Female Urinary Incontinence Flashcards
What are the components of the urinary tract?
Upper and lower tracts
What are the components of the female upper urinary tract?
Kidneys
Ureters
What are the components of the female lower urinary tract?
Bladder and urethra
What is the function of the female upper urinary tract?
Low pressure distensible conduit with intrinsic peristalsis
Transport urine from nephrons via ureters to the bladder
What is the function of the female lower urinary tract?
Low pressure storage of urine
Efficient expulsion of urine at appropriate place and time
At what rate does the bladder fill?
0.5-5ml/min
What mechanism protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder?
Vesico-ureteric mechanism - one way valve which allows urine to flow only from kidney to ureter to bladder
What are the functions of the sympathetic and parasympathetic innervations of the bladder?
Sympathetic - storage, activated when under pressure
Parasympathetic - power, if in a relaxed environment and need to empty bladder, parasympathetic will do this
What is the function of the pudendal nerve innervating the bladder?
Voluntary control - works to contract started muscles and control the need to urinate (i.e. controls voluntary urination)
As the bladder fills, it accommodates increasing volume at a constantly low pressure, what occurs due to giving rise to gradual awareness of filling?
Inhibition of contraction
What is the role of cortical activity in bladder filling?
Activates a reciprocal guarding reflex by rhabdosphincter contraction, increasing sphincter contraction and resistance
Activates sympathetic pathway, reciprocal inhibition of the parasympathetic pathway
Medicates contraction of the bladder base and proximal urethra
Why does there need to be coordination between the bladder and the urethra?
Bladder emptying - bladder needs to contract and urethra relax
What is involved in normal bladder emptying?
Detrusor contraction
Urethral relaxation
Sphincter coordination
Absence of obstruction or anatomical shunts
Cortical influence controls coordination - activation of parasympathetic pathway and inhibition of sympathetic pathway
Parasympathetic - contracts bladder, relaxes urethra
What is the epidemiology of female urinary incontinence?
1 in 4 women by age 60 report incontinence
10-25% of women aged 15-60 report urinary incontinence
15-40% of women over the age of 60 in the community report incontinence
More than 50% of women in nursing homes are incontinent
From ages 25-50, what is the main type of incontinence?
Stress incontinence
After this point, overactive bladder takes over - urgency +/- urge incontinence +/- increased daytime frequency +/- nocturia
What is the ICS (2002) definition of urinary incontinence?
Any involuntary leakage of urine
What is the ICS (2002) definition of stress urinary incontinence?
Involuntary leakage on effort or exertion, on sneezing or coughing
What is the ICS (2002) definition of urge urinary incontinence?
Involuntary leakage accompanied or immediately preceded by urgency
What is the ICS (2002) definition of mixed urinary incontinence?
Involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing
What is the impact of urinary incontinence?
Significantly impairs quality of life
Reduces social relationships and activities
Impair emotional and psychological wellbeing e.g. self-esteem issues, social isolation
Impair sexual relationships
Embarrassment and diminished self-esteem
It is due to the impact of urinary incontinence on women’s QoL that medical help is sought
What are the risk factors for urinary incontinence?
Chronic cough Age Parity Menopause Smoking Medical problems Increased intra-abdominal pressure Pelvic floor trauma Denervation Connective tissue disease Surgery
What are the main risk factors for female urinary incontinence?
Pregnancy and childbirth - incontinence problems are common in pregnancy
What is involved in the assessment of a patient with urinary incontinence?
History
Examination
Investigations
Management
What are the most important aspects of history in a patient with urinary incontinence?
Age
Parity, mode of deliveries, weight of heaviest baby
Smoking
HRT
Medical conditions
- DM, important to rule out polyuria and incontinence
- anti-hypertensives, may cause incontinence which stops when medication is stopped
- glaucoma, anticholinergics for incontinence absolutely contraindicated in glaucoma
- heart/kidney/liver problems
- cognitive problems
- anti-depressants/anti-psychotics
Previous PFMT, surgical treatment of SUI or POP
Effect on quality of life is very important - find out how much it interferes with day-to-day activities
What are the irritation symptoms?
Urgency - sudden compelling need to void that is difficult to defer
Increased daytime frequency (> 7 or an increase of 50% more than normal for that patient)
Nocturia (> 1), up to age 60 normal night time urination is one per night, after this point it increases by 1 per decade (if any)
Dysuria
Haematuria - red flag symptoms
Urgency usually associated with frequency and nocturia
What are the incontinence symptoms?
Stress UI
Urgency UI
Coital incontinence (need to ask specifically)
Severity e.g. how many incontinence pads used per day
What are the voiding symptoms?
Straining to void
Interrupted flow
Recurrent UTI
What do you need to know about the patient’s fluid intake?
Quantity
Content
What are the important prolapse symptoms?
Vaginal lump
Dragging sensation in vagina
What are the bowel symptoms important in incontinence?
Anal incontinence
Constipation
Faecal evacuation dysfunction
IBS
What should be noted in a 3 day urinary diary?
