Female urinary incontinence Flashcards
Upper tract of urinary tract involves
kidneys
ureters
Lower tract of urinary tract involves
bladder
urethra
Definition of the upper tract of the urinary tract
Low pressure distensible conduit with intrinsic peristalsis which transports urine from nephrons to the bladder
Rate of bladder filling
0.5-5mls/min
Function of lower tract of urinary tract
low pressure storage of urine
efficient expulsion of urine at an appropriate place and time
Function of vesico-ureteric mechanism
Protects the nephrons from any damage to secondary to retrograde transmission of back pressure or infection of the bladder
Nerves that supply the storage function of the bladder
Hypogastric nerve (sympathetic) T10-L2
Nerves that supply the voiding function of the bladder
pelvic nerve (parasympathetic) S2-4
Nerves that supply the voluntary aspect of the bladder
Pudendal nerve (somatic) S2-4
How does the bladder empty?
- detrusor contraction
- urethral relaxation
- sphincter contraction
- cortical influence (pontine micturition centre)
What happens from the cortical influence (pontine micturition centre) in the emptying of the bladder?
Activation of parasympathetic pathway and inhibition of sympathetic pathway
Types of urinary incontinence
Urinary incontinence
Stress urinary incontinence
Urge urinary incontinence / Overactive bladder
Mixed urinary incontinence
Definition of urinary incontinence
ANY involuntary leakage of urine
Definition of stress urinary incontinence
Involuntary leakage on effort of exertion, on sneezing or coughing. Intraabdominal pressure exceeds the urethral pressure, resulting in leakage
Definition of urge incontinence
Involuntary leakage accompanied by or immediately preceded by urgency
Definition of mixed incontinence
Involuntary leakage of urine accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing
Prevalence of urinary incontinence increases with….
Age
Impact of urinary incontinence
May significantly impact QoL
Reduce social relationships and activities
Impair emotional and psychological well being
Impair sexual relationships
Embarrassment and diminished self esteem
Pathology of stress and urge incontinence
Anatomical defect in the anterior vaginal wall and pubo-urethral ligament -> urethral/bladder neck closure dysfunction and USI
Risk factors for urinary incontinence
age parity menopause smoking medical problems increased intraabdominal pressure pelvic floor trauma denervation connective tissue disease surgery pregnancy and childbirth
Main risk factor for stress incontinence
Pregnancy and childbirth
Symptoms of urinary incontinence
Irritation symptoms
- urgency
- sudden compelling desire to void that is difficult to defer
- increased daytime frequency (>7)
- nocturia (>1)
- dysuria
- haematuria
- urgency usually associated with frequency, nocturia, and urgency
- Incontinence
- stress UI
- urgency UI
- coital incontinence
- severities pads/day
- voiding
- straining to void
- interrupted flow
- recurrent UTI
- Prolapse symptoms
- vaginal lump
- dragging sensation in vagina
- Bowel symptoms
- anal incontinence
- constipation
- faecal evacuation dysfunction
- IBS
Investigations for urinary incontinence
History and examination 3 day urinary diary Effect on QoL Urinary dipstick Urinalysis (multistix +/- MSSU) Post voiding residual voiding assessment Urodynamics
When is the investigation of urodynamics ONLY indicated?
if surgical treatment is implicated
Urodynamics involves…
Uroflytometery
Multi-channel cystometry
Treatment of urinary incontinence
- Nothing
- Conservative
- Physiotherapy - PFMT for stress UI, bladder retraining for urgency UI
- Yentreve (Duloxetine) or antimuscarinics
- Surgery
In the treatment of urinary incontinence, when is Duloxetine used?
If PFMT failed or would be enhanced by Does not wish surgery Not fit enough for surgery After failed surgery When patients family are not complete
Definition of Overactive Bladder Syndrome (OBS)
A symptom complex (symptom syndrome) usually related to urodynamically demonstrable detrusor overactivity (DO) but may also be due to other uterovesical dysfunction
Who does overactive bladder syndrome affect?
Both sexes
All ages
Types of detrusor overactivity in overactive bladder syndrome
neurogenic (relevant neurological condition)
Idiopathic
Defining symptoms of overactive bladder syndrome
Urgency +/- urgency incontinence
Frequency
Nocturia
Definition of urge
The complaint of a sudden, compelling desire to pass urine that is difficult to defer
Definition of urge incontinence
The complaint of involuntary leakage accompanied or immediately preceded by urgency
Definition of frequency
The complaint by the patient who considers they void too often by the day, usually accompanies urgency +/- urge UI
Definition of nocturia
The complaint that the individual has to wake at night one or more times to void, usually accompanying urgency +/- urge incontinece
Risk factors for urge incontinence
Advanced age
Diabetes
UTI
Smoking
Treatment for overactive bladder syndrome
Lifestyle interventions - normalise fluid intake - reduce caffeine, fizzy drinks - stop smoking - weight loss Bladder training programme Antimuscarinics Tri-cyclic antidepressants Botox Neuromodulation
What are the 3 stages of urgency incontinence?
Mild
- can keep it
- do not have to stop conversation to go to the toilet
Moderate
- Have to stop the conversation as cannot wait to go to the toilet
Severe
- Has to go to the toilet right away otherwise will have an accident
How many women > 40 y/o have Urinary incontinence?
30 - 40%
How many women < 24 y/o have urinary incontinence?
12 - 14%
What is the most common type of urinary incontinence?
Stress UI
% of people who get each type of UI
Stress - 43%
Urgency / OAB - 21%
Mixed - 35%
Pathology of an overactive bladder
The bladder is contracting too much due to activity from nerves and the micturition centre
Pathology of stress incontinence
Problem with the pelvic floor - weak levator ani muscles
Cannot control urethra properly
Increased IAP
What does IAP stand for?
Intra abdominal pressure
What fruits in particular can make you go to the toilet?
Citrus fruits
Describe bladder retraining
Hold urine for 2 hours then go
Increase the time in between each time you go until up to 4 hours
This impulses the brain not to contract every time that the patient needs to go
What surgery can be done for stress UI?
Colposuspension
MUS (tapes)
What does MUS stand for?
Mid urethral slings
Which of the treatments for SUI is very invasive?
Colposuspension
What surgery can be done for urgency UI?
Botox injection every 6 - 9 months
- into detrusor muscle so it does not contract
- however self catheterisation required every 3 - 4 hours
Sacral nerve modulation
- Use tibial nerve to stimulate nerves around the bladder
- not commonly used
1st line treatment for urge incontinence
Bladder retraining
1st line treatment for stress incontinence
PFMT
Give an example of an antimuscarinic
Oxybutylin
On urodynamics, what does a high voiding detrusor pressure and a low peak flow rate indicative of?
Bladder outflow obstruction
What would indicate a vesicovaginal fistula?
Patients with continuous dribbling in continence after prolonged labour and from a country with poor obstetric services
Investigation of vesicovaginal fistula
Urinary dye studies
What is the investigation of choice in incontinence where the diagnosis is uncertain or there is plans for surgery?
Urodynamic studies
