Female Urinary Incontinence Flashcards
What are the 2 components of the Urinary Tract?
Wat is the Vesico-ureteric mechanism?
The 2 mutually dependent components of the urinary tract include:
-
Upper Tract (Kidneys and Ureters)
- Low pressure distensible conduit with intrinsic peristalsis
- Transport urine from nephrons via ureters to bladder.
-
Lower Tract (Bladder and Urethra)
- Bladder fils at rate 0.5 - 5ml/min
- Low pressure storage of urine.
- Efficient expulsion of urine at appropriate time & place.
Vesico-ureteric mechansism:
- protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder.
Which nerves are responsible for maintaining urine stoarge?
Hypogastric nerve (sympathetic)
T10-L2
What nerves are responsible for voiding of urine?
Pelvic Nerve (PS)
S2-4
What nerve is reponsible for the voluntary control of urination?
Pudendal nerve (somatic)
S2-4
Ouutline how a filling bladder maintains a low pressure.
How are we aware that the bladder is gradually filling?
The bladder is a distenible ag, therefore its stretch can ensure increased volume has a limited/no effect on increasing the pressure.
Outline the link between bladder filling and cortical activity.
- Cortical activity: Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
- Activates Sympathetic pathway &
- Reciprocal inhibition of the Parasympathetic pathway
- Mediates contraction of bladder base and proximal urethra.
What are the processes that take place in bladder emptying?
What is cortical influence of this?
- Detrusor contraction
- Urethral Relaxation
- Spincter co-ordination
- Absence of Obstruction or anatomical
Cortical Influence (Pontine Micturition Centre)
–> Activation of PS pathway & inhibtion of sympathetic pathway.
Defintions:
- Urinary Incontinence
- Stress Urinary Incontinence
- Urge Urinary incontinence
- Mixed Urinary incontinence
- Urinary Incontinece
- ANY involuntary leakage of Urine.
- Stress Urinary Incontinence
- Involuntary leakage on effort or exertion, on sneezing or coughing.
- Urge incontience
- Involuntary leakage accompanied by or immediately preceded by urgency.
- Mixed urinary incontinence
- Involuntary leakage accompanied by or immediately preceded by urgency & on effort of exertion, or on sneezing or coughing.
How does the prevalence of Incontinence vary with age?
Prevelence increases with age.
What is the impact of Urinary Incontinece?
Urinary Incontinences impact is primarily in terms of its effect on Quality of Life.
- Reduce social relationships and activities.
- Impair emotional and psycological well-being.
- Impair sexaul relationships
- Embarrassement and diminished self esteem.
Due to this impact of women’s QoL that medical help is sought - however this is after many years of suffering (average 5 years).
What are the risk factors for Urinary Incontinence?
- Age
- Parity - childbirth is the main risk factor.
- Menopause
- Smoking
- Medical problems
- Increased abdo pressure
- Pelvic floor trauma
- Denervation
- CT disease
- Surgery
In a history with Urinary Incontinece - what subjects need to be approached?
- Age, parity, mode of deliveries, weight of heaviest baby, Smoking, HRT,
- Medical Conditions:
- DM
- anti-HTN medications
- Glaucoma
- Heart/Kidney/Liver problems, Cognitive problems, Anti-depressants/ anti-psychotics.
- Previous PFMT, Surgical treatment of SUI or POP
What “iritation Symptoms” can a patient with Urinary Incontinence present with?
- Urgency
- Increased daytime frequency
- Nocturia
- Dysuria
- Haematuria
What incontince symptoms can someone with UI present with?
- Stress UI
- Urgency UI
- Coital Incontinence
- Severity - How many pads/days?
What voiding symptoms can a patient present with?
- Straining to void
- Interrupted flow
- Recurrent UTI
What are the Prolpase and Bowel Symptoms that patients with UI can present with?
Prolapse
- Vaginal Lump / Dragging sensation in vagina
Bowel Symptoms
- Anal Incontinece
- Constipation
- Faecal Evacuation Dysfunction
- IBS
What doe the 3 day Urinary Diary take into account?
- Fluid intake: Quantity & Quality
- Urine Out-Put (exclude Nocturnal Polyuria)
- Daytime Frequency,
- Nocturia
- Average voided volume.
What examinations need to be carried out on women with bladder/pelvic floor problems?
- General
- Abdominal
- Nerological
- Gynaegological
- Pelvic Floor Assesment (Oxford Scale)
What things are being looked flor on examination of the women with bladder/ pelvic floor problems?
- Prolapse
- Stress incontinence
- Uro-genital atrophy changes
- Pelvic mass (space occupying leasion)
- Pelvic floor tone, strength, awareness
What investigations can be used in UI?
- Urinalysis: Multistix +/- MSSU
- Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties.
- Urodynamics: ONLY indicated if surgical treatment is contemplated.
What are the different types of management that can be used in UI?
- Lifestyle changes
- Medical treatments
- Physiotherapy
- Surgery
What is the management of Stress Urinary Incontinence?
Stress incontinence occurs when intra-abdominal pressure exceeds urethral pressure, resulting in leakage.
Urethral closure pressure is increased by:
- Pelvic Floor Muscle Training
- Surgery
- Pharamcological agents
What lifestyle changes can be implemented to manage UI?
- Stop smoking
- Lose weight
- Eat more healthily - stops constipation
- Stop drinking alcohol and caffeine
What are the benefits of Pelvic Floor Muscle Training?
- Reinforce corticol awareness of muscle groups
- Hypertrophy of existing muscel fibres
- General increase in muscle tone
More effective than vaginal cones, electrical stimulation and no treatment.
What is the Pharamocological management of UI?
Duloxetine - restricted for treatement of moderate to severe stress incontinence, should be part of an overall management strategy which includes Pelvic Floor Exercises.
Who should recieve Duloxetine?
Primary Care
- If PFMT has failed or would be enhanced by prescribing Duloxetine.
Secondary Care
- Does not wish surgery.
- Not fit for surgery.
- After failed surgery.
- When patients family is not complete.
What is the “intergral theory of Female UI”?
Both Stress and Urge incontinence arise from the same anatomical defect in the anterior vaginal wall & pubo-urethral ligament (PUL).
Urethral/bladder neck closure dysfunction and USI.
How can a Suburethral Hammock help UI?
Suburethral Hammock laxity might result in stimulation of bladder neck stretch receptors, provoking a premature micturition reflex and Urgency Incontinence.
What is TVT?
Mid-urethral Slings
Retro-pubic TVT
- Tension-free vaginal tape (TVT) - minimally invase procedure to reinforce the structures supporting the urethra.
- Depends on the hammock theory for continence.
- 80% cure at 11 years follow up.
As effective as colposuspension for treating USI up to 2 years.
Less operative and postop morbidity.
TVT has replace colposuspension as the first choice procedure in SUI treatment.
What is overactive bladder syndrome?
What are the defining symptoms?
- A symptom complex usually, but not always related to urodynamically demonstrable detrusor overactivity.
Symptoms:
- urgency - without uregency incontinence
- frequency
- nocturia
Risk facotrs for urge incontinece?
- Advanced age
- Diabetes
- Urinary tract infections
- Smoking
What is the managemnt of OAB?
- Treat symptoms
- No immediate cure
- Multidisciplinary approach
- Requires dedicated team
Consrevative:
Life Style Interventions
- Normalise fluid intake
- Reduce caffeine, fizzy drinks, chocolate
- Stop smoking
- Weight loss
Bladder training programme
- Timed voiding with gradullay increasing intervals.
Pharmacological treatment of OAB?
Antimuscarinic
Tri-cyclic antidepressants
Botox
Neuromodulation
