically, you you create a form of outflow obstruction because you you you, um, sort of a partially obliterate that urethra meatus. And that just helps you have sometimes incontinence, um, at your pubic suspension. You might have heard of this. It's comical that colpo suspension of vertical position pension is basically where you have, um, on operation to tie up the room on the round ligament, which just supports everything and stops the stops the urethra from being hyper mobil because of a week pellicle eso that sometimes helps urethra slings on artificial sphincters of a nice picture for both of these. So urethra, string and sling, You might have fun noticed. It was in the news a few years ago about all the litigation that was happening with this, but so it's It's slowly, um, out of date now used to be very common, but it's reserve select patients now, but basically you have a mesh which is inserted under urethra, and it just sort of hooks the urethra and supports it to stop licking. That's for women on in men, especially after prostatectomy cetera. You put in this artificial urethral sphincter, which, as you can see, is a sphincter. There's a pump that's that's in the in the test in the scrotum. Next the testicle, which you can deflate when you need to pee. Onda reinflate when you want to stay dry. On the other ball of the pelvis is Mr Reservoir Affair. They can come over there from when you want to deflate this thing. So this's kind of the extreme off incontinence management stress incontinence management. Um, Andi, it's It's both fairly major operations and have their own complication rates. Um, looking more it overactive bladder treatment. So this is more sort of urgency. Urge urgency, incontinence. Again, there's conservative treatment, so you can have you can advise the patient to train their bladder. Well, that means is when they get the urge to pee, tell them to try and hold it for a least another minute or two. Um, distract themselves with something else on Do. You can prolong that to five minutes and then 10 minutes, the idea being to try and stretch your bladder out on go overcome the urgent urgency. Wage Um, A Z I said before, caffeine is a stimulant that would help for a Novak to bladder, so you can advise them to reduce caffeine intake. And that's not just tea and coffee, but you have to consider fizzy drinks a swell they sometimes have. Caffeine on alcohol should be reduced not because it's a stimulant, but because it's a diuretic, so people with an overactive bladder will fill up their bladders quicker. Onda, I need teo eat pee more, uh, moving on from that you can prescribe medication. So at the common ones, you might have heard of anticholinergic medication, and they come in different types. So the commonest ones are exhibiting in solifenacin and told me, Fester Teradyne is also a one that's used on. They have slightly different side effect profiles, but essentially they're the same class of medication. The main side effects to be aware of with these is that it can cause a dry mouth and eyes on constipation. Um, but it can be quite helpful at reducing urgency, urgency and urgency. Incontinence, uh, big know, knows to using this This medication. If a patient has acute closed angle glaucoma on Dinelli as it can confuse them. Recently, over the last 10 years, uh, a new medication came out called Mayer. Bigger on this is a beat up three agonist be 23 receptors are only found in the bladder, so it's very selective That has a low side effect profile. Um, so this is this is good as a second line after canticle in addicts have been tried Or where am tickling metrics off Country contra indicated for ladies some. There's some evidence to show that post menopausal women who have topical Easter gene can can benefit from improved symptoms, including symptoms of being continents. Um, moving on from medication. We have, um, different types of procedures. You conduce. So neuromodulation is this sort of a surgery, but basically, this's a sacral nerve stimulator implant on. If you remember, your neurology s 234 keeps poop off the floor, but it also keeps your in off the floor. So, um, basically, you implant into the back a stimulator which has leads that run into thie nerve roots off s 234 on that basically is turned on on stimulates the nerves. Which contracts the sphincter. Um interest cycle pharmacology. So interval cycle means in the bladder. Eso There are various, uh, sort of chemicals if you like, or agents you can give. Um, I a literal is an example. Know all of them A licensed for urgency and urgency incontinence. But some have been effective on basically, they replace something called the gag layer off the bladder, which is a natural protective layer on the inside of the bladder on to help prevent infection on direct a shin. Um, again, that's no, no, technically licensed. But it can be It can help for that, Um, people who have, um, overactive bladders proven all urodynamics on. They tried medication, and nothing's worked Can move on toe, have Botox injections on the Botox. Basically, um, paralyzes the detrusor muscle in places on means that it stops the overactive waves in the bladder so they don't get as many overactive ways waves. This is most commonly used for people with, um, neurological diseases like a mess, but it can be used for people with severe overactive bladder treatment. That racket bladder symptoms, um, finally surgery and this is very rare to do for incontinence and over activity. But sometimes way Do reserve it for people where their quality of life is not good and they're not managing. Basically, surgery is aimed to increase the functional bladder capacity on decrease. The maximal detrusor pressure on that protects the upper tract upper urine tract. So especially remember, we spoke about