7.8- Urinary Incontinence Flashcards
60% of women post-partum will experience urinary incontinence. For the majority this goes away within a year, however it remains with 12%. Define Urinary incontinence
It is the involuntary loss of urine that is objectively demonstrable + impact on QoL (social/hygienic problem)
State the types of urinary incontinence
Stress incontinence
Urgency Incontinence
Overflow incontinence
Anatomical
Autonomic
Risk factors of stress incontinence are those of pelvic organ prolapse. Define Stress incontinence
Involuntary loss of urine due to increased intraabdominal pressure or weakness of pelvic support
Define Urgency incontinence
Give the RFs associated with urge incontinence
Involuntary loss of urine due to urgency (not reaching bathroom on time)
Lifestyle factors: Fizzy drinks, spicy food, tea, coffee, smoking, decreased mobility
Comorbidities: Diabetes, stroke
Diuretics incl. alcohol
Define Overflow incontinence
State the 2 common causes of it
What specific investigation would be useful to diagnose this
Involuntary loss of urine due to overfilling of bladder => pressure exceeds that of sphincter. It is characterized by incomplete bladder emptying => PVR (post-voidal residual) and dribbling of urine.
Typically caused by pelvic organ prolapse in women causing outlet obstruction (Cystourethrocele)!! as well as detrusor underactivity (as opposed to urgency which would be overactivity)
A patient presents with a constant leakage of urine that is not in excessive quantities. What do they likely have?
What type of urinary incontinence is being displayed here?
What RF can lead to this?
Vesicovaginal! or ureterovaginal or urethrovaginal Fistula
Anatomical incontinence
RF: Previous abdominal/pelvic surgeries, IBD (crohn’s), IBS, chemoradiation, infection
Give the 2 most common causes of anatomical urinary incontinence
Fistula and congenital ectopic ureter
What is the main cause of autonomic incontinence?
Spinal trauma
Others include: Cauda equina, conus medullaris, and complication of a surgery affecting nerves governing micturition
What nerves/nerve roots govern mictruition
Parasympathetic via S2-S4 -> detrusor contract, sphincter relax
Sympathetic via T10-L2 -> detrusor relax, sphincter contract
Pudendal nerve S2-S4 -> motor innervation to urethral sphincter
What level are pathological fractures most common in
T10-L2, more specifically T12/L1
State the general workup of a patient presenting with urinary incontinence (no details just steps in the workup)
Routine:
History
Abdo + pelvic examination
Labs and general investigations
Urinalysis + PVR (post-voidal residual)
Extra:
+/- Urodynamic testing
+/- Cystourethroscopy (most invasive)
How would you contrast a person with urgency incontinence from stress incontinence
First, it is important to note that a patient may have both
Urge incontinence is characterized by Sudden urge (not being able to reach toilet before leaking) frequency, !Nocturia (waking up to pee at night)!, Enuresis
Stress incontinence is typically characterized by exacerbating factors like coughing, laughing, lifting…
You are asked to take a history of a patient presenting with urinary incontinence. Go for it
1) Onset + description - precipitating factors, dysuria (constant vs occasional vs exacerbating factor)
2) Severity (quantify) + impact on QoL: wearing pads, self-isolating, avoiding exercise, !toilet mapping!
3) Urgency vs stress: Sudden urge (not being able to reach toilet before leaking) frequency, !Nocturia!, Enuresis
4) RFs:
Lifestyle factors: Fizzy drinks, spicy food, tea, coffee, smoking, decreased mobility
Comorbidities: Diabetes, stroke
Diuretics incl. alcohol
5) Rule out UTI (fever, Dysuria, flank pain)
5) Inv./tx to date: voiding diary, urological studies/successful tx
6) Recent trauma to head or spine
What findings may you find on a pelvic exam of a patient presenting with incontinence
Inspection: Perineal skin irritation, infection, hygiene. Constant flow? fistula
Bimanual:
1) weakness of vaginal walls/prolapse (ask patient to strain to assess strength and check for urine leakage during that)
2) vaginal atrophy
What findings are you assessing for on urinalysis in a patient presenting with urinary incontinence
looking for evidence of UTI (blood, nitrates, pyuria)
Glycosuria (diabetes) also do OGTT, HBA1c for that
When conducting urinalysis, a post-voidal residual may be performed as well at the bedside via x-ray. What is this testing for? What results would warrant further investigation?
It tests for how much urine is left after voiding
>50ml is abnormal
Note that this may be different based on bladder size and age
Briefly state what urodynamic studies are assessing
Study investigating both the phase of bladder filling (cystometry) and bladder emptying (uroflowmetry)
You are conducting urodynamic studies assessing the bladder filling. What is this called and how is it conducted?
How would you use that to determine if a patient is having stress or urinary incontinence?
Cystometry. It assesses the pressure/volume relationship on bladder filling. 500 ml of saline is inserted into urinary catheter to fill the bladder and the pressure is recorded. Intrabdominal pressure is measured via rectal or vaginal catheter. Detrusor pressure is P bladder - P intraabdominal as P bladder = P detrusor + P intraabdominal
Urge incontinence is characterized by detrusor hyperactivity => P bladder and P detrusor will both be equally elevated
Stress incontinence is characterized by increased intraabdominal pressure (and weakness of pelvic floor muscles) => P bladder and P abdomen .
