Female Urinary Incontinence Flashcards
What is the upper urinary tract?
Kidneys & ureters
Low pressure distensible conduit with intrinsic peristalsis
What is the lower urinary tract?
Bladder & urethra
Low pressure storage of urine
How quickly does the bladder fill with urine?
0.5-5mls/min
What is the nerve supply to the bladder?
Hypogastric nerve (sympathetic) T10-L2 - STORAGE
Pelvic nerve (parasympathetic) S2-4 - VOIDING
Pudendal nerve (somatic, voluntary) - S2-S4
What cortical activity occurs during bladder filling?
Activation of reciprocal guarding reflex by rhabdosphincter (sphincter consisting of striated muscle) contraction, increased sphincter contraction & resistance
Sympathetic activation, reciprocal parasympathetic inactivation –> mediates contraction of bladder base & proximal urethra
What occurs in bladder emptying?
Detrusor contraction
Urethral relaxation
Sphincter co-ordination
Absence of obstruction or anatomical shunt
Cortical influence (pontine micturition centre) –> activation of parasympathetic pathway and inhibition of sympathetic pathway
Define urinary incontinence
Any involuntary leakage of urine
Define stress urinary incontinence
Any involuntary leakage of urine on effort/exertion/sneezing/coughing
Define urge urinary incontinence
Involuntary leakage accompanied by or immediately proceeded by urgency
Define mixed urinary incontinence
Involuntary leakage accompanied by or immediately preceded by urgency & on effort/exertion/sneezing/coughing
Prevalence of IU increases with what?
Age
UI is not lifethreatening so why do we Rx it?
QoL issue
Impairs relationships, activity, emotion and mental well being
May lead to embarrassment and low self-esteem
What are the risk factors for UI?
Age Parity Menopause Smoking Medical problems Increased intra-abdominal pressure (heavy physical labour) Pelvic floor trauma (e.g. childbirth) Denervation Connective tissue dx Surgery
What are the main RFs for stress incontinence?
Pregnancy & childbirth
What do you want to ask in your hx of UI?
Age, parity, mode of delivery, wt of heaviest baby, smoking, HRT Medical conditions Prev pelvic muscle floor trauma/training, surgical Rx of SUI or POP Irritation symptoms Incontinence symptoms Voiding symptoms Fluid intake Effect on QoL out of ten Prolapse symptoms Bowel symptoms
What do you want to ask about irritation symptoms?
Urgency - sudden, compelling desire to void that is difficult to feder Increased daytime frequency (>7x) Nocturia (>1x) Dysuria Haematuria
What do you want to ask about voiding symptoms?
Straining to void
Interrupted flow
Recurrent UTI
What do you want to ask about fluid intake?
Quality & quantity
What do you want to ask about prolapse symptoms?
Vaginal lumps
Dragging sensation in vagina
What bowel symptoms do you want to ask about?
Anal incontinence
Constipation
Faecal evacuation dysfunction
IBS
What should be your initial assessment of a patient with UI?
3 day urinary diary
Fluid intake, urine output, daytime freq, nocturia, avg. voided volume, caffeine intake, accidents and what she was doing at the time
How do you examine a woman with bladder/pelvic floor problems?
Ht, wt
Abdominal - bladder distension
Neurological - esp sacral segment, assess lower limb movement, cognitive dx (esp in elderly), mobility
Gynae - prolapse, urogenital atrophy, pelvic mass, pelvic floor tone, strength, awareness
Pelvic floor assessment - Oxford scale
What is the Oxford grading scale for pelvic floor muscles?
0 - no muscle activity 1 - minor muscle flicker 2 - weak muscle activity wo circular contraction 3 - moderate muscle contraction 4 - good muscle contraction 5 - strong muscle contraction
What Ix can you do for UI?
Urinalysis - multistix +/- MSSU
Post-voiding residual volume assessment (usually bladder scanning) - only if symptoms of voiding difficulties
Urodynamics - only if surgery contemplated
How do you manage UI?
Lifestyle changes
Medical Rx
Physiotherapy
Surgery
When does stress UI occur?
When intra-abdominal pressure exceeds urethral pressure (damage to sphincter, weak pelvic floor muscles, sphincter) –> leakage
Can increase urethral closure pressure by PFMT, surgery & drugs
What lifestyle changes should be advised for UI?
Stop smoking
Lose weight
Eat more healthily to avoid constipation
Stop drinking alcohol & coffee
What does PFMT do?
Reinforces cortical awareness of muscle groups
Hypertrophy of existing muscles
General increase in muscle tone & strength
How many times should you do PFMT?
3 sets 5x day
What meds can you use for SUI?
Duloxetine
Only if mod-severe, PFMT has failed/would be enhanced in primary care, or surgery not wished for in secondary care
What is colposuspension?
Suturing of bladder neck above pelvic floor (holding it in a lifted position)
Prevents involuntary leaks in those with SUI
What is the integral theory of female UI?
Both SUI and UUI arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament –> bladder/urethral neck closure dysfunction –> UI
What is the hammock theory of female UI?
Pubocervical fascia provides hammock like support for visceral neck and therefore is a backboard for compression of the proximal urethra during increased intra-abdominal pressure
Loss of this support would lead to equal transmission of iap
What is retropubic TVT?
Tension free vaginal tape
Minimally invasive procedure that reinforces the structures supporting the urethra
Used for Rx of SUI
What kind of tape is used for TVT?
Polypropene permanent synthetic tape
Monofilament macroporous
Which of TVT and colposuspension is most effective?
Same effectiveness for SUI
TVT 1st line as less operative/post-operative morbidity
What are common surgical complications with TVT?
Bladder perforation, vaginal and urethral erosions, vascular injuries
What is overactive bladder syndrome?
Due to detrusor over activity
Urgency +/- frequency/nocturia
Usually caused by involuntary detrusor contraction during filling that are either spontaneous/provoked
What is neurogenic overactive bladder syndrome?
Abnormal detrusor contractions that are related to a neurologic condition
Who is OAB most common in?
Older woman
Define urinary frequency
Complaint of voiding too often by day
Define nocturia
Complaint that they wake up at night once or more time to void
What are risk factors for urge incontinence?
Advanced age
DM
Urinary tract infections
Smoking
How do you Rx OAB?
Symptomatically
NO immediate cure
What lifestyle interventions help in OAB?
Normalise fluid intake Reduce caffeine, fizzy drinks, chocolate Stop smoking Wt loss Bladder training programme
What is involved in the bladder training programme?
Timed voiding with gradually increased intervals
Attempts to re-establish cortical control over detrusor
What drugs can you use to Rx OAB?
Antimuscarinics (e.g. solifenacin, fesoteridine, oxybutynin oral options, kentera patches are transdermal)
TCAs, e.g. imipramine
What procedures can you offer for OAB?
Botulinium toxin (A and B) - lasts for 6-9m CISC - clean intermittent self catheterisation Neuromodulation - needle stimulation of S2-4 (--> reflex inhibition of detrusor muscle)
