Female urinary incontinence

Question 1

What is the upper urinary tract?

- pressure is?

Answer 1

kidneys and ureter

• low pressure distensible conduit with intrinsic peristalsis

Question 2

what does the UUT DO?

Answer 2

Transport urine from nephrons via ureters to the bladder.

Question 3

What is the lower urinary tract?

Answer 3

Bladder & Urethra

Question 4

rate of bladder filling is?

- storage of urine pressure is?

Answer 4

0. 5-5 mls/min

- low

Question 5

what is the Vesico-ureteric mechanism?

Answer 5

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

Question 6

nerve supply to the bladder?

• for storage
• voiding
• voluntary

Answer 6

pelvic nerves
- hypogastric nerve (sympathetic T10-L2)

• pelvic nerve - parasympathetic S2-4
• pudendal nerve - S2-S4 - voluntary

Question 7

bladder filling - what does it have to do?

Answer 7

Accommodate increasing volume at constantly low pressure.

Question 8

cortical activity means what in terms of bladder filling ? (3)

Answer 8

Activating a reciprocal guarding reflex

• Rhabdosphincter contraction
• increase sphincter contraction & resistance.

Question 9

Cortical activity activates and mediates what 3 things?

Answer 9

• Activates Sympathetic pathway &
• Reciprocal inhibition of the Parasympathetic pathway
• Mediates contraction of bladder base and proximal urethra

Question 10

Bladder emptying is due to what contraction and what relaxation?

• needs co-ordination of what?
• needs the absence of?

Answer 10

• Detrusor
• Urethral
• Sphincter
• Obstruction or anatomical shunts (Cystocele, Diverticulum)

Question 11

what is the cortical influence off bladder emptying (pathways affected)? - what micturition centre is it?

Answer 11

• Pontine

- Activation of parasympathetic pathway & Inhibition of Sympathetic pathway

Question 12

what % of women between age 15-60 report UI?

Answer 12

10-25%

Question 13

what are the impacts of UI?

Answer 13

• impair the QoL.
• Reduce social relationships and activities.
• Impair emotional and psychological well- being.
• Impair sexual relationships.
• Embarrassment and diminished self- esteem.

Question 14

Risk factors of UI?

Answer 14

Age
Parity
Menopause
Smoking
Medical problems
Inc Intra abdo pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery

Question 15

what is the main risk factor for SI?

Answer 15

Pregnancy & Childbirth

Question 16

What are crucial history questions to ask a female presenting with UI?

Answer 16

Age, parity, mode of deliveries, weight of heaviest baby, Smoking, HRT,

Question 17

Medical conditions to ask about in UI history?

Answer 17

DM, anti-HTN medications, Glaucoma, Heart/Kidney/Liver problems, Cognitive problems, Anti-depressants/ anti-psychotics.

Question 18

what may be irritation symptoms someone presents with?

Answer 18

Urgency ; Sudden compelling desire to void that is difficult to defer.

• Increased daytime frequency (>7)
• Nocturia (>1)
• Dysuria
• Haematuria ☻

Question 19

what is urgency usually associated with? (5)

Answer 19

with frequency, nocturia and urgency incontinence

Question 20

what are incontinence symptoms? (4)

Answer 20

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

Question 21

what are voiding symptoms?

Answer 21

Straining to void
Interrupted flow
Recurrent UTI ☻

Question 22

scale of how much Urinary leakage affects day to day activities

Answer 22

0 -10

Question 23

what are prolapse symptoms (3)

Answer 23

Vaginal Lump/ Dragging sensation in vagina

Question 24

what are bowel symptoms? (4)

Answer 24

Anal Incontinence, Constipation, faecal evacuation dysfunction, IBS.

Question 25

patient assessment - feature (5) | - test u may do?

Answer 25

- Fluid intake: Quantity & Quality - Urine Out-Put (exclude Nocturnal Polyuria) - Daytime Frequency, - Nocturia - Average voided volume. urine dipstick

Question 26

Examination of the women with Bladder/ Pelvic floor problems (5 types)

Answer 26

- General - Abdominal - Neurological - Gynaecological - Pelvic floor assessment (Oxford Scale)

Question 27

Examination of the women with bladder/ pelvic floor problems - what are you looking for?