Fluid intake - quality and quantity Urine output - exclude nocturnal polyuria Daytime frequency Nocturia Average voided volume
What examinations should be done of a woman with urinary incontinence?
General Abdominal Neurological Gynaecological Pelvic floor assessment for muscle tone Prolapse Stress incontinence Uro-genital atrophy changes Pelvic mass Pelvic floor tone, strength and awareness Try to exclude physical/structural causes
What investigations should be done for a woman with urinary incontinence?
Urinalysis - multistix +/- MSSU
Post-voiding residual volume assessment if symptoms of voiding difficulty, usually done by bladder scanning
Urodynamics - only indicated if surgical treatment contemplated or clinical picture unclear, or failed conservative management
What is the management of urinary incontinence?
Lifestyle changes
Medical treatment
Physiotherapy
Surgery
When does stress incontinence occur?
When intra-abdominal pressure exceeds urethral pressure, resulting in leakage
What is urethral closure pressure increased by?
Pelvic floor muscle training, surgery and pharmacological agents
What lifestyle changes can you advise for a woman with urinary incontinence?
Stop smoking
Weight loss
Eat more healthily to avoid constipation
Stop drinking alcohol and caffeine
What should all patients with urinary incontinence receive?
Conservative treatment - unless the patient does not want it, it has previously failed, or there are not the correct facilities
What is the first line management of urinary incontinence?
Pelvic floor muscle training or bladder retraining
What are the effects of pelvic floor muscle training?
Reinforcement of cortical awareness of muscle groups
Hypertrophy of existing muscle fibres
General increase in muscle tone and strength
More effective than no treatment and more effective than electrical stimulation and vaginal cones
What is the pharmacological management of urinary incontinence?
Yentreve (Duloxetine)
First and currently only drug licensed for the treatment of moderate to severe stress urinary incontinence
Should be part of overall management strategy that includes pelvic floor muscle training
Given in primary care if pelvic floor muscle training has failed or would be enhanced with duloxetine
Given in secondary care if patient doesn’t want/isn’t fit for surgery, after failed surgery or when patient’s family isn’t complete
Incontinence happens if the proximal urethra falls below the level of the pelvic floor, what surgery can be done to correct this?
Colposuspension
What is the integral theory of female urinary incontinence?
Both stress and urge incontinence arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament leading to urethral/bladder neck closure dysfunction and USI
Suburethral hammock laxity might result in stimulation of bladder neck stretch receptors, provoking a premature micturition reflex and urgency incontinence
What are mid-urethral slings?
Mesh-based operation which makes a hammock around the urethra to resemble that which is normally created by the vagina
What is tension-free vaginal tape (TVT)?
Introduced in 1996 as a minimally invasive procedure to reinforce the structures supporting the urethra, depends on the hammock theory for continence
When is TVT as effective as colposuspension?
For the treatment of primary SUI for up to 2 years - less operative and post-operative morbidity
TVT now replaces colposuspension as the first choice procedure in surgical treatment of SUI
What are the concerns over safety of TVT?
Common surgical complications - bladder perforation 1-21%
Vaginal and urethral erosions
Several vascular injuries
What is overactive bladder syndrome?
A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity
What are the defining symptoms of overactive bladder syndrome?
Urgency (with/without urinary incontinence) usually with frequency and nocturia
What are the symptoms of overactive bladder syndrome?
Urgency
Urge incontinence
Frequency
Nocturia
What are the risk factors for urge incontinence?
Advanced age Diabetes Urinary tract infections Smoking Symptoms may come and go
What is the management of overactive bladder syndrome?
Treat symptoms
No immediate cure
MDT approach
Requires dedicated team
What is the conservative management of overactive bladder syndrome?
Lifestyle interventions
Normalise fluid intake
Reduce caffeine, fizzy drinks and chocolate
Smoking cessation
Weight loss
Bladder training programme - timed voiding with gradually increasing intervals, with continence nurse
What is bladder retraining?
Re-establishment of cortical control over detrusor function and voiding
Achieved by timed bladder emptying programme
What are the pharmacological treatments available for overactive bladder syndrome?
Oral antimuscarinic or anticholinergic; Solifenacin (5-10mg) Fesoteridin (4-8mg) Trospium chloride (60mg) Darifencain (7.5-15mg) - constipation, FI Lyrinel XL (10-20mg) Oxybutinin (5-10mg/tds)
Transdermal - kentera patches
Tricyclic antidepressants - imipramine
What are the benefits of botox for overactive bladder syndrome treatment?
200-200 unit (12U/kg)
75% cure and significant improvement
Effects last 6-9 months
What are the features of neuromodulation for the treatment of overactive bladder syndrome?
Needle stimulation (S2-4) Reflex inhibition to the detrusor muscle Cheap Minimally invasive 70% improvement in refractory OABS
What are the disadvantages of botox for treatment of OABS?
Weakens bladder muscles
1/10 require catheterisation
