Female urinary incontinence Flashcards
Upper urinary tract
kidney and ureter
low pressure distensible - intrinsic peristalsis
urine from nephrons to the ureters to bladder
Lower urinary tract
bladder and urethra
low pressure storage of urine
filling rate of bladder
0.5-5mls/min
function of vesico-ureteric mechanism
protect nephrons from retrograde transmission of back pressure or infection from the bladder
bladder nerve supply - storage
hypogastric T10-L2
sympathetic
bladder nerve supply - voiding
pelvic nerve S2-4
parasympathetic
bladder nerve supply - voluntary
pudendal nerve S2-4
somatic
Cortical activity function - bladder filling
increase sphincter contraction and resistance
how does cortical activity work in bladder filling
activate sympathetic pathway
reciprocal inhibition of the parasympathetic
contraction of bladder base and proximal urethra
Bladder emptying
detrusor contraction
urethral relaxation
sphincter co-ordination
absence of obstruction
Cortical influence in bladder emptying
pontine micturition centre
activate parasympathetic and inhibit sympathetic
Urinary incontinence
Any involuntary leakage of urine
stress UI
involuntary leakage on effort, sneezing, coughing etc
urge UI
involuntary leakage accompanied or preceded by urgency
Mixed UI
involuntary leakage accompanied or immediately preceded by urgency and on effort, sneezing etc
Epidemiology of incontinence
10-25% of 15-60
15-40% of over 60
>50% in nursing homes
Impact of UI
QOL sexual life social activities psychological self esteem
Main risk factor for incontinence
parity and childbirth
Other risk factors for incontinence
pelvic surgery age menopause smoking/alcohol medical increase intra abdominal pressure pelvic floor trauma denervation connective tissue disease
Incontinence - history
- age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
- medical conditions, DM, glaucoma, heart/kidney/liver
- previous PFMT, surgical treatment of SUI or POP
Irritation symptoms
urgency, >7 day, nocturia, dysuria, haematuria
incontinence symptoms
SUI, UUI, coital, severity - number of pads
Voiding symptoms
straining, interrupted flow, recurrent UTI
Prolapse symptoms
vaginal lump, dragging sensation
Bowel symptoms - incontinence
IBS, constipation, anal incontinence
3 days urine diary
fluid intake - quantity and content urine output daytime frequency nocturia average voidal volume
Examination
general eg BMI abdo - distention neurological - sacral lower limb gynaecological pelvic floor assessment prolapse SUI uro-genital atrophy pelvic mass pelvic floor, tone, strength, awareness
Investigations
urinalysis
post voiding residual volume
urondynamics - uroflowmetry and cystometry
4 broad management methods for incontinence
lifestyle changes
surgery
pharmacological
physio
How to increase urethral closure pressure in SUI
PFMT
surgery
pharmacology
lifestyle changes
stop smoking
lose weight
eat healthy
stop drinking alcohol
PFMT - 3 basic principles of what it does
reinforce cortical awareness of muscle groups
hypertrophy of existing muscle groups
general increase in muscle tone and strength
Pharmacological treatment for SUI
duloxetine
Colposuspension
raise bladder neck - surgery
Integral theory of female UI
both arise from problem with anterior vagina wall/pubo-urethral ligament
USI - urethral/bladder neck closure dysfunction
UUI - suburethral hammock laxity
TVT function
reinforce structure supporting urethra
First line for SUI surgery
TVT
concerns over TVT
bladder perforation
vaginal and urethral erosions
several vascular injuries
TOT side effect
thigh pain
cause of OAB
detrusor overactivity
OAB symptoms
urgency, frequency, nocturia, UUI
urgency
complaint of sudden, compelling desire to pass urine
OAB treatment
fluid intake, reduce caffeine, stop smoking, weight loss
bladder training programme
Bladder retraining
re-establish cortical control over detrusor
timed bladder emptying programme
pharmacological treatment of OAB
anti-muscarinic - oral or transdermal
tri cyclic antidepressants
Recent advances in OAB treatment
botox
neuromodulation (S2-4)
