Female urinary incontinence Flashcards
What does the urinary tract consist of?
2 mutually dependent components:
- Upper tract = kidneys and ureters
- Lower tract = bladder and urethra
What is the role of the upper tract of the urinary system?
Low pressure distensible conduit with intrinsic peristalsis
Transports urine from nephrons via ureters to bladder
What is the role of the lower tract of the urinary system?
Low-pressure storage of urine
Efficient expulsion of urine
What rate does the bladder fill at?
0.5-5mls/min
What is the vesico-ureteric mechanism?
Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from bladder
What nerves supply the bladder?
Hypogastric nerve (sympathetic T10-L2) Pelvic nerve (parasympathetic S2-4) Pudendal nerve (somatic S2-4)
What does the hypogastric nerve (sympathetic T10-L2) supply and control?
Detrusor muscle
Storage - causes relaxation of the detrusor muscle, promoting urine retention
What does the pelvic nerve (parasympathetic S2-4) supply and control?
Detrusor muscle
Voiding - contraction of the detrusor muscle, stimulating micturition
What does the pudendal nerve (somatic S2-4) supply and control?
External urethral sphincter
Innervates the external urethral sphincter, providing voluntary control over micturition
What does cortical activity control in regards to the bladder?
Increases sphincter contraction and activity
Activates sympathetic pathway & reciprocal inhibition of the parasympathetic pathway
Mediates contraction of bladder base and proximal urethra
In simple terms, does sympathetic innervation aid voiding or storage?
Storage
In simple terms, does parasympathetic innervation aid voiding or storage?
Voiding
What physiologically happens during bladder emptying?
Detrusor contraction
Urethral relaxation
Sphincter co-ordination
Where is the cortical activity in the brain helping with micturition?
Pontine micturition centre
What does the pontine micturition centre control in terms of voiding?
Activation of parasympathetic pathway
Inhibition of sympathetic pathway
What is mixed urinary incontinence (UUI)?
Involuntary leakage accompanied by or immediately preceded by urgency & on effort or exertion, sneezing or coughing
How is the prevalence of UI affected with age?
Increases with age
What impact does UI have on life?
Impair QoL Reduce social relationships/activities Impair emotional/psychological well being Impair sexual relationships Embarrassment/self-esteem
What are risk factors for UI?
Age Parity Menopause Smoking Increased intraabdo pressure Pelvic floor trauma Denervation Connective tissue disease Surgery
What is the main risk factor for stress incontinence?
Pregnancy & childbirth
What might you ask in patient Hx of UI?
Age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
Medical conditions: DM, anti-HTN medications, glaucome, cognitive problems, anti-depressants/anti-psychotics
Previous PFMT, surgical treatment of SUI or POP
What are irritation symptoms?
Urgency Increased daytime frequency Nocturia Dysuria Haematuria
What are voiding symptoms?
Straining to void
Interrupted flow
Recurrent UTI
What is OAB (overactive bladder) usually associated with?
Frequency
Nocturia
Urgency
What are prolapse symptoms?
Vaginal lump
Dragging sensation in vagina
What are bowel problems associated with UI?
Anal incontinence
Constipation
Faecal evacuation dysfunction
IBS
What can be assessed in patients with UI?
3 days urinary diary: fluid intake, urine output, daytime freq, nocturia, average voided volume
Urine dipstick
What should be examined in a woman with bladder/pelvic floor problems?
General Abdominal Neurological Gynaecological Pelvic floor assessment
What is the scale for assessing pelvic floor?
Oxford Scale
What are you looking for in an examintion in a woman with bladder/pelvic floor problems?
Prolapse SI Uro-genital atrophy changes Pelvic mass (space occupying lesion) Pelvic floor tone, strength, awareness
What are investigations for urinary incontinence?
Urinalysis: Dipstix +/- MSSU
Post voiding residual volume assessment
Urodynamics
When is urodynamic studies indicated?
If surgical treatment contemplated
What is the management for UI?
Lifestyle changes
Medical treatments
Physio
Surgery
What lifestyle changes can be made for UI?
Stop smoking
Lose weight
Eat healthier to avoid constipation
Stop alcohol and caffeine
What does pelvic floor muscle training do?
Reinforcement of cortical awareness of muscle groups
Hypertrophy of existing muscle fibres
General increase in muscle tone and strength
What drug for moderate to severe stress UI (SUI)?
Duloxetine
What should Duloxetine be prescribed with?
Pelvic floor muscle training (PFMT)
Who should receive Duloxetine?
PFMT failed or would be enhanced with Duloxetine
Or if no surgery in secondary care
What is the theory related to SUI and the mechanism of continence at the time of increased intra-abdominal pressure?
Pressure-Transmission Theory
Where is the anatomical defect in both SUI and UUI?
Anterior vaginal wall and pubo-urethral ligament (PUL)
What anatomical feature might provoke a a premature micturition reflex and UI?
Suburethral hammock laxity resulting in stimulation of bladder neck stretch receptors
What are surgical treatments for UI?
TVT - tension-free vaginal tape
Colposuspension
What happens in surgery with tension-free vaginal tape (TVT)?
Minimally invasive procedure to reinforce the structures supporting the urethra
What is the first choice treatment in the surgical treatment of SUI?
TVT
What is overactive bladder syndrome?
Symptom related to urodynamically demonstrable detrusor overactivity (DO)
What are the symptoms of overactive bladder?
Urgency (with/without UI)
Frequency
Nocturia
What are risk factors for urge incontinence?
Advanced age
Diabetes
UTIs
Smoking
What type of condition is OAB?
Chronic - symptoms may wax and wain
What is the management for OAB?
Treat symptoms
No immediate cure
MDT approach
Lifestyle: normalise fluid intake, reduce caffeine, chocolate, stop smoking, weight loss
Bladder training programs: timed voiding gradually increasing intervals
What is the pharmacological treatment for OAB?
Antimuscarinics: solifenacin
Tri-cyclic antidepressants: imipramine
Botox
Neuromodulation
