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Reproductive Medicine > Female urinary incontinence > Flashcards

Female urinary incontinence Flashcards

1
Q

What part of the nervous system controls the external urethral sphincter?

A

Somatic nervous system

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2
Q

What is the approximate volume at which the sensation of needing to void becomes apparent?

A

Approximately 200 mls

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3
Q

What are reversible causes of urinary incontinence?

A
  • UTI
  • Delerium
  • Medications - diuretics, anticholinergics
  • Constipation - leading to faecal impaction
  • Polyuria
  • Urethral irritability - vaginal atrophy
  • Prolapse
  • Bladder stones and tumours
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4
Q

What are irreversible (but treatable) causes of urinary incontinence?

A
  • Prostatic hypertrophy - overflow incontinence
  • Overactive bladder syndrome/detrusor overactivity
  • Stress incontinence - pelvic muscle weakness
  • Fistula - bladder to vagina
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5
Q

What environmental factors can increase the risk of incontinence?

A
  • Bed bound
  • Reduced mobility
  • Where the toilet is/ease of access
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6
Q

What would you ask about when assessing urinary incontinence?

A
  • Urgency symptoms - time between needing to go and voiding, know when they need to pass urine
  • Stress symptoms -laughing, weight lifting
  • Obstructive symptoms - force, hesitancy, dribbling
  • Polyuria
  • Dysuria
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7
Q

What are the symptoms of stress incontinence?

A

Urine leak on movement, coughing, laughing, squatting, etc.

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8
Q

How would you evaluate someone with stress incotinence?

A
  • Examination
  • Dipstick
  • General bloods
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9
Q

What medical treatment would you use to treat stress incontinence?

A
  • Physio - pelvic floor exercises
  • Oestrogen cream
  • Duloxetine - SSRI
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10
Q

What surgery can be used to correct stress incontinence if no other treatment has worked?

A

TVT/colposuspension - 90% cure at 10 years

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11
Q

What are the features of urge incotinence?

A
  • Urgency - may have incontinence
  • Frequency
  • Nocturia
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12
Q

What can cause urge incontinence?

A
  • Bladder Stones
  • Stroke/Parkinsons
  • UTI
  • Diabetes
  • Atrophic vaginitis
  • Urethritis
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13
Q

How would you treat urge incontinence?

A

https://cks.nice.org.uk/incontinence-urinary-in-women#!scenario:1

  1. Lifestyle advice - reduce caffeine, stop smoking, lose weight
  2. Bladder retraining
  3. Anti-cholinergics - Oxybutinin, tolterodine, darifenacin
  4. Nocturia - Consider desmopressin
  5. Vaginal atrophy - oestrogen cream

​If these fail - refer to 2o care for other options - Botulinum toxin A, percutaneous sacral nerve stimulation, cystoplasty, and urinary diversion

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14
Q

What are characteristics of urinary retention with overflow incontinence?

A
  • Poor urine flow
  • Double voiding
  • Hesitancy
  • Post micturition dribbling
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15
Q

What can cause raised residual bladder volume in an elderly patient?

A
  • Prostatic hypertrophy
  • Urethral stricture
  • Bladder diverticulum
  • Pelvic organ prolapse - female only
  • Hypocontractile detrusor
  • Bladder tumour
  • Drugs
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16
Q

What is a neuropathic bladder?

A

An underactive bladder secondary to neurological disease, typically MS or stroke

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17
Q

How does a neuropathic bladder present?

A

Overflow incontinence

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18
Q

How would you treat a neuropathic bladder?

A

Catheterisation is the only treatment

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19
Q

How would you assess urinary incontinence?

A
  1. Physical examination
  2. Urine Dipstick +/- MSSU
  3. Bladder scan - residual volume
  4. QOL assessment and Bladder Diary
  5. Urodynamic studies
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20
Q

What information can be gained from a bladder diary?

A
  • 24 hr urine output
  • Number and severity of inconitnence episodes
  • Max/minimum voided volumes
  • Diurnal variation
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21
Q

When is bladder retraining indicated?

A

Overactive bladder syndrome

22
Q

When is pelvic floor training indicated?

A

Stress incontinence

23
Q

When would the use of antimuscarinics such as oxybutinin be indicated in urinary incontinence?

A

Overactive bladder/Urge incontinence

24
Q

When would performing a surgical TURP be indicated?

A

Urinary Retention with overflow incontinence/outflow obstruction - when the medications have not worked

25
Q

When would a TVT operation be considered?

A

Stress incontinence - when medications and physiotherapy have failed to work

26
Q

When would culposuspension be indicated in urinary incontinence?

