Female Urinary Incontinence Flashcards
upper tract in the urinary system includes
kidneys and ureters
what is the characteristic of the upper tract?
low pressure distensible conduit with intrinsic peristalsis which transport urine from nephrons via ureters to the bladders
Lower tract in the urinary system includes
bladder and urethra
rate at which bladder fills
0.5 - 5 ml/min
what is the characteristic of the lower tract ?
low pressure storage of urine with efficient expulsion of urine at appropriate place and time
what is urinary incontinence?
involuntary leakage of urine
what is stress urinary incontinence?
involuntary leakage of urine on exertion/coughing/ sneezing
what is urge urinary incontinence?
any involuntary leakage of urine accompanied by or immediately preceded by urgency
what is mixed urinary incontinence?
involuntary leakage of urine accompanied or immediately preceded by urgency which occur on exertion or coughing or sneezing
what is the function of the vesico ureteric mechanism?
to protect the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
what are the sympathetic nerve supply of the micturition system?
hypogastric nerve
T10-L2
what happen to the muscle and urethra during storage phase ?
detrusor muscle relaxes and urethral sphincter contracts
which nerve supply is active during storage?
sympathetic
what is the parasympathetic nerve supply
pelvic nerve
S2-S4
what effect does this have on the bladder and urethra ?
contraction of bladder and relaxation of the urethra
what is the somatic nerve supply of the micturition system?
pudendal nerve
S2-S4
why is somatic innervation important ?
for voluntary control of the micturition system
explain the process of bladder filling
- bladder accomodate increasing volume at constantly low pressure
- there is a gradual rise of awareness of filling
- cortical acitivity - activates reciprocal guarding reflex by the rhabdosphincter contraction which increase sphincter contraction and resistance
- there is also an activation of the sympathetic pathway and reciprocal inhibition of the parasympathetic pathway
- which mediates the contraction of the bladder base and proximal urethra
explain the process of bladder emptying
- detrusor muscle contraction
- urethra relaxation
- coordination of sphincter
- absence of obstruction of anatomical shunt such as cystocele or diverticulum
- cortical influence by the pontine micturition centre –> activation of the parasympathetic system and reciprocal inhibition of the sympathetic pathway
how many % of women aged 15-60 y experience urinary incontinence?
10-25%
how many % of women aged >60 y experience urinary incontinence ?
15-40%
prevalence increase with …..
age
impact of urinary incontinence (UI)
- may impair QoL
- reduce social activities and relationship
- impair emotional and psychological wellbeing
- impair sexual relationship
- embarassment and diminished self esteem
QoL is important, on average women sought mediacl help after how long bcs of the impact of UI on their QoL?
5 years
what are the risk factors for UI ? (12)
age menopause parity surgery pelvic floor trauma medical problems denervation pregnancy and childbirth smoking connective tissue disease increased intraabdominal pressure
out of those what are the main rf for stress incontinence?
childbirth and pregnancy
questions to be asked during hx taking for UI
age parity mode of delivery weight of heaviest baby smoking HRT medical condition previous PFMT, surgical treatment for POP or SUI - especially any failed ones
which medical condition and medication is important to be asked?
Diabetes mellitus
antihypertensive
- diuretics increase frequency of urinating
diazoxide - is used to treat hypoglycaemia and they reduce urethral resistance and thus precipitate SUI
glaucoma
heart or kidney or liver problems - need to reduce dose of meds given
cognitive problems- some meds can worse their cognitive problems
antidepressants or anti-psychotics
what are the irritation symptoms ?
increased daytime frequency(>7) urgency nocturia (>1) haematuria dysuria
which of the irritation symptoms may need to go through another pathway depending on how patient present ?
haematuria - frank haematuria may not be due to cystitis esp in those over 50 y and may have to go through the haematuria pathway
what are the incontinence symptoms ?
stress UI
urgency UI
coital incontinence
what are the voiding symptoms ?
interrupted flow
straining
recurrent UTI
which of the voiding symptoms may go through another pathway if significant ?
recurrent UTI
what do you have to check in terms of fluid intake ?
quantity and quality
what are the prolapse symptoms ?
vaginal lump or dragging sensation in vagina
what are the bowel symptoms ?
anal incotinence, constipation, faecal evacuation dysfunction, IBS
what method of assessment do you use ?
