Female Urinary Incontinence

Question 1

rate of filling of the bladder

Answer 1

0.5-5ml/min

Question 2

what reflex protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bldder?

Answer 2

vesico ureteric

Question 3

rhabdosphincter contraction

Answer 3

increase
sphincter contraction and resistance. This cortical activity results in: activation of the sympathetic pathway, reciprocal inhibition
of the parasympathetic pathway and mediates contraction of the bladder base and proximal urethra.

Question 4

describe the action of the bladder emptying

Answer 4

The detrusor contracts and urethra relaxes, this combined with sphincter coordination allows bladder emptying. The absence or obstruction or anatomical shunts in the urinary tract may result in cystocele and diverticulum. The pontine micturition center exerts a cortical influence over this pathway. Activation of parasympathetic pathways and inhibition of sympathetic pathway occurs.

Question 5

define urinary incontinence

Answer 5

any involuntary leakage of urine

Question 6

define stress urinary incontinence

Answer 6

involuntary leakage on effort or exertion, on sneezing, or coughing

Question 7

define urge urinary incontienence

Answer 7

involuntary leakage accompanied by or immediately preceded by urgency

Question 8

define mixed urinary incontinence

Answer 8

Involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing

Question 9

what causes stress urinary incontinence

Answer 9

This occurs when intra-abdominal pressure exceeds urethral pressure, resulting in leakage. Urethral closure is increased by: pelvic floor muscle training, surgery, and pharmacological agents.

Question 10

impacts of urinary incontinence

Answer 10

Urinary incontinence may significantly impair the quality of life of the woman. It may cause her to reduce her social relationships and activities. It impairs emotional and psychological well-being. It may also impair sexual relationships. Incontinence causes embarrassment and diminished self-esteem. It is due to the impact of UI on a woman’s quality of life that medical help is sought. However, this is after many years of suffering – average 5 years.

Question 11

risk factors for urinary incontiennce

Answer 11

• Age
• Parity
• Menopause
• Smoking
• Medical problems
• Increased intra-abdominal pressure
• Pelvic floor trauma
• Denervation
• Connective tissue disease
• Surgery
Pregnancy and childbirth are the main risk factor for stress incontinence. The problem with childbirth
is that a large object must pass through a constricted channel with both the object and channel
emerging unscathed.

Question 12

history of urinary incontinence

Answer 12

• Age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
• Medical conditions
o DM, anti-hypertension medications, glaucoma, heart/kidney/liver problems, cognitive problems, anti-depressants/anti-psychotics
• Previous PFMT (pelvic floor muscle training), surgical treatment of stress incontinence or
pelvic organ prolapse

Question 13

urinary incontience complaints

Answer 13

• Irritation symptoms
o Urgency
o Increased daytime frequency >7
o Nocturia >1
o Dysuria
o Haematuria
• Incontinence symptoms
o Stress UI
o Urgency UI
o Coital incontinence
o Severity – how many pads/days
• Voiding symptoms
o Straining to void
o Interrupted flow
o Recurrent UTI
• Fluid intake: quantity and content
• Effect on QoL
• Prolapse symptoms
o Vaginal lump/dragging sensation in vagina
• Bowel symptoms
o Anal incontinence, constipation, fecal evacuation dysfunction, IBS
• 3-day urinary diary
o Fluid intake: quantity and quality
o Urine out-put (exclude nocturnal polyuria)
o Daytime frequency
o Nocturia
o Average voided volume
• Urine dipstick

Question 14

examination of urinary incontinence

Answer 14

• General
• Abdominal
• Neurological
• Gynecological
• Pelvic floor assessment (Oxford Scale)
• Prolapse
• Stress incontinence
• Uro-genital atrophy changes
• Pelvic mass (space occupying lesion)
• Pelvic floor tone, strength, awareness

Question 15

investigations of urinary incontinence

Answer 15

• Urinalysis – mutlistix +/- MSSU
• Post voiding residual volume assessment (usually by bladder scanning) only if symptoms of voiding difficulties
• Urodynamics – only indicated if surgical treatment is contemplated