Answer 27

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

Question 28

Investigations you can carry out?

Answer 28

- Urinalysis: Multistix +/- MSSU - Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties. - Urodynamics: ONLY indicated if surgical treatment is contemplated.

Question 29

Management of UI?

Answer 29

- Lifestyle changes - stop smoking, weight loss, eat healthy to avoid constipation, avoid caffeine and alcohol - Medical treatments - Physiotherapy - Surgery

Question 30

When does stress urinary incontinence occur?

Answer 30

intra-abdominal pressure exceeds urethral pressure, resulting in leakage

Question 31

urethral closure pressure is increased by? (3)

Answer 31

- pelvic floor muscle training - surgery - pharmacological agents

Question 32

Why should you carry out pelvic floor muscle training?

Answer 32

- reinforcement of cortical awareness of muscle groups - hypertrophy of existing muscle fibres - general increase in muscle tone and strength

Question 33

what is the only drug licensed for severe stress incontinence?

Answer 33

duloxetine

Question 34

who should receive duloxetine

Answer 34

if PMFT has failed - they do not want surgery - failed surgery - not fit for surgery

Question 35

why do stress and urge incontinence arise?

Answer 35

anatomical defect in the anterior vaginal wall & pubo-urethral ligament (PUL). - Urethral/bladder neck closure dysfunction and USI

Question 36

what laxity might result in stimulation of bladder neck stretch receptors? - what may this provoke?

Answer 36

Suburethral Hammock - a premature micturition reflex and Urgency Incontinence

Question 37

what is a minimally invasive procedure used to reinforce the structures supporting the urethra?

Answer 37

Tension-free vaginal tape (TVT)

Question 38

what is the only drug licensed for severe stress incontinence?

Answer 38

duloxetine

Question 39

who should receive duloxetine

Answer 39

if PMFT has failed - they do not want surgery - failed surgery - not fit for surgery

Question 40

why do stress and urge incontinence arise?

Answer 40

anatomical defect in the anterior vaginal wall & pubo-urethral ligament (PUL). - Urethral/bladder neck closure dysfunction and USI

Question 41

what laxity might result in stimulation of bladder neck stretch receptors? - what may this provoke?

Answer 41

Suburethral Hammock - a premature micturition reflex and Urgency Incontinence

Question 42

TVT Vs Colposuspension

Answer 42

TVT is as effective as Colposuspension for the treatment of primary USI up to 2 years.

Question 43

First choice treatment for SUI?

Answer 43

TVT

Question 44

What is Overactive Bladder Syndrome (ICS Definition)?

Answer 44

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

Question 45

defining symptoms

Answer 45

urgency (with/without urgency incontinence), usually with frequency and nocturia

Question 46

what is urge incontinence?

Answer 46

The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency

Question 47

Describe what DO is like?

Answer 47

involuntary detrusor contractions during filling - spontaneous or provoked - neurogenic when there is a relevant neurologic condition or idiopathic when there is no defined cause

Question 48

prevalence of OAB?

Answer 48

increases with age, and is slightly higher in women

Question 49

Risk Factors for Urge Incontinence? (4)

Answer 49

- Advanced age - Diabetes - Urinary tract infections - Smoking

Question 50

OAB is a..?

Answer 50

chronic condition

Question 51

what is nocturia?

Answer 51

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

Question 52

OAB conservative management - lifestyle interventions

Answer 52

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

Question 53

what is a bladder training programme?

Answer 53

Timed voiding with gradually increasing intervals - Continence nurse

Question 54

what treatment is used for OAB?

Answer 54

Antimuscarinic

Question 55

Oral treatment options for OAB?

Answer 55

``` 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) ```

Question 56

Transdermal treatement for OAB?

Answer 56

Kentera Patches

Question 57

Tri-cyclic antidepressants for OAB include?

Answer 57

Imipramine

Question 58

anticholinergic agents currently used In the UK for OAB?

Answer 58

atropine, propantheline, | trospium chloride, and propiverine, a calcium antagonist and anticholinergic

Question 59

Recent advances - drugs and methods for OAB? 2 TYPES - what are they and what do they do

Answer 59

``` Botulinum Toxin (A&B) NDO/ IDO ``` - Neuromodulation Needle stimulation (S2-4) Reflex Inhibition to the Detrusor muscle