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Female Urinary Incontinence Flashcards

1
Q

What does the vesico-ureteric mechanism?

A

Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder

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2
Q

What rate does the bladder fill at?

A

0.5-5mls/min

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3
Q

What are the 2 components of the urinary tract?

A

Upper tract

  • Kidneys and ureters
  • A low pressure distensible conduit with intrinsic peristalsis

Lower tract

  • Bladder and urethra
  • A low pressure storage of urine
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4
Q

What nerves are involved in the storage of urine?

A

Hypogastric nerve
Sympathetic
T10-S2

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5
Q

What nerves are involved in the voiding of urine?

A

Pelvic nerve
Parasympathetic
S2-S4

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6
Q

What nerves are involved in the voluntary control of the bladder?

A

Pudendal nerve
Somatic
S2-4

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7
Q

What cortical activity is involved in the filling of the bladder?

A

Cortical activity activates a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
-Activates symptathetic pathway
-Reciprocal inhibition of the parasympathetic pathway
M
-Mediates contraction of bladder base and proximal urethra

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8
Q

What occurs during bladder emptying?

A

Cortical influence from pontine micturition centre leads to activation of parasympathetic pathway and inhibition of the sympathetic pathway

  • Detrusor contraction.
  • Urethral Relaxation.
  • Sphincter co-ordination.
  • Absence of Obstruction or anatomical shunts
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9
Q

Urinary incontinence

A

ANY involuntary leakage of urine

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10
Q

Stress urinary incontinence

A

Involuntary leakage on effort or exertion, on sneezing or coughing

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11
Q

Urge urinary incontinence

A

Involuntary leakage accompanied by or immediately preceded by urgency

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12
Q

Mixed urinary incontinence

A

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

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13
Q

What is the epidemiology of urinary incontinence?

A
  • 10-25% of women age 15-60 report urinary incontinence.
  • 15-40% of women over age 60 in the community report incontinence.
  • More than 50% of women in nursing homes are incontinent.
  • W.H.O. recognizes incontinence as an international health concern.
  • Prevalence increases with age
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14
Q

What is the impact of UI?

A
  • UI may significantly impair the QoL.
  • Reduce social relationships and activities.
  • Impair emotional and psychological well- being.
  • Impair sexual relationships.
  • Embarrassment and diminished self- esteem.
  • It is due to the impact of UI on women ’ s
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15
Q

Why do women generally seek medical help for UI?

A

Due to deterioration of QoL

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16
Q

What are the risk factors for UI?

A
  • Age
  • Parity
  • Menopause
  • Smoking
  • Medical problems
  • Increased intra abdominal pressure
  • Pelvic floor trauma
  • Denervation
  • Connective tissue disease
  • Surgery
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17
Q

What are the main risk factors for SI?

A

Pregnancy and childbirth

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18
Q

How is a patient with UI assessed?

A
  • History
  • Examination
  • Investigations
  • Managment
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19
Q

What history should be obtained for UI?

A
  • 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
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20
Q

What are the 3 types of symptoms a patient may present with?

A
  • Irritation symptoms
  • Incontinence symptoms
  • Voidng symptoms

-Also may have prolapse of bowel symptoms

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21
Q

What irritation symptoms may a patient present with?

A
  • Urgency ; Sudden compelling desire to void that is difficult to defer.
  • Increased daytime frequency (>7)
  • Nocturia (>1)
  • Dysuria
  • Haematuria
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22
Q

What incontinence symptoms may a patient present with?

A
  • Stress UI
  • Urgency UI
  • Coital Incontinence
  • Severity: How many pads/ day?
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23
Q

What us urgency usually associated with?

A

Frequency and nocturia

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24
Q

What voiding symptoms may a patient present with?

A
  • Straining to void
  • Interrupted flow
  • Recurrent UTI
25
Q

What prolapse symptoms may a patient present with?

A
  • Vaginal lump

- Dragging sensation in vagina

26
Q

What bowel symptoms may a patient present with?

A
  • Anal incontinence
  • Constipation
  • Faecal evacuation
  • Dysfunction
  • IBS
27
Q

What investigations should be carried out?

A
  • QoL assessment
  • 3 day urinary diary
  • Urinalysis (MSSU an dipstick)
  • Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties.
  • Urodynamics: ONLY indicated if surgical treatment is contemplated.
28
Q

What should be noted in a 3 day urinary diary?

A
  • Fluid intake: Quantity & Quality
  • Urine Out-Put (exclude Nocturnal Polyuria)
  • Daytime Frequency,
  • Nocturia
  • Average voided volume.
29
Q

What examination should a woman presenting with UI have?

A
  • General
  • Abdominal
  • Neurological
  • Gynaecological
  • Pelvic floor assessment (Oxford scale)
30
Q

What should be looked at on examination of a women presenting with UI?