compliance and the bladder not being able to stretch. Sometimes if you have a tiny bladder that doesn't stretch on, you're trying to hold that in. Then the urine's got to go somewhere, so it's gonna start refluxing up the ureters and can potentially damage the kidneys on. So you might want to keep the kidney safe by by doing this Operation ast to really options at something called a clam cystoplasty where basically, you open the bladder, um, on stick a bit of bowel on top to increase the capacity off off the bladder. And also the bit of bowel is obviously know a muscle so it doesn't contract. So even if the bladder has overactive waves and it contracts, then the bit of bowel can expand instead of her instead of the patient leaking on that funny, there's a urinary diversion where you you cut the ureters from where they join the bladder on, Put it into a piece of I Liam, which comes out as a stoma as a back that's called. I'll conjure it. Uh, that's quite extreme for my treatment. Um, I just wanted to talk about incontinence in elderly people because it's very common, and you will face it. Onda. They will have a variety of different causes from the classification that we had. But I thought this was a useful anagram for you to remember. So transient causes of your incontinence and elderly just remember, remember, diapers. Um, so a defect Elyria infection could cause, uh, transient incontinence, um, traffic vaginitis for your arthritis on pharmaceuticals. I look at the medications on Cross off any that don't need to be given psychological problems on excess fluid input or output. So diarrhetics if they have congestive cardiac failure or no nocturnal diuresis is, which is where they produce a lot of urine at night. And that's very common in people with special people with heart failure because they have peripheral edema on a well, the excess fluid pools in their legs on. Then, when they go to sleep, they lie flat on, do a lot fluid gets reabsorbed back into their intravascular system and goes through the kidneys And the diaries, um, restricted mobility. So, you know, if they're they have poor mobility and they can't get the flu on time. They might leak. Um, Andi. Finally, Constipation, stool impaction. So those are some things for you to be aware of? Um, if you did face that elderly person, the continents, you take a history of examination going through your causes, diapers, causes, um, you'd want to do some investigation. So their urine creatinine. You could look at frequency or early in childhood or bladder diary that we spoke off. Look at that post void residual to make sure that emptying their bladder Well, um, you obviously want to do urine dip to extrude infection or an undiagnosed diabetes or hey, mature except Trump. You can do a stress test or get him to cough, see if they leak, have to check for stress incontinence, evaluate their home environment. Can they get to the loo? Do they have to climb three flights of stairs just to get the flu? You know, what's the story? That and obviously physio and occupational helped a therapy can help with that, um, And then finally, for patients that you think of fit you can do urodynamics. You wouldn't do urodynamics and people you didn't think of 50 surgery Because, um, a lot of the provenge I a gross is from that will require further treatment. Often this is surgery. Um, so how would you manage them again? Conservative management. Pelvic floor exercises. Treat any a traffic pattern. Itis optimal. Optimize their mobility and access to the toilet on DA Really good trick is timed Voiding a lot of elderly paper patients sort of forget themselves that sitting on the sofa there, watching, telling, drinking multiple cups of tea and then before they know if they need to pee on, they don't have time to get to the toilet. So you can tell them. Look, every every three hours set it set alarm took off every three hours. When the alarm goes off, get up and go to the loop on that sort of pre emptive voiding to avoid incontinence. A medical therapy. Remember? We said anticholinergics, you tend to not give too elderly because it can exacerbate a confusion and delirium. So you you'd probably go for my Rebecca on straight away. That's the beach or three agonist on. They're finally for those fit you can consider Corpus a Spence in. Well, we're in artificial sphincter little tapes, very briefly, some other types of incontinence which we as urologists encounter. So obviously, we we do a lot of, uh, prostatectomies. We remove prostates that have prostate cancer. Onda um, if we do that part of the operation is removing the prostate on Ben reattaching the bladder neck to the urethra. Uh, so essentially, they don't have a sphincter anymore, because the sphincter is in the part of the prostatic urethra on, but they need to use your pelvic floor muscles to keep themselves dry. So we we get people to build up their pelvic floor muscles even before their operation on, but it's natural for them to have a little leak after the operation. But generally speaking, most men are dry within a year after After there a prostatectomy. Those that aren't may require an artificial urethra sphincter, and that tends to, uh, quite well, um, fistulas so you can get a vesical vaginal fistula where the bladder the weather is a fistula between the bladder and the vagina. or the bladder and the rectum s. So that would be a colon cycle Fistula on. Do a a leak either from there to join a or from the rectum. Um, the main causes in the developing countries are prolonged or obstructed labor, but there are other risk factors. Like I said, grader therapy, for example, makes everything quite fragile and rigid All the tissues, and you can get a breakdown there, and it causes fistula helping surgery malignancy. Uh, endometrial assistant, the