3 day urinary diary recording - fluid intake (quantity and quality), urine output, day time frequency, nocturia, average voided volume
urine dipstick
what are the examination that should be done ?
general abdominal neuro gynaecological pelvic floor assessment
Gynaecological assessment incl?
prolapse stress incontinence urogenital atrophy changes pelvic mass pelvic floor tone, strenngth and awareness
what scale is used for pelvic floor assessment?
oxford scale
what are the possible investigations to be used
- urinalysis: multistix +/- MSSU
- post voiding residual volume using bladder scan
- urogram
when do you do post voiding residual volume scan ?
if have voiding symptoms
who are investigated using urodynamics ?
in those where surgery is contemplated
those with urge incontinence may not need this prior to surgery unless-those with voiding difficulties , concomitant prolapse , previous failed continence surgery
those with overactive bladder
as well as those with predominant SUI symptoms as well as on clinical examination will need urodynamics prior to primary surgical treatment if it is associated with prolapse or voiding difficulties
if someone have OAB on scan what do you do? what if not ?
if + –> offer SNM or botox
if -ve –> consider botox or SNM
ranking the investigations required for UI
1st is urine dipstix or MSSU
2nd - urodynamics
3rd - assessment of residual urine volume using bladder scan
management of urinary incontinence
- lifestyle changes
- normalise fluid intake
- stop smoking
- lose weight
- eat moer healthily to avoid constipation
- stop drinking caffeinated drinks and alcohol - medical treatment
- for modeate to severe SUI - duloxetine and should be in combination with PFMT
- For OAB - anticholinergic mirabegron and vaginal oestrogen
- urethral bulking - physiotherapy
- PFMT +/- electrical stimulation or vaginal cones - surgery
- synthetic MUS / mesh –> no longer used now
- autologous or rectus fascial sling
- colposuspension
everyone should first get conservative treatment unless?
patient do not wish
previously failed
no facilities
when do we go for medical treatment ?
when PFMT has failed or would be enhanced by this drug or if do not wish for surgery not fit for surgery after failed surgery when patient's family is not complete `
what are the first choice surgical treatment ?
- colposuspension
- autologous or rectus fascial sling
Colposuspension procedure is based on what theory?
pressure transmission theory
what do they do in colposuspension ?
can be done open or laparoscopic
lift the lateal vaginal wall to the level of bladder neck up to the ischiotibal ligament
so hammock around bladder neck and thus when patient cough or sneeze - it is supporting the bladder neck and prevent incontienence
both SUI and UUI arise from same anatomical defect in ……
anterior vaginal wall and the pubourethral ligament
why does breakdown of the pubourethral ligament cause incontinence?
because that ligament act as a hammock below mid urethral level and keeps urethra well supported and the area in the mid urethral level as high pressure zone and keeps the continence
when do we do periurethral bulking ?
not medically fit
not complete family
succes rate for the periurethral bulking
70% at 1 y and 45% at 2 y and has long term success tho the long term adverse effect is not really known
who wont be referred to PFMT?
those who score 3 or 4 on the oxford scale as it wont be effective
what happen in PFMT?
it will reinforce the cortical awareness of muscle groups
aim to hypertrophy the existing muscle group as well as general increase in tone and strength of the muscle
what are the definining symptoms of the OAB ?
urgency with or without urgency incontinence
usually with frequency and nocturia
Detrusor overactivty is further classified as
neurogenic
or
idiopathic
prevalence of OAB increases with …. and is slightly higher in …
age
women
risk factor for urge urinary incontinence
advanced age
diabetes
UTI
smoking
management of OAB
treat symptoms
no immediate care
MDT
conservative management:
- lifestyle intervention - normalise fluid intake, reduce fizzy drinks and chocolate and caffeine, stop smoking and weight loss
- bladder training program - timed voiding with gradually increased interval
pharmacological:
- antimuscarinic (oral or transdermal)
- tricyclic antidepressants - imipramine
- B3 agonist - mirabigone
more recent advances
- botox
- neuromodulation
oral antimuscarinics includes?
solifenacin feosteridine trospium darifencain lyrinel oxybutinin
explain about the use of botox
botulinum toxin
inserted using cystoscopy
effect last 6-9 months
some may require CISC - 10% may require self catheterisation
is there a different dose for neurogenic or idiopathic OAB?
yes
idiopathic - 100-150 unit
200-300 in neurogenic
explain about the use of neuromodulation
needle stimulates S2-S4
reflex inhibition of the detrusor muscle
minimally invasive and cheap
continuously give impulses to this area to inhibit impulses going to the pontine micturition centre and thus reduce sensation of urgency
needle in neuromodulation stimulate which level of nerve?
S2-S4