A
  • Prolapse
  • Stress incontinence
  • Uro-genital atrophy changes
  • Pelvic mass (space occupying leasion)
  • Pelvic floor tone, strength, awareness
31
Q

What are the principles of management?

A
  • Lifestyle changes
  • Medical treatments
  • Physiotherapy
  • Surgery
32
Q

When does stress incontinence occur?

A

When intra-abdominal pressure exceeds urethral pressure resulting in leakage

33
Q

What is urethral closure increased by?

A
  • Pelvic floor muscle training
  • Surgery
  • Pharmacological agents
34
Q

What lifestyle changes should be advised as part of management?

A
  • Stop smoking
  • Lose weight
  • Eat more healthily to avoid constipation
  • Stop drinking alcohol and caffeine
35
Q

Who should receive conservative treatment for UI?

A

Everyone unless

  • Patient doesn’t wish it
  • Previously failed
  • No facilities
36
Q

What does pelvic floor muscle lead to?

A
  • Reinforcement of cortical awareness of muscle groups
  • Hypertrophy of existing muscle fibres
  • General increase in muscle tone and strength
37
Q

What is the effectiveness of pelvic floor muscle training?

A

60-70% cure or significant improvement

38
Q

What is the only drug licensed for the treatment of moderate to sever SUI?

A

Duloxetine

39
Q

Who should receive duloxetine?

A

Primary care
-If PFMT has failed or would be enhanced by duloxetine

Secondary care

  • Does not wish surgery
  • Not fir for surgery
  • After failure surgery
  • When the patients family is not complete
40
Q

What anatomical defect is associated with SUI and UUI?

A
  • Defect in the anterior vaginal wall and pubo-urethral ligament
  • Urethral/bladder neck closure dysfunction and USI
41
Q

What can suburethral hammock laxity result in?

A

Stimulation of bladder neck stretch receptors provoking a premature micturition reflex and urgency incontinence

42
Q

How can the structures supporting the urethra be reinforced?

A
  • Tension free vaginal tape
  • Minimally invasive
  • Depends on hammock theory
  • 80% cure rate at 11 years follow up
  • Polypropylene permenant Synthetic Tape; Monofilament & Macro-porous.
43
Q

What surgical management options are there?

A
  • Colposuspension

- TVT

44
Q

What are the common surgical complications of TVT?

A
  • Bladder perforation
  • Vaginal and urethral erosions
  • Vascular injuries attributed to blind penetration of the retro-pubic space
45
Q

Overactive bladder syndrome

A

A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)

46
Q

What are the defining symptoms of overactive bladder syndrome?

A
  • Urgency (with/without UUI)
  • Frequency
  • Nocturia
47
Q

Urgency

A

The complaint of a sudden, compelling desire to pass urine that is difficult to defer

48
Q

Frequency

A

Usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids too often by day

49
Q

Nocturia

A

Usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void

50
Q

What are the risk factors for UI?

A
  • Advanced age
  • Diabetes
  • UTI
  • Smoking
51
Q

How does the prevalence of OAB change with age?

A
  • Increases with age

- More common in women until 65

52
Q

What are the principles of management for OAB?

A
  • Treat symptoms
  • No immediate cure
  • Multidisciplinary approach
  • Requires dedicated team
53
Q

How can OAB be treated conservatively?

A

Life style interventions:

  • Normalise fluid intake
  • Reduce caffeine, Fizzy drinks, Chocolate
  • Stop Smoking
  • Weight loss

Bladder training programme:
-Timed voiding with gradually increasing intervals - Continence nurse

54
Q

What is the principle of bladder retraining?

A

The re-establishment of cortical control over detrusor function and voiding

55
Q

How is bladder retraining achieved?

A

Timed bladder emptying programme

56
Q

What pharmacological treatment is there for OAB?

A 
-Antimuscarinic
(Oral): 
-Solifenacin (Vesicare 5-10mg ) 
-Fesoteridine (Toviaz 4-8 mg)
-Trospium Chloride (60mg XL)
-Darifencain (Emselex 7.5-15 mg ) – Constipation; FI
-Lyrinel XL (10-20 mg ) 
-Oxybutinin (5-10 mg/ tds)
(Transdermal:)
-Kentera Patches

Tri-cyclic antidepressants:
-Imipramine

57
Q

What are the recent advances for UI management?

A
  • Botox

- Neuromodulation

58
Q

What are the features of botox treatment?

A
  • Botulinum Toxin (A&B)
  • NDO/ IDO
  • 200-300 Unit (12U/Kg)
  • Cystoscopy/ GA
  • 75% Cure & Significant Improvement
  • Effects last for 6-9 months
  • CISC
59
Q

What are the features of neuromodulation treatment?

A
  • Needle stimulation (S2-4)
  • Reflex Inhibition to the Detrusor muscle
  • Cheap
  • Minimally invasive
  • 70% improvement in Refractory OAB$

Reproduction (34 decks)

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