Female Urinary Incontinence Flashcards
What does the vesico-ureteric mechanism?
Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
What rate does the bladder fill at?
0.5-5mls/min
What are the 2 components of the urinary tract?
Upper tract
- Kidneys and ureters
- A low pressure distensible conduit with intrinsic peristalsis
Lower tract
- Bladder and urethra
- A low pressure storage of urine
What nerves are involved in the storage of urine?
Hypogastric nerve
Sympathetic
T10-S2
What nerves are involved in the voiding of urine?
Pelvic nerve
Parasympathetic
S2-S4
What nerves are involved in the voluntary control of the bladder?
Pudendal nerve
Somatic
S2-4
What cortical activity is involved in the filling of the bladder?
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
What occurs during bladder emptying?
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
Urinary incontinence
ANY involuntary leakage of urine
Stress urinary incontinence
Involuntary leakage on effort or exertion, on sneezing or coughing
Urge urinary incontinence
Involuntary leakage accompanied by or immediately preceded by urgency
Mixed urinary incontinence
Involuntary leaked accompanied by or immediately preceded by urgency and on effort or exertion or on sneezing or coughing
What is the epidemiology of urinary incontinence?
- 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
What is the impact of UI?
- 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
Why do women generally seek medical help for UI?
Due to deterioration of QoL
What are the risk factors for UI?
- Age
- Parity
- Menopause
- Smoking
- Medical problems
- Increased intra abdominal pressure
- Pelvic floor trauma
- Denervation
- Connective tissue disease
- Surgery
What are the main risk factors for SI?
Pregnancy and childbirth
How is a patient with UI assessed?
- History
- Examination
- Investigations
- Managment
What history should be obtained for UI?
- 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
What are the 3 types of symptoms a patient may present with?
- Irritation symptoms
- Incontinence symptoms
- Voidng symptoms
-Also may have prolapse of bowel symptoms
What irritation symptoms may a patient present with?
- Urgency ; Sudden compelling desire to void that is difficult to defer.
- Increased daytime frequency (>7)
- Nocturia (>1)
- Dysuria
- Haematuria
What incontinence symptoms may a patient present with?
- Stress UI
- Urgency UI
- Coital Incontinence
- Severity: How many pads/ day?
What us urgency usually associated with?
Frequency and nocturia
What voiding symptoms may a patient present with?
- Straining to void
- Interrupted flow
- Recurrent UTI
What prolapse symptoms may a patient present with?
- Vaginal lump
- Dragging sensation in vagina
What bowel symptoms may a patient present with?
- Anal incontinence
- Constipation
- Faecal evacuation
- Dysfunction
- IBS
What investigations should be carried out?
- 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.
What should be noted in a 3 day urinary diary?
- Fluid intake: Quantity & Quality
- Urine Out-Put (exclude Nocturnal Polyuria)
- Daytime Frequency,
- Nocturia
- Average voided volume.
What examination should a woman presenting with UI have?
- General
- Abdominal
- Neurological
- Gynaecological
- Pelvic floor assessment (Oxford scale)
What should be looked at on examination of a women presenting with UI?
- Prolapse
- Stress incontinence
- Uro-genital atrophy changes
- Pelvic mass (space occupying leasion)
- Pelvic floor tone, strength, awareness
What are the principles of management?
- Lifestyle changes
- Medical treatments
- Physiotherapy
- Surgery
When does stress incontinence occur?
When intra-abdominal pressure exceeds urethral pressure resulting in leakage
What is urethral closure increased by?
- Pelvic floor muscle training
- Surgery
- Pharmacological agents
What lifestyle changes should be advised as part of management?
- Stop smoking
- Lose weight
- Eat more healthily to avoid constipation
- Stop drinking alcohol and caffeine
Who should receive conservative treatment for UI?
Everyone unless
- Patient doesn’t wish it
- Previously failed
- No facilities
What does pelvic floor muscle lead to?
- Reinforcement of cortical awareness of muscle groups
- Hypertrophy of existing muscle fibres
- General increase in muscle tone and strength
What is the effectiveness of pelvic floor muscle training?
60-70% cure or significant improvement
What is the only drug licensed for the treatment of moderate to sever SUI?
Duloxetine
Who should receive duloxetine?
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
What anatomical defect is associated with SUI and UUI?
- Defect in the anterior vaginal wall and pubo-urethral ligament
- Urethral/bladder neck closure dysfunction and USI
What can suburethral hammock laxity result in?
Stimulation of bladder neck stretch receptors provoking a premature micturition reflex and urgency incontinence
How can the structures supporting the urethra be reinforced?
- 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.
What surgical management options are there?
- Colposuspension
- TVT
What are the common surgical complications of TVT?
- Bladder perforation
- Vaginal and urethral erosions
- Vascular injuries attributed to blind penetration of the retro-pubic space
Overactive bladder syndrome
A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)
What are the defining symptoms of overactive bladder syndrome?
- Urgency (with/without UUI)
- Frequency
- Nocturia
Urgency
The complaint of a sudden, compelling desire to pass urine that is difficult to defer
Frequency
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
Nocturia
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
What are the risk factors for UI?
- Advanced age
- Diabetes
- UTI
- Smoking
How does the prevalence of OAB change with age?
- Increases with age
- More common in women until 65
What are the principles of management for OAB?
- Treat symptoms
- No immediate cure
- Multidisciplinary approach
- Requires dedicated team
How can OAB be treated conservatively?
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
What is the principle of bladder retraining?
The re-establishment of cortical control over detrusor function and voiding
How is bladder retraining achieved?
Timed bladder emptying programme
What pharmacological treatment is there for OAB?
-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
What are the recent advances for UI management?
- Botox
- Neuromodulation
What are the features of botox treatment?
- Botulinum Toxin (A&B)
- NDO/ IDO
- 200-300 Unit (12U/Kg)
- Cystoscopy/ GA
- 75% Cure & Significant Improvement
- Effects last for 6-9 months
- CISC
What are the features of neuromodulation treatment?
- Needle stimulation (S2-4)
- Reflex Inhibition to the Detrusor muscle
- Cheap
- Minimally invasive
- 70% improvement in Refractory OAB$