A

Stress incontinence - if medical management fails - GOLD STANDARD

27
Q

When would duloxetine be indicated in urinary incontinence?

A

Stress incontinence

28
Q

When would oestrogen cream be indicated for in urinary incontinence?

A

Stress incontinence

29
Q

When would regular toileting be indicated for in urinary incontinence?

A
  • Dementia
  • Urge incontinence
30
Q

What are the indication for catheter insertion?

A
  • Symptomatic urinary retention
  • Outflow obstruction + renal failure/hydronephrosis
  • AKI - accurate urine monitoring
  • Intensive care
  • Sacral pressure sores + incontinence
  • Other methods cause stress to a frail individual
31
Q

When is the insertion of a catheter not indicated?

A
  • Immobility - even from stroke
  • Heart failure
  • Monitoring fluid balance in a continent patient
  • Nursing convenience
  • Asymptomatic chronic retention - refer to urology first
32
Q

How could you manage urinary incontinence which is still present after treating reversible cause without the use of a catheter?

A
  • Environmental modification
  • Regular/individual toileting programme
  • Pad/pants
  • Drainage sheath/condom catheter
  • Intermittent catheterisation
33
Q

When should you consider refering to urology for urinary incontinence?

A

After failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)

34
Q

How would you manage a blocked catheter?

A
  • Consider cause - stones, infection, sediment, constipation, bladder tumour
  • Remove and replace
  • Maintain good fluid intake
  • Consider saline washouts - if sediment
35
Q

How would you manage someone who’s catheter was bypassing?

A
  • Consider cause - irriation of bladder causing contraction, infection, sphincter incompetence from long term catheterisation
  • Exclude blockage
  • If no residual - reduce catheter diameter
36
Q

How would you manage someone with a catheter infection?

A
  • Send urine culture
  • Remove catheter where possible
  • Ensure adequate hydration
  • Abx - as narrow pectrum as possible once cultures received
37
Q

How would you decide if it was appropriate to treat a catheter infection?

A

Only treat if clinically significant infection - Fever, malaise, delerium, pain, abnormal inflammatory markers

Remember - dark, cloudy, smelly urine does not always indicate infection - more commonly dehydration

38
Q

What part of the autonomic nervous system causes contraction of the neck of the bladder and the internal urethral sphincter?

A

Sympathetic Nervous System - a-adrenoreceptor

39
Q

What part of the autonomic nervous system causes contraction of the bladder?

A

Parasympathetic Nervous System

40
Q

What part of the autonomic nervous system controls relaxation of the bladder?

A

Sympathetic - ß - adrenoreceptor

41
Q

What is stress incontinence?

A

Involuntary leakage on effort or exertion, on sneezing or coughing. Most commonly due to a weak bladder outlet

42
Q

What is urge incontinence?

A

Involuntary leakage accompanied by or immediately preceded by urgency (immediate need)

A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)

43
Q

What is urinary retention with overflow incontinence?

A

This is where the outlet of the bladder does not relax properly, or the detrusor muscle is too weak. Over time, urine builds up within the bladder and causes incontinence due to overflow

50
Q

What spinal levels are involved in storage of urine?

A

T10 - L2 (hypogastric nerve)

51
Q

What spinal levels are involved in voiding and voluntary sphincter control?

A

S2-S4 (pelvic and puedendal nerves)

52
Q

What would you look for on examination of someone with features of stress incontinence?

A
  • Examine pelvic floor for:
    • Weaknesses
    • Prolapse
    • Pelvic masses
  • Look for leaking with full bladder on standing
53
Q

What are risk factors for the development of stress incontinence?

A
  • Obesity
  • Pregnancy
  • Post-menopause
54
Q

How might you assess if incontinence is being caused by retention with overflow?

A
  • Palpate bladder post voiding
  • Post void bladder scan
55
Q

In terms of figuring out what is causing urinary incontinence, what might you want to exclude?

A
  • Neurological comorbidity - Parkinsons, Stroke, MS
  • Faecal impaction - Digital RE
56
Q

How would you investigate urge incontinence?

A

Urodynamic studies

57
Q

What is involved in a bladder diary?

A

A diary that records times and amounts of urine passed, leakage episodes, pad usage and other information such as fluid intake, degree of urgency and degree of incontinence. A bladder diary should cover variations in the usual activities, such as both working and leisure days.

This is normally taken over a period of 3 days

58
Q

What investigation would you consider doing first in a woman presenting with incontinence?

A

Urine dipstick

Reproductive Medicine (43 decks)

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