2- Urinary incontinence and prolapse Flashcards
what innervation is the bladder under during storage phase
Under control by the sympathetic and somatic nervous system.
- sympathetic (hypogastric)= detrusor muscle and IUS
- somatic = EUS
as the bladder fills the rugae distend and a constant pressure in the bladder is maintained… how many ml of urine can the bladder hold before the pressure changes
150ml
outline the storage phase of micturition
- To stimulate storage, impulses from the cerebral cortex travel to the pons (slow impulses) via afferent sensory neurones
o Pons is responsible for coordinating the actions of the urinary sphincters and the bladder
o Area involved in storage phase= pontine continence centre (L (lateral)- region of the pons) - Stretch receptors of sensory neurones (afferent) detect stretch in the detrusor muscle of the bladder – send feedback to 2 locations:
o Sensory neurone enters the spinal cord between S2-S4 (S2, S3, S4 keeps the poo and wee off the floor) but ascends to higher levels of the spinal cord where they synapse at T10-L2 with sympathetic pre-ganglionic neurones
o Stretch receptors in detrusor muscle also send feedback to the cerebral cortex allows us to know when we need to wee - Impulses travel from the spinal cord to the bladder via the sympathetic hypogastric nerve (nerve roots T10-13) and have an effect on the:
o Detrusor muscles- relaxation of the bladder wall via stimulation of B3- adrenoreceptors in the fundus and the body of the bladder
o Internal urethral sphincter (IUS)- contraction of IUS via stimulation of alpha1- adrenoreceptors at the bladder neck - EUS is under voluntary somatic control
o Impulses travel to the EUS via the pudendal nerve (S2-4) to nicotinic (cholinergic) receptors on the striated muscle resulting in contraction of the sphincter - L (lateral) centre important for deferring micturition
o Sends actions down through the cord which stimulate the pudendal motor neurones
o Maintains continence
during the voiding phase of micturition the bladder is under
parasympathetic control
- pelvic nerve
outline the voiding phase of micturition
- Afferent nerves (sensory S2-4) of the bladder signal the need to void around 400ml of filling, this signal projects to the cerebrum and pontine micturition centre (M (medial)- centre)
- Upon the voluntary decision to urinate, neurones of the pontine micturition centre fire to excite the sacral preganglionic neurones.
- There is subsequent parasympathetic stimulation to the Pelvic Nerve (S2-4) causing a release of ACh, which works on M3 muscarinic ACh receptors on the detrusor muscle, causing it to contract and increase intra-vesicular pressure.
- When we decide to wee, M centre (in pontine micturition centre) sends inhibitory impulses to L centre (Onuf’s nucleus), with a resultant reduction in :
Sympathetic stimulation to the internal urethral sphincter causing relaxation.
Relaxation of external sphincter by inhibiting the pudendal nerve micturition can proceed
History taking for UI
Opening
- introduce self
- confirm patient name and DoB
- explain what you will do
- gain consent
Presenting complaint
- *whats brought you in today?
History of presenting complaint
-Stree or urge symptoms predominant?
- SOCRATES
- Site (if there is any pain)
- Onset- how and when did the symptoms develop ‘how long have you had incontiennce’
- Character- when does it happen? When coughing/ laughing? Randomly?
- Radiation (if pain)
- Associated symptoms e.g. fever for UTI, faecal incontinence etc
- Time course
- Exacerbating/ relieving
- Severity e.g. how its effecting quality of life e.g. how often e.g. use of pads
* - frequency of urination
* frequency of incontinence
* nightime urination
* use of pads and changing clothes
* lifestyle modifications
ICE
Systemic enquiry
- Systemic: fevers (e.g. UTI), weight change (e.g. malignancy
- Gastrointestinal: abdominal pain (e.g. peritoneal dialysis associated infection), bowel habits
- Neurological: any change in senstation down there
Past medical history
- Do you have any past medical history?
- Previous bowel or bladder problems
- Have you ever been pregnant
- associated symptoms: prolapse, faecal symptoms
Obstetircs
- birthweight
- forcep delivery
- perineal trauma
- duration of second stage
**Surgical
- hysterectomy
- pelvic floor repair
- incontinence operations
**Allergies
Drug history
- are you taking any prescribed medication or over the counter remidies e.g. diuretic, antibitoics
- any use of pads
Family history
- “Have any of your first-degree relatives been diagnosed with kidney, bladder or prostate problems?”
**Social history
**- general social context
- smoking
- alcohol
- fluid intake
- caffeine
- BMI
- drug use
- diet and fluids
- occupation
Closing
- summarise
- ask if any questions or concerns
- thank the patient**
specific questions to ask patient complaining of UI
A medical history should distinguish between the types of incontinence. Try to differentiate between urinary leakage with coughing or sneezing (stress incontinence), and incontinence due to a sudden urge to pass urine with loss of control on the way to the toilet (urge incontinence).
- A need to urinate frequently.
- A sudden, strong urge to urinate.
- Inability to urinate.
- A blocked urine stream.
- Leakage of urine while sleeping.
- Possible urinary tract infection.
examination of patient with UI
General
* Obesity
Abdominal examination
* Scars
* Abdominal/pelvic masses
Intimate examination
* * Pelvic organ prolapse
* Atrophic vaginitis
* Urethral diverticulum
* Pelvic masses
* Assess for pelvic tone
Neurological
During the examination, ask the patient to cough and watch for leakage from the urethra.
what is used to measure strength of pelvic muscle contractions
bimanual examination askthe woman to squeeze against the examining fingers.
This can be graded using the modified Oxford grading system:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
investigations for UI
- Bladder diary
- Urine dipstick testing
- Pad test
- Post-void residual bladder volume
- Urodynamic tests
- Cystoscopy
- US for renal tract abnormalities
A bladder diary tracks
fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
why dipstick testing?
look for infection, microscopic haematuria and other pathology.
Post-void residual bladder volume
should be measured using a bladder scan to assess for incomplete emptying.
when are urodynamic tests used
used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
Urodynamic tests
Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken:
- Cystometry measures the detrusor muscle contraction and pressure
- Uroflowmetry measures the flow rate
- Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
- Post-void residual bladder volume tests for incomplete emptying of the bladder
- **Video urodynamic testing **involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Pad tests
- Objective measure of amount of leakage
- Duration 1 hour to 24 hours
renal tract imaging/ cystoscopy when?
To investigate
* recurrent UTI
* haematuria
* Pain
Usually indicated to investigate:
* haematuria
* recurrent UTI
* painful bladder
* “sensory urgency”
Types of urinary incontinence
stress
urge
mixed
overflow
RF for UI
- Increased age
- Postmenopausal status
- Increase BMI
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions, such as multiple sclerosis
- Cognitive impairment and dementia
*
urge incontinence pathophysiology
overactivity of the detrusor muscle of the bladder.
UUI also called
overactive bladder
Presentation of UUI described by patients
- The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
- Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
- This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
uterine prolapse
uterus itself descends into the vagina.
rectocele
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
cysrtocele
caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.
examination of pelvic prolapse
- Ideally, the patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.
- A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele.
The women can be asked to cough or “bear down” to assess the full descent of the prolapse.
Sims speculum
