female urinary incontinence Flashcards
what are the 2 components of the urinary tract (important!!)
upper - kidneys and ureters, low pressure distensible conduit w/ intrinsic peristalsis (verniculation), transports urine from nephrons via ureters to bladder
lower - bladder and urethra, low pressure storage of urine, efficient expulsion of urine at appropriate place and time
rate of bladder filling
0.5-5mls/min
rate of bladder filling
0.5-5mls/min
what is the vesico-ureteric mechanism
between UUT and LUT
one way valve
protects the nephrons from any damage 2y to retrograde transmission of back pressure/infection from the bladder
nerve supply to the bladder
s**torage - hypogastric nerve (**symp), T10-L2 - relaxation of bladder and contraction of ureteric sphincter
voiding - p**elvic nerve (**p**arasymp), S2-4 (**power), contraction of bladder and relaxation of sphincter
voluntary - pudendal nerve (somatic), S2-4
bladder filling
accomodate increasing volume at constantly low pressure
inhibition of contractions by giving rise to gradual awareness of filling
distensable bladder wall
cortical activity and bladder filling
activating a reciprocal guarding reflex by rhabdosphincter contraction, increase sphincter contraction and resistance
activates sympathetic pathway
reciprocal inhibition of the parasympathetic pathway
mediates contraction of bladder base and proximal urethra
bladder emptying
detrusor contraction
urethral relaxation
sphincter co-ordination
absence of obstruction (cystocele, diverticulum etc)
cortical influence on bladder emptying
pontine micturition centre
activation of parasympathetic pathway and inhibition of sympathetic pathway
what is urinary incontinence - UI
ANY involuntary leakage of urine
what is stress urinary incontinence -SUI
involuntary leakage on effort or exertion, on sneezing or coughing
what is urge urinary incontinence - UUI
involuntary leakage accompanied by or immediately preceded by urgency
what is mixed urinary continence - MUI
involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing
epidemiology of UI
10-25% of women aged 15-60
15-40% of women >60
>50% of women in nursing homes
WHO international health concern
prevalence increases w/ age
impact of UI
UI may significantly impact QOL
reduce social relationships and activities
impair emotional and psychological well being
impair sexual relationships
embarrassment and diminished self esteem
impact on QOL is why women seek help but often after yrs of suffering (~5yrs)
risk factors for UI
age
pregnancy
parity
menopause
smoking
medical problems
chronic increased intra-abdo pressure
pelvic floor trauma
denervation
connective tissue disease
surgery
what is the main risk factor for SUI
pregnancy and childbirth
large object passing through a constricted channel
patient assessment for UI
hx
examination
investigations
management
hx for UI
age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
medical conditions: DM, anti-HT medications, glaucoma, heart/kidney/liver problems, cognitive problems, anti-depressants/psychotics
previous PFMT, surgical treatment of SUI/POP
irritation symptoms
urgency - sudden compelling desire to void that is difficult to defer
increased daytime frequency (>7)
nocturia (>1)
dysuria
haematuria (red flag; frank, not cystitis, >50, smoker)
incontinence symptoms
SUI
UUI
coital incontinence
severity - how many pads/day
patient assessment - complaint
irritation symptoms
incontinence symptoms
voiding symptoms
OAB (overactive bladder) - usually associated w/ frequency, nocturia and urgency
fluid intake - quantity and content
effect on QOL
prolapse symptoms
bowel symptoms
voiding symptoms
straining to void
interrupted flow
recurrent UTI - red flag
prolapse symptoms
vaginal lump
dragging sensation in vagina
bowel symptoms
anal incontinence
constipation
fecal evacuation dysfunction
IBS
patient assessment following hx taking
2-3 days urinary diary
urine dipstick
urinary diary
fluid intake - quantity and content
urine ouput - excluding nocturnal polyuria
daytime frequency
nocturia
avg voided volume
examination of a women w/ bladder/pelvic floor problems
general/abdo
neuro - if indicated by hx
gynae - prolapse; stress incontinence; uro-genital atrophy changes; pelvic mass; pelvic floor tone, strength, awareness
investigations for urinary incontinence
urinalysis - multistix +/- MSSU
post-voiding residual volume assessment - bladder scanning
urodynamics
what is urodynamics
study of bladder/urethral physiology to detect underlying pathology that may explain symptoms
invasive set of tests that are only indicated if surgical treatment is contemplated
women w/ SUI symptoms may not need urodynamics prior to surgery unless symptoms of voiding difficulties/concomitant prolapse or prev failed continence surgery
indications for urodynamics
confirm diagnosis
differentiate SUI vs detrusor overactivity vs MUI
investigate voiding symptoms
NICE guidelines for urodynamics
- do not perform prior to conservative UI management
- perform in women w/ refractory OAB
- women w/ predominant SUI symptoms and demonstratable SUI on examination, perform prior to 1y surgical treatment for SUI if associated prolapse or VD symptoms
DO management following urodynamics for refractory OAB
if DO confirmed → offer botox, SNM