You are conducting urodynamic studies and are assessing bladder voiding. What is this called? What information does it provide?
Uroflowmetry
Measure total volume voided (post-voidal residual), peak flow (obstruction), and detrusor activity (neurological)
Differentiates if the problem is overflow incontinence, outflow obstruction, or weak detrusor (neurological such as stroke)
T or F: Leaking during physical activity is a feature of only stress incontinence
False urge incontinence may also have it as many have symptoms of both
What is the pathophysiology of urge incontinence?
Overactive bladder/hyperactive detrusor (which is why P detrusor increases with P bladder.
This means that the detrusor muscle in uninhibited and has involuntary contractions on bladder filling (kinda similar to how rubbing the uterus makes it contract)
Urge incontinence is characterised by hyperactivity of the detrusor muscle. How might this occur. Give 4 reasons
Spinal cord injury (conus medullaris)
Neuromuscular disorders
MS
Altered microflora
Bladder neck obstruction
Idiopathic
Give 5 symptoms of urge incontinence
Urgency (directly when feeling to void)
Incontinence (not able to reach toilet)
small Volume but high frequency
Nocturia 2 or more times/night
+/- mixed with stress incontinence
How would you confirm the diagnosis of urge incontinence once youve finished the history?
It is often enough by itself but with urodynamic studies via cystometry showing equally increased pressure of detrusor and bladder on bladder filling
Give the full management plan of a patient presenting with nocturia, urgency, and frequency. The patient does not have a fever and is negative on urinalysis for blood, nitrates, and pyuria
Conservative: Physiotherapy -> Behavioural therapy/bladder training via biofeedback
+ Urge incontinence RF reduction => cut down on smoking, alcohol (diuretic), fizzy drinks, coffee, tea, spicy food. control diabetes (compliance)
Medical: Anticholinergic agents (oxybutynin)
Or beta 3 agonist (much more SE)
Surgical:
Cystoscopy + Intravesical Botox Injections
Clam Ileocystoplasty
Urinary Diversion (rarely performed)
What is clam ileocystoplasty?
Its in the name. It uses an intestinal segment to enlarge the bladder.
GA -> segment of intestine used as graft (sutured back) -> bladder incision -> suture intestinal segment there.
What is urinary diversion
Ureters attached to bowel (very invasive)
What is the mechanism of action of anticholinergic agents?
Give an example
What are the side effects of anticholinergic agents? give 3
Give one contraindication. If it is contraindicated, what would you give a patient with urge incontinence instead?
Oxybutynin, tolteridine
Anti cholinergic = antiPNS => Symptoms: tachycardia, blurred vision, urine retention, xerostomia!
Contraindications: Narrow angle glaucoma, SVT, Gastric retention
Instead, I would give B3 agonist
What age group does Urge incontinence typically present at?
Same question for stress incontinence
Urge -> 45-49
Stress -> post-menopausal => 52+
What is the pathophysiology of Stress incontinence?
Urethral hypomotility (insufficient pelvic support => prolapse)
and/or Instrinsic sphincter deficiency.
What can cause the intrinsic sphincter deficiency seen in stress incontinence?
Neuromuscular damage (Pudendal or PNS/SNS)
Deficiency of estrogen in post-menopausal women
How would you manage a patient presenting with stress incontinence but no evidence of prolapse. Give the full management plan.
Conservative: Same as prolapse => RF modification (weight, dietitian referral, Kegel exercises by physiotherapy referral, smoking cessation, laxative for constipation)
+ Biofeedback/bladder training
+ Urge incontinence RF reduction => cut down on smoking, alcohol (diuretic), fizzy drinks, coffee, tea, spicy food. control diabetes (compliance)
+ Incontinence Pessary (normal pessary but with a knob)
Medical: Local oestrogen cream (PV)
Laxatives for chronic constipation
SNRI: Duloxetine (it increases pudendal nerve activity)
Surgical: urethral bulking (bulking agents inserted into urethra)
Autologous slings
Mesh TVT/TOT (currently suspended)
Burch Colposuspension
Briefly explain the procedure of autologous slings.
The procedure for autologous slings for stress urinary incontinence involves surgically harvesting a strip of the rectus fascia/fascia lata (patient’s own tissue) and using it to create a supportive sling around the urethra or bladder neck.
This sling acts to support the bladder and urethra, preventing involuntary leakage of urine during physical activities that increase abdominal pressure, such as coughing or sneezing
Very very briefly explain Mesh TVT vs TOT
TVT is tension-free vaginal tape: Mesh inserting a synthetic mesh tape under the mid-urethra to provide support ands prevent leakage
TOT is TransObturator Tape: Exactly the same (miurethra) but here it is a synthetic mesh tape passed through the obturator foramen
Very briefly explain Burch Culposuspension
Burch colposuspension procedure involves surgically lifting and securing the bladder neck to the iliopectineal ligament of the pelvis, thereby providing support to the urethra and reducing stress urinary incontinence.