pelvis, inflammatory bowel disease. All these conditions could cause a fistula. I'm finally going onto the rare causes you can get a female urethra started killam on. Basically, this is a as it says that diverticulum in the urethra. It can be confused for a Barthel insist, but it's the three DS on to diagnose it Are dysuria post void dribbling, which is very uncommon in women on disporting here, which means pain during sex. Um, Andi, normally you have to diagnosis with an MRI, and it's treated with an excision. Uh, so there was just some things for you to be aware off. Um, and I think that concludes my talk. Eh? So thank you for joining at for listening on, but I'd be happy to take any questions now. And I don't know exactly if you wanted to do this now or after questions. Perfect. Thanks. And I have probably go back just to the previous idea. That site was quite a couple of questions here, so I'll just run through them one by one. Um, so that's a look. So, first of all, we have a question. How does a week tell that full cause theory? Throw hyper mobility. Basically, the bladder drops. Um, so the urethra is not a nice straight urethra, so it's kind of kinked a little bit on it. It can move, move around so the bladder might not empty very well, or the movements in there in the urethra. It can cause a bit of leaking. Who has to do with week ligaments supporting the bladder? So it's not help Taught in place is just I've been all over the place, right? That makes sense. And and someone asks what has taken the police of the female mesh implant. I think that was referring to one of the pictures earlier. Yeah, it still happens, but it's reserved for, um specific women. I think they're more inclined to do, um, tests like urodynamics to prove it before they they go on. But I called the suspension as his taken over. A bit of that on do conservative treatment on Do you read through a bulking agent. So, uh, a lot. A lot of other things that are listed here. Great. Okay, that sounds good. Um, someone asked, Is there any role for anti cholinergics or be three agonists in symptomatic relief of cystitis? Ah, depends what kind of cystitis you're talking about. But no. If you if you're just talking about urine infection, then know you treat that with, you know, antibiotics. If you're talking about interstitial cystitis, then that's a different diagnosis on for that. You give introverts cycle agents like I'll year old. Uh huh. Which puts here. Where's that you give them? You give more interval cycle for treatment on there. They're really good at treating chronic cystitis because they as I said to you, they rebuild that natural defense layer that mash natural defense barrier within the bladder. Which, which means that, um, there's less irritation to the European proof That sounds good. And also with a clam. Cystoscopy not just lied to you. Retention? Uh, no, because it can cystoplasty know because you still have, um, bladder. You still have to truce a muscle. You know, it's no, you're not replacing the bladder with bowel completely. You're just attaching a patch of bowel onto bladder, so the bladder still squeezes. It's just go up touch. Great. Okay, that sounds fine. And George has asked the question here. Can you speak about how you would adopt your treatment for urinary incontinence in the elderly with psychological problems like learning disabilities or dementia? Ah, good question. There's no easy answer. Um, a lot of help from a big multidisciplinary team. Psychologists. You could do things like, especially for learning disability. You could do things like incentives S o. If you get them to go to the loo. Pre emptively. Um, Teo, you know, so that they don't They're not waiting till they're bursting to go. You can give them some sort of incentive on. There's there's means in ways, but it's it's not easy. Great. And someone's mentioned here, um, about PTNS treatment. Ah, yeah, that's basically like script sacral nerve stimulator with peripheral stimulation. I think he's going on about, but it's essentially the same thing. You through feedback, you're stimulating the same loves. Teo Teo contract the sphincter. It's it's not used as much a cycle nursery later. It depends on the center. Some centers are very much for them. But, um, from what I've seen, nice people, you second lasting very. That's fine. And, um, just one more question from Juhan in a female urethra. Diverticulums. Does that mean that you're in collects in the day? Particularly correct? Yeah, that's that's That's where they leak from. It's because there's it's in the urethra on gum on, basically with movement kind of squish is the started kill American. That's that's how I leak on They get dysuria because that, uh, that collected pocket of your intense to get slightly infected and inflamed and her perfect Great. That sounds good. Thank you very much. Tonight, that isn't there's any more questions of the moment, so every move onto the next slide. If anyone does happen to have any other questions later on, feel free to send it on. Email the urology. Mind the bleep dot com mail address, and I'll be happy to get back to you on that and otherwise feeling free to use the QR code on the right for feedback. And you can get a certificate from that. Um, if the QR code isn't working for any reason, I'm gonna go ahead and pop the link for the feedback form in the chart boxes. Well, just, uh, in case you need to on gum. Make sure you join us next time. Next time gonna be out last session in the urology Siris. Then it's gonna be focused on practical tips and tricks, Basically, for your for junior doctors and not just doctors, but anyone in the house care system. Ready? So have a good night and thank you again sometime for everything. Appreciate it. I think he's by right, right.