Female urinary incontinence

Question 1

outline the female urinary tract

Answer 1

Upper tract kidneys and ureters: Low pressure distensible conduit with intrinsic peristalsis, Transport urine from nephrons via ureters to the bladder. Lower tract bladder and urethra: Bladder fills at a rate of 0.5-5 mls/min, Low pressure storage of urine. Efficient expulsion of urine at appropriate time and place. Vesico-ureteric mechanism protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder.

Question 2

outline the cortical activity of bladder filling and its details

Answer 2

Cortical activity: activating a reciprocal guarding reflex rhabdosphincter contraction: increase sphincter contraction and resistance: Activates sympathetic pathway, Reciprocal inhibition of parasympathetic pathway, Mediates contraction of bladder base and proximal urethra

Question 3

how is bladder emptying carried out?

Answer 3

Detrusor contraction/ Urethral relaxation/ Sphincter co-ordination/ Needs absence of obstruction or anatomical shunts
Cortical influence = activation of parasympathetic and inhibition of sympathetic

Question 4

ICS Definition of Urinary incontience

Answer 4

any innvoluntary leakage of urine

Question 5

ICS Definition of stress urinary incontinence

Answer 5

involuntary leakage on effort or excretion on increased intraabdominal pressure e.g. due to sneezing or coughing

Question 6

ICS Definition of urge urinary incontinence

Answer 6

Strong sudden need to urinate, followed by bladder contraction which results in involuntary leakage.

Question 7

ICS Definition of mixed urinary incontinence

Answer 7

involuntary leakage accompanied by or immediately preceeded by urgency and on effort or excretion, or on sneezing or coughing.

Question 8

what are the rf’s for UI

Answer 8

age, parity, menopause, smoking, medical problems (increased intraabdo pressure, pelvic floor trauma, denervation, connective tissue damage, surgery)

Question 9

what is asked in pateient assessment hx?

Answer 9

• Age, parity, mode of deliveries, weight of heaviest baby, smoking
• Medical conditions: DM, anti-HTN meds, glaucoma, heart/kidney/liver problems, cognitive problems
• Surgical treatment of SUI or POP

Question 10

irritation sy

Answer 10

Urgency, Increased daytime frequency (>7), Nocturia (>1), Dysuria, Haematuria

Question 11

incontinence sy

Answer 11

Stress UI, Urgency UI, Coital incontinence, Severity

Question 12

voiding sy

Answer 12

Straining to void, Interrupted flow, Recurrent UTI

Question 13

what is monitiored in a 3 day urinary diary?

Answer 13

Fluid intake: quantity and quality, Urine out-put, Daytime frequency, Nocturia, Average voided volume

Question 14

what is commonly found on examination of a woman with stress incontinence?

Answer 14

visible leakage of urine on coughing, prolapse of the uterus.

Question 15

what is looked for on examination?

Answer 15

Prolapse, Stress incontinence, Uro-genital atrophy changes, Pelvic mass (space occupying lesion), Pelvic floor tone, strength, awareness

Question 16

Ix

Answer 16

Urinalysis = MSSU + dipstick, Post voiding residual volume assessment – bladder scanning if symptoms of voiding difficulties, Urodynamic – only indicated if surgical treatment is contemplated

Question 17

Mx - lifestyle changes

Answer 17

Stop smoking, Lose weight, Eat more healthily to avoid constipation, Stop drinking alcohol and caffeine

Question 18

Mx - medical

Answer 18

Duloxetine = the first and currently only drug licensed for the treatment of moderate to severe stress urinary incontinence. Should be part of an overall management strategy including pelvic floor muscle training (PFMT)
When it’s used: Primary care: if PFMT has failed or could be enhanced by duloxetine, Secondary care: Does not wish surgery, Not fit for surgery, After failed surgery.
TOPICAL OESTROGENS

Question 19

Mx - physiotherapy

Answer 19

PELVIC FLOOR EXERCISES- Reinforcement of cortical awareness of muscle groups, Hypertrophy of existing muscle fibres, General increase in muscle tone and strength, Needs a well-motivated patient and do a few times each day and an experienced physio with a special interest.
VAGINAL CONES
PESSARIES (RING OR SHELF)

Question 20

Mx - surgical

Answer 20

TENSION-FREE VAGINAL TAPE (TVT) is a minimally invasive procedure that reinforces the structures supporting the urethra, Depends on ‘hammock theory’ for continence, TVT is first choice procedure in surgical treatment of SUI.
Or BURCH COLPOSUSPENSION.

Question 21

concerns over TVT…

Answer 21

Bladder perforation (1-21%), Vaginal and urethral erosions, Vascular injuries attributed to blind penetration of retro-pubic space

Question 22

Integral theroy of female UI

Answer 22

Both stress and urge incontinence arise from the same anatomical defect in the anterior vaginal wall & pubo-urethral ligament (PUL).
Suburethral hammock laxity might result in a stimulation of bladder neck stretch receptors, provoking a premature micturition reflex and urgency incontinence.

Question 23

What are the defining sy of overactive bladder syndrome?

Answer 23

urgency with frequency and nocturia

Question 24

rf’s of OABS

Answer 24

Advanced age, Diabetes, Urinary tract infections, Smoking

Question 25

Mx

Answer 25

Treat symptoms, No cure, Multidisciplinary approach, Requires dedicated team, Lifestyle interventions: Normalise fluid intake, Reduce caffeine, Stop smoking, Weight loss.
Bladder training programme – specialist continence nurse – re-establishment of corticol control over detrusor function and voiding.