Female Urinary Incontinence Flashcards
The urinary tract consists of 2 mutually dependant components - what are they?
Upper tract (Kidneys & Ureters):
- A low pressure distensible conduit with intrinsic peristalsis
- Transport urine from nephrons via ureters to the bladder.
Lower tract (Bladder & Urethra):
- The bladder fills at rate of 0.5-5 mls/min
- A low-pressure storage of urine
- Efficient expulsion of urine at appropriate place & time
what is the Vesico-ureteric mechanism?
protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
what is the bladders nevre supply?
Bladder filling:
Accommodate increasing volume at constantly ___ pressure
Inhibition of contractions by giving rise to gradual __________ of filling
Cortical activity: Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance:
- Activates __________ pathway &
- Reciprocal inhibition of the ___________ pathway
- Mediates _________ of bladder base and proximal urethra
low
awareness
Sympathetic
Parasympathetic
contraction
what is involved in bladder emptying?
Detrusor contraction
Urethral Relaxation
Sphincter co-ordination
Absence of Obstruction or anatomical shunts (Cystocele, Diverticulum)
Cortical Influence (Pontine micturition centre) - Activation of parasympathetic pathway & Inhibition of Sympathetic pathway
what is the definition of urinary incontinence (UI)?
any involuntary leakage of urine
what is the definition of stress urinary incontinence (SUI)?
involuntary leakage on effort or exertion, on snezzing or coughing
what is the definition of urge urinary incontinence (UUI)?
invuluntary leakage acompanied by or immediatley preceded by urgency
what is the definition of mixed urinary incontinence (MUI)?
involuntary leak acoompanied by or immediatley preceded by urgency and on effort or exertion, or on sneezing or coughing
what is the epideimology of incontience
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
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 QoL that medical help is sought however after many years of suffering (average 5 years)
what are the risk factors for UI?
- Age
- Parity
- Menopause
- Smoking
- Medical problems
- Increased Intra abdo pressure
- Pelvic floor trauma
- Denervation
- Connective tissue disease
- Surgery
what is the main risk factor for SI?
pregnancy and childburth
how is a patient assessment done?
- History
- Examination
- Investigations
- Management
what should be asked in a history?
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
Patient Assessment - Complaint:
what are some irritaiton symptoms?
Urgency; Sudden compelling desire to void that is difficult to defer
Increased daytime frequency (>7)
Nocturia (>1)
Dysuria
Haematuria
Patient Assessment - Complaint:
what are some incontinence symptoms?
Stress UI
Urgency UI
Coital Incontinence
Severity: How many pads/day?
Patient Assessment- Complaint:
what are some voiding symptoms?
Straining to void
Interrupted flow
Recurrent UTI
Patient Assessment- Complaint:
what are prolapse symptoms and also what are some bowel symptoms?
Prolapse Symptoms: Vaginal Lump/Dragging sensation in vagina
Bowel symptoms: Anal Incontinence, Constipation, faecal evacuation dysfunction, IBS
for a patient assessment you can do a 3 days Urinary Diary, what does this record?
you can also do a urine dipstick aswell
Fluid intake: Quantity & Quality
Urine Out-Put (exclude Nocturnal Polyuria)
Daytime Frequency,
Nocturia
Average voided volume
Examination of the women with Bladder/Pelvic floor problems
what different areas are exmained?
General
Abdominal
Neurological
Gynaecological
Pelvic floor assessment (Oxford Scale)
Examination of the women with bladder/pelvic floor problems - what thing smay you think/be invesitgating?
Prolapse
Stress incontinence
Uro-genital atrophy changes
Pelvic mass (space occupying leasion)
Pelvic floor tone, strength, awareness
what investigaitons can be done?
- 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:
- Measures flow rate (Q) of urine in ml/s
- Flow rate is dependent on the urethral resistance, strength of detrusor contraction and abdominal straining
what managment is used?
Lifestyle changes
Medical treatments
Physiotherapy
Surgery
what causes stress incontinence and what can help it?
what lifestlye changes can help incontinence?
Stop smoking
Lose weight
Eat more healthily to avoid constipation
Stop drinking alcohol and caffeine
conservative treatment of UI - whos hould recieve it?
how does pelvis floor muscle training (PFMT) help?
what pharmacological treamtent is used for SUI?
who should receive duloxetine?
what is colposuspension?
Colposuspension is an operation to treat stress incontinence in women
In colposuspension, your surgeon lifts the neck of your bladder into the correct position and holds it in place with stitches. This helps to prevent urine from leaking.
“Integral Theory Of Female UI”:
Both Stress and Urge incontinence arise from the same anatomical defect in the _______ vaginal wall & __________ ligament (PUL) - Urethral/bladder neck closure dysfunction and USI
Suburethral Hammock _____ might result in stimulation of bladder neck _______ receptors, provoking a premature micturition reflex and Urgency Incontinence
anterior
pubo-urethral
laxity
stretch
Mid-urethral Slings
Retro-pubic TVT
what is TVT?
Tension-free vaginal tape (TVT) was introduced into clinical practice by Ulmsten in 1996 as a minimally invasive procedure to reinforce the structures supporting the urethra
Depends on the “Hammock theory” for continence
80% Cure at 11 years follow-up
Polypropylene permenant Synthetic Tape; Monofilament & Macro-porous
RCT: TVT Vs Colposuspension - which is better?
TVT is as effective as Colposuspension for the treatment of primary USI up to 2 years.
81% Vs 80% Objective cure rates
43% Vs 37% Subjective Cure rates
Less Operative & Postoperative Morbidity
TVT has NOW ________ the Colposuspension as the First Choice procedure in the Surgical Treatment of SUI
replaced
Efficacy: Long-term results (8 year outcome): 80% cure rate
what is Overactive Bladder Syndrome (ICS Definition)?
A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)
Defining symptoms: urgency (with/without urgency incontinence), usually with frequency and nocturia
OAB syndrome occurs in both sexes and at all ages (including children)
Prevalence of OAB increases with age, and is slightly higher in women
OAB results in significant social, psychological, occupational, domestic, physical, and sexual problems
the bladder, which is a bag made of muscle, squeezes (contracts) suddenly without you having control and when the bladder is not full. OAB syndrome is a common condition where no cause can be found for the repeated and uncontrolled bladder contractions
what are the symptoms of OAB (overactive bladder)?
Urgency: The complaint of a sudden, compelling desire to pass urine that is difficult to defer
Urge incontinence: The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency
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 Urge Incontinence?
Advanced age
Diabetes
Urinary tract infections
Smoking
OAB is a chronic condition therefore Symptoms may wax and wane
what is OAB Management?
- Treat symptoms
- No immediate cure
- Multidisciplinary approach
- Requires dedicated team
what is OAB Conservative management?
• 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 are osme recent advances?
