19: Urinary incontinence Flashcards
Diagnostic evaluationof UI (urinary incontinence) includes ?
a thorough history and physical examination, urine analysis and culture, stress test, cotton-swab test, and use of a voiding diary. Urodynamics (cystometrogram, uroflowmetry) can be used as indicated.
Risk factors for UI
age, hormonal status, obesity, diabetes, impaired functional status, some neurologic disorders, pregnancy, vaginal delivery, pelvic surgery, medication (e.g., alpha-blockers), smoking, and genetic factors
Stress incontinence is characterized by
leaking with physical activity such as coughing, sneezing, lifting, or exercising.
-intravesical pressures exceed intraurethral pressure
Stress incontinence treatment
lifestyle and behavioral modification, incontinence pessaries, and surgical management (supportive slings for the urethra and bladder neck)
Urgency incontinence is characterized by ?
leaking associated with urgency and may exhibit detrusor overactivity
causes of detrusor overactivity
most idiopathic
-UTI, bladder stones, cancer, diverticula, and neurologic disorders (stroke, multiple sclerosis, Alzheimer disease).
urgency incontinence treatment
goal?
lifestyle and behavioral modification, anticholinergic medication. Surgical procedures include sacral and peripheral nerve stimulation, bladder injections, and augmentation cystoplasty
goal: to relax the bladder, suppress involuntary bladder contractions, and enhance urine storage
Overflow incontinence is most commonly due to ?
decreased detrusor contractions caused by medications or neurologic disease; (obstruction and postoperative overdistension occur less frequently in women)
primary symptom of overflow incontinence is ?
how to treat?
urinary retention with continuous dribbling. It is usually treated with self-catheterization and/or medications to increase bladder contractility (cholinergic agents) and lower urethral resistance (alpha-adrenergic agents).
Bypass incontinence is ?
how to treat?
painless, continuous urine leakage usually due to vesicovaginal, urethrovaginal, or ureterovaginal fistulas.
treated surgically with repair of the urinary fistula.
most common causes of urinary fistulas in the United States?
In developing countries, total incontinence caused by ? often leads to urinary fistula.
pelvic radiation and pelvic surgery
obstetric trauma/obstructed labor
Functional incontinence is ?
causes?
seen most commonly in what patients?
urinary loss due to the physical and/or mental inability to attend to voiding cues.
Causes: physical impairment, dementia and delirium, and medications.
-most commonly in nursing homes and in geriatric and psychiatric patients.
mixed (urinary) incontinence
(stress + urgency) Involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing
Urinary continence at rest is possible because the ? exceeds the ?
intraurethral pressure exceeds the intravesical pressure.
- Continuous contraction of the internal sphincter
- external sphincter provides about 50% of urethral resistance and is the second line of defense against incontinence
Sympathetic control of the bladder is achieved via the ?
hypogastric nerve originating from T10 to L2 of the spinal cord.
-prevents micturition by contracting the bladder neck and internal sphincter
Parasympathetic control of the bladder is supplied by the ?
pelvic nerve derived from S2, S3, and S4 of the spinal cord
-allows micturition, contraction of detrusor muscle
the somatic nervous system aids in voluntary prevention of micturition by innervating the striated muscle of the ? through what nerve?
external sphincter and pelvic floor
the pudendal nerve
stress test is performed by ?
filling the bladder with up to 300 mL of normal saline or sterile water through a catheter. The patient is asked to cough, and the clinician observes to verify the loss of urine
-urine leakage is witnessed by the clinician: genuine stress incontinence
postvoid residual (PVR) is obtained by ?
to rule out ?
alternative ?
catheterization of the bladder after voiding. -use to rule out urinary retention and infection.
-alternative is to measure the postvoid residual with an ultrasound bladder scanner. The upper limits of a normal postvoid residual have been reported as 50 to 100 mL.
cotton swab test purpose?
to diagnose a hypermobile urethra associated with stress incontinence
-insert lubricated cotton swab into the urethra to the angle of the urethrovesical junction When the patient strains as if urinating, the UVJ descends and the cotton swab moves upward. The change in cotton swab angle is normally less than 30 degrees and a value of greater than 30 degrees is consistent with a hypermobile urethra
Urodynamics evaluates
urethral function (urethrocystometry, urethral pressure profilometry), bladder filling (cystometry), and bladder emptying (uroflowmetry and voiding cystometry or pressure flow studies).
cystometry measures ?
the pressure and volume relationship of the bladder during filling and/or pressure flow study during voiding
-assesses bladder sensation, bladder capacity, detrusor activity, and bladder compliance
hammock theory
the urethra lies on the supportive layer of the endopelvic fascia and anterior vaginal wall
-during a cough the urethra is compressed against this hammock-like supportive layer with a resultant increase in urethral closure pressure
stress incontinence Lifestyle and behavioral modifications include ?
weight loss, caffeine restriction, fluid management, bladder training, pelvic floor muscle exercises (Kegel exercises), and physical therapy (biofeedback, magnetic therapy, and electrical stimulation)
medical therapy for stress incontinence
limited, none FDA approved
Alpha-adrenergic agonists (midodrine, pseudoephedrine), beta-adrenergic receptor antagonists and agonists (clenbuterol, propranolol), TCAs (imipramine), and SNRIs (duloxetine), estrogen
? are used to physically elevate and support the urethra, which restores normal anatomic relationships
Incontinence pessaries and other intravaginal devices
stress incontinence sx treatment
abdominal retropubic urethropexies (Burch procedures), bladder neck slings (aim to resuspend the hypermobile urethra), and tension-free midurethral slings (tension-free vaginal tape, transobturator tape) (provide reinforcement at the midurethra to the pubic bone, suburethral vaginal hammock, and pubococcygeus muscles)
intrinsic sphincter deficiency may benefit from ?
periurethral or transurethral placement of bulking agents to improve sphincter tone
medications for urgency incontinence
Oxybutynin, Tolterodine, Fesoterodine (Toviaz), Solifenacin (Vesicare), Trospium (Sanctura), Darifenacin (Enablex)
Surgical treatments for urgency incontinence include ?
sacral and peripheral neuromodulation, bladder injections, and augmentation cystoplasty, Posterior tibial nerve stimulation, Botulinum toxin (not FDA approved), augmentation cystoplasty
Treatment strategy in overflow incontinence is geared toward ?
relieving urinary retention, increasing bladder contractility, and decreasing urethral obstruction
Medical management of overflow incontinence
agents to reduce urethral closing pressure (prazosin, terazosin, phenoxybenzamine) and striated muscle relaxants (diazepam, dantrolene) to reduce bladder outlet resistance. Cholinergic agents (bethanechol) are used to increase bladder contractility. Intermittent self-catheterization to avoid UTIs and retention
Patients with overflow incontinence due to bladder outlet obstruction caused by a continence procedure benefit from ?
surgical correction of the obstruction
diagnosing vesicovaginal and ureterovaginal fistulas
Methylene blue or indigo carmine instilled into the bladder in a retrograde fashion can be visualized leaking through the fistula into the vagina
-If a ureterovaginal fistula is present, the retrograde dye test will be negative and the IV dye test will be positive.
how to identify the number and location of the fistulas after dye tests
Cystourethroscopy and the voiding cystourethrogram (VCUG) IV pyelogram (IVP) and retrograde pyelogram (localized)