Question 16

management of urinary incontinence

Answer 16

• Lifestyle changes
o Stop smoking
o Lose weight
o Eat more healthily to avoid constipation
o Stop drinking alcohol and caffeine
• Medical treatments
• Physiotherapy
• Surgery

Question 17

pelvic flow muscle training aims

Answer 17

1. Reinforcement of cortical awareness of muscle groups
2. Hypertrophy of existing muscle fibres
3. General increase in muscle tone and strength

Question 18

discuss duloxetine in the management of urinary intinence

Answer 18

This is the first and currently the drug licensed for the treatment of moderate to severe stress urinary incontinence. The Scottish Medicines Consortium (SMC) has now approved Duloxetine for restricted use in the treatment of moderate to severe incontinence. It should be part of an overall management strategy that should include pelvic floor muscle training.

Question 19

who should recieive duloxetine for urinary incontinence

Answer 19

• Primary care
o If PFMT has failed or would be enhanced by the prescribing of duloxetine
• Secondary care
o Does not wish surgery
o Not fit for surgery
o After failed surgery
o When the patient’s family is not complete

Question 20

integral theory of female urinary incontinence

Answer 20

Both stress and urge incontinence arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament – urethral/bladder neck closure dysfunction and USI. Sub urethral hammock laxity might result in stimulation of the bladder neck stretch receptors, provoking a premature micturition reflex and urge incontinence.

Question 21

mid urethral slings, retro-pubic TVT in urinary incontience

Answer 21

Tension-free vaginal tape (TVT) was introduced into clinical practice by Ulmsten in 1996 as a minimally
invasive procedure to reinforce the structures supporting the urethra. It depends on the Hammock
theory for continence. 80% cure at 11 years follow up. The tape is polypropylene permanent synthetic
tape, monofilament and macro-porous. TVT is as effective as colposuspension for the treatment of
primary USI up to two years. There is less operative and postoperative morbidity associated with TVT
when compared to colposuspension. TVT has now replaced colposuspension as the first-choice
treatment procedure in the surgical treatment of SUI.

Question 22

what is overactive bladder syndrome

Answer 22

A symptom complex, usually, but not always, related to urodynamically demonstrable detrusor overactivity. Defining symptoms: urgency (+/- urge incontinence), usually with frequency and Nocturia.

Question 23

risk factors for urge incontinence

Answer 23

advanced age, diabetes, UTIs, smoking. OAB is a chronic condition
and therefore symptoms may wax and wane.

Question 24

management of overactive bladder syndrome

Answer 24

• Treat symptoms
• No immediate cure
• MDT
• Requires dedicated team
• Conservative management
o Life style interventions
§ Normalize fluid intake
§ Reduce caffeine, fizzy drinks, chocolate
§ Stop smoking
§ Weight loss
o Bladder training programme
§ Timed voiding with gradually increasing intervals – continence nurse
• Pharmacological treatment
o Antimuscarinic
§ Oral
• Solifenacin (Vesicare 5-10mg)
• Fesoteridine (Toviaz 4-8mg)
• Trospium chloride (60mg XL)
• Darifenacin (Emselex 7.5-15mg) – constipation
• Lyrinel XL (10-20mg)
• Oxybutynin (5-10mg/tds)
§ Transdermal
• Kentera patches
o Tricyclic antidepressants
§ Imipramine

Question 25

botox in urinary incontinece

Answer 25

§ Botulinum toxin (A+B)
§ NDO/IDO
§ 200-300 units (12 U/Kg)
§ Cystoscopy/GA
§ 75% cure and significant improvement
§ Effects last for 6-9 months
§ CISC

Question 26

neuromodulation in urinary incontinence

Answer 26

§ Needle stimulation
§ Reflex inhibition to the detrusor muscle
§ Cheap
§ Minimally invasive
§ 70% improvement in refractory OABS