if no DO confirmed → consider botox/SNM
management of UI
lifestyle changes
medical
physiotherapy
surgical
conservative management for UI
MUST be offered to ALL women w/ UI
- 60-70% of women will not come back for further surgery
should be completed prior to contemplating surgical treatment
where not possible (rare) - documentation and MDT discussion
lifestyle changes for UI
normalise fluid intake (1.5-2L/day)
reduce caffeine, fizzy drinks, chocolate
stop smoking
weight loss
avoid constipation and chronic cough
what is offered to every woman w/ UI
physiotherapist for pelvic floor muscle training (unless score of 3 or 4)
(+/- electrical stimulation, vaginal cones)
pharmacological treatment for UI
SUI - duloxetine
OAB - anticholinergics - Mirabegron and vaginal oestrogen
PFMT
- reinforcement of cortical awareness of muscle groups
- hypertrophy of existing muscle fibres
- general increase in muscle tone and strength
evidence for PFMT
more effective than no treatment
more effective than electrical stimulation
more effective than vaginal cones
60-70% cure/significant improvement - experienced physio w/ special interest and well motivated patient
what is PFMT
pelvic floor muscle training
Duloxetine for SUI
aka Yentreve
selective noradrenaline reuptake inhibitor
- 1st and currently only drug licensed for treatment of moderate - severe SUI
- should be part of overall management strategy including PFMT
continence theory and surgical management - NICE guidelines
synthetic MUS (mesh)
autologus (rectus) fascial slings
colposuspension
urethral bulking
surgical management of UI - synthetic MUS
- RP-TVT (retro-pubic approach, tension-free vaginal tape) = all mesh based procedures continue to be suspended in UK for concerns on safety
native tissue surgery is now the most common
surgical management of UI - autologous (recuts) fascial slings
modified aldrige vs sling on string
how can colposuspension be carried out
open
laparoscopic
what is colposuspension and what does it depend on
uses stitches to support the neck of the bladder so that it can’t move about and cause stress incontinence
pressure - transmission theory
lifts lateral vaginal wall up at the level of the neck of the bladder
stitch it to the iliopectineal ligament
creates a hammock around the bladder neck
what is the integral theory of female UI
SUI and UUI arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament (PUL)
→ urethral/bladder neck closure dysfunction and SUI
suburethral hammock laxity might result in stimulation of bladder neck stretch receptors, provoking premature micturation reflex and UUI
synthetic (mesh) mid-urethral slings - retropubic TVT
- what is it
- what does it rely on
- effectiveness
tension free vaginal tape - introduced as a minimally invasive procedure to reinforce the structures supporting the urethra
depends on the hammock theory for continence
80% cure at 11yrs
polypropylene permanent synthetic tape
autologous (rectal) fascial sling
abdominal incision
create sling from abdominal rectus sheath
insert vaginally as with TVT
creates hammock around mid-urethral level
peri-urethral bulking
- who is it for
- success rate
- not medically fit for surgery or not completed family
- success rate 70% at 1yr, 45% at 2yrs
- ? long term success and adverse effects
SUI surgery rates
2007-2016
48% reduction in MUS in 2016 vs 2008
defining symptoms of OAB
urgency (w/ or w/o urgency incontinence)
usually associated w/ frequency and nocturia
usually (but not always) related to urodynamically demonstratable detrusor overactivity
define urgency
sudden, compelling desire to pass urine that is difficult to defer
define urge incontinence
involuntary leakage of urine accompanied or immediately preceded by urgency
define frequency
usually accompanies urgency w/ or w/o urge incontinence
pt considers that they void too often during the day
define nocturia
usually accompanies urgency w/ or w/o UI and is the complaint that the individual has to wake at night ≥1 time to void
risk factors for OAB and UI
advanced age
DM
UTI
smoking
OAB is a chronic condition therefore symptoms may come and go
OAB management
treat symptoms
no immediate care
MDT approach
OAB conservative management
lifestyle interventions - normalise fluid intake; reduce caffeine, fizzy drinks and chocolate; stop smoking; weight loss
bladder training programme - time voiding w/ gradually increasing intervals w/ continence nurse
OAB pharmacological treament
anti-muscarinic
mirabegron - beta 3 agonist andispasmodic
tri-cyclic antidepressant - imipramine
antimuscarinics for OAB
oral
- solifenacin (vesicare 5-10mg)
- fesoteridine (toviaz 4-8mg)
- trospium chloride (60mg XL)
- darifencain (emselex 7.5-15mg)
- lyrinel XL (10-20mg)
- oxybutinin (5-10mg/tds)
transdermal
- kentera patches
don’t need to know all individual names, just that there is oral or transdermal
botox for OAB
botulinum toxin
Neurogenic DO/Idiopathic DO
200-300 unit (12U/kg) - for NDO, 1001-50U for IDO
cytoscopy/GA
75% cure and sig improvement
effects last 6-9mths
CISC - 10% pts
neuromodulation for OAB
needle stimulation - S2-S4
reflex inhibition to detrusor muscle
cheap
minimally invasive
70% improvement in refractory OAB
what are the management options for OAB if medication fails
botox
sacral neuromodulation
