Female Urinary Incontinence Flashcards
1
Q
upper tract in the urinary system includes
A
kidneys and ureters
2
Q
what is the characteristic of the upper tract?
A
low pressure distensible conduit with intrinsic peristalsis which transport urine from nephrons via ureters to the bladders
3
Q
Lower tract in the urinary system includes
A
bladder and urethra
4
Q
rate at which bladder fills
A
0.5 - 5 ml/min
5
Q
what is the characteristic of the lower tract ?
A
low pressure storage of urine with efficient expulsion of urine at appropriate place and time
6
Q
what is urinary incontinence?
A
involuntary leakage of urine
7
Q
what is stress urinary incontinence?
A
involuntary leakage of urine on exertion/coughing/ sneezing
8
Q
what is urge urinary incontinence?
A
any involuntary leakage of urine accompanied by or immediately preceded by urgency
9
Q
what is mixed urinary incontinence?
A
involuntary leakage of urine accompanied or immediately preceded by urgency which occur on exertion or coughing or sneezing
10
Q
what is the function of the vesico ureteric mechanism?
A
to protect the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
11
Q
what are the sympathetic nerve supply of the micturition system?
A
hypogastric nerve
T10-L2
12
Q
what happen to the muscle and urethra during storage phase ?
A
detrusor muscle relaxes and urethral sphincter contracts
13
Q
which nerve supply is active during storage?
A
sympathetic
14
Q
what is the parasympathetic nerve supply
A
pelvic nerve
S2-S4
15
Q
what effect does this have on the bladder and urethra ?
A
contraction of bladder and relaxation of the urethra
16
Q
what is the somatic nerve supply of the micturition system?
A
pudendal nerve
S2-S4
17
Q
why is somatic innervation important ?
A
for voluntary control of the micturition system
18
Q
explain the process of bladder filling
A
- 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
19
Q
explain the process of bladder emptying
A
- 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
20
Q
how many % of women aged 15-60 y experience urinary incontinence?
A
10-25%
21
Q
how many % of women aged >60 y experience urinary incontinence ?
A
15-40%
22
Q
prevalence increase with …..
A
age
23
Q
impact of urinary incontinence (UI)
A
- may impair QoL
- reduce social activities and relationship
- impair emotional and psychological wellbeing
- impair sexual relationship
- embarassment and diminished self esteem
24
Q
QoL is important, on average women sought mediacl help after how long bcs of the impact of UI on their QoL?
A
5 years
25
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
```
26
out of those what are the main rf for stress incontinence?
childbirth and pregnancy
27
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
```
28
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
29
what are the irritation symptoms ?
```
increased daytime frequency(>7)
urgency
nocturia (>1)
haematuria
dysuria
```
30
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
31
what are the incontinence symptoms ?
stress UI
urgency UI
coital incontinence
32
what are the voiding symptoms ?
interrupted flow
straining
recurrent UTI
33
which of the voiding symptoms may go through another pathway if significant ?
recurrent UTI
34
what do you have to check in terms of fluid intake ?
quantity and quality
35
what are the prolapse symptoms ?
vaginal lump or dragging sensation in vagina
36
what are the bowel symptoms ?
anal incotinence, constipation, faecal evacuation dysfunction, IBS
37
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
38
what are the examination that should be done ?
```
general
abdominal
neuro
gynaecological
pelvic floor assessment
```
39
Gynaecological assessment incl?
```
prolapse
stress incontinence
urogenital atrophy changes
pelvic mass
pelvic floor tone, strenngth and awareness
```
40
what scale is used for pelvic floor assessment?
oxford scale
41
what are the possible investigations to be used
- urinalysis: multistix +/- MSSU
- post voiding residual volume using bladder scan
- urogram
42
when do you do post voiding residual volume scan ?
if have voiding symptoms
43
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
44
if someone have OAB on scan what do you do? what if not ?
if + --> offer SNM or botox
| if -ve --> consider botox or SNM
45
ranking the investigations required for UI
1st is urine dipstix or MSSU
2nd - urodynamics
3rd - assessment of residual urine volume using bladder scan
46
management of urinary incontinence
1. lifestyle changes
- normalise fluid intake
- stop smoking
- lose weight
- eat moer healthily to avoid constipation
- stop drinking caffeinated drinks and alcohol
2. medical treatment
- for modeate to severe SUI - duloxetine and should be in combination with PFMT
- For OAB - anticholinergic mirabegron and vaginal oestrogen
- urethral bulking
3. physiotherapy
- PFMT +/- electrical stimulation or vaginal cones
4. surgery
- synthetic MUS / mesh --> no longer used now
- autologous or rectus fascial sling
- colposuspension
47
everyone should first get conservative treatment unless?
patient do not wish
previously failed
no facilities
48
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 `
```
49
what are the first choice surgical treatment ?
- colposuspension
| - autologous or rectus fascial sling
50
Colposuspension procedure is based on what theory?
pressure transmission theory
51
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
52
both SUI and UUI arise from same anatomical defect in ......
anterior vaginal wall and the pubourethral ligament
53
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
54
when do we do periurethral bulking ?
not medically fit
| not complete family
55
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
56
who wont be referred to PFMT?
those who score 3 or 4 on the oxford scale as it wont be effective
57
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
58
what are the definining symptoms of the OAB ?
urgency with or without urgency incontinence
| usually with frequency and nocturia
59
Detrusor overactivty is further classified as
neurogenic
or
idiopathic
60
prevalence of OAB increases with .... and is slightly higher in ...
age
| women
61
risk factor for urge urinary incontinence
advanced age
diabetes
UTI
smoking
62
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
63
oral antimuscarinics includes?
```
solifenacin
feosteridine
trospium
darifencain
lyrinel
oxybutinin
```
64
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
65
is there a different dose for neurogenic or idiopathic OAB?
yes
idiopathic - 100-150 unit
200-300 in neurogenic
66
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
67
needle in neuromodulation stimulate which level of nerve?
S2-S4
