Incontinence Flashcards
Types of urinary incontinence
Stress
Urgency
Mixed
Overflow
Functional
Over active bladder (technically not always incontinent)
True - communication of bladder with vagina/rectum from fistula (eg IBD, cancer)
What is stress urinary continence?
Involuntary leakage of urine on effort, exertion, sneezing or coughing (increased intrabdominal pressure)
what is urgency urinary incontinence?
Involuntary leakage of urine accompanied by or immediately preceded by urgency
What is mixed urinary incontinence?
involuntary leakage of urine associated with urgency and with exertion, effort, sneezing or coughing
What is overflow incontinence?
Involuntary release of urine when the bladder becomes overly full - weak bladder muscle or blockage (may not be getting signals to brain etc)
What is over active bladder?
Frequent and sudden urge to urinate that may be difficult to control - can be wet (incontinent) or dry
What is functional incontinence?
Bladder and muscles are fine but cannot make it to toilet in time due to mobility issues. Eg OA, paralysis of legs etc
Which incontinence is most prevalent?
Over active bladder - wet and dry most prevalent then:
Stress incontinence
Urgency
Then mixed
Symptoms of overactive bladder
Urgency
Increased frequency
Nocturia
How does urinary incontinence prevalence change with age?
Increases as you get older
Increase for women of childbearing age due to impacts of pregnancy and childbirth on pelvic floor and bladder
Risk factors for urinary incontinence - obs and gynae
Pregnancy and childbirth - foetus pressure and trauma during birth
Pelvic surgery - muscles/nerve injured?
Pelvic prolapse
Risk factors for urinary incontinence -predisposing factors
Race
Family predisposition
Anatomical abnormalities
Neurological abnormalities
Risk factors for urinary incontinence - promoting
Obesity
Age
Co-morbidities
Increased intra abdo pressure
UTI
Drugs
Menopause
Cognitive impairement
Why does menopause promote urinary incontinence?
Loss of oestrogen = atrophy of genitalia and sometimes loss of pelvic floor tone from atrophy
Quality of life with urinary incontinence?
MASSIVELY affected - some cannot leave the house worried of embaressment, hygiene worries, cost - pads, change of underwear etc.
What else could result in frequency, urgency and nocturia?
UTI
How can we classify lower urinary tract symptoms?
By stage of micturition:
Storage
Voiding
Post-micturition
Storage lower urinary tract symptoms
Increased frequency
Urgency
Nocturia
Incontinence
Voiding lower urinary tract symptoms
Slow stream
Splitting/spraying
Intermittency
Hesitancy
Straining
Terminal dribble
Post micturition lower urinary tract symptoms
Post-micturition dribble
Feeling of incomplete emptying
Additional history needed from female presenting with frequency, urgency and nocturia
Fluid intake - caffeine/alcohol as diuretic effects
Previous pelvic surgery
Childbirths - large babies?
How long?
Uterovaginal prolapse?
Faecal incontinence too?
What else can cause polyuria?
Diabetes - check for this too
Dermatomes to examine when checking neurological cause for incontinecne
S2, 3 and 4
- back of thigh, bum cheek)
(keep the wee and poo off the floor)
Examinations needed for incontinence presentation - male and female
BMI - obesity?
Abdo exam - palpable bladder suggests retention and problems voiding
Examine S2,3,4 dermatomes - neuro cause?
Examinations needed for incontinence presentation - males only
Digital rectal exam - check for enlarged prostate
Examinations needed for incontinence presentation - females
External genitalia stress test - get pt to cough and see if leakage
Vaginal exam
Investigations for incontinence presentation
MANDATORY - Urine dipstick: rule out UTI, haematuria, proteinuria, glucosuria
Non invasive urodynamics maybe:
Frequency-volume chart
Bladder diary (longer than 3 days)
Post-micturition residual volume - voiding problems? use catheterisation following urination or bladder scan pre and post void
Optional investigations for incontinence presentation
Invasive urodynamics - pressure and flow studies
Pad tests - wear pad, has dye if urinate and can weigh pad to see liquid amount
Cystoscopy - camera in urethra to bladder
Invasive urodynamics probes used and what these measure
Probe in bladder - measure intravesicle pressure (bladder pressure)
Probe in vagina/rectum - measure abdominal pressure
Detrusor pressure = intravesical pressure minus abdominal pressure
What is pt asked to do in urodynamic testing?
Empty bladder - urinate
Bladder is then filled with set amount of saline
Measurements are taken when pt coughs to see if bladder/detrusor pressure rises etc
What does the urethra run through and what does this mean?
Through pelvic floor - strengthening this can help incontinence
What does weakened pelvic floor result in?
Prolapse - usually supports rectum, bladder and uterus in women
Lifestyle conservative management for incontinence
Modify fluid intake
Weight loss
Stop smoking
Decrease caffeine intake
Avoid constipation - increases pressure
Timed voiding - schedule
Interventions for patients which lifestyle changes haven’t helped and are unsuitable for surgery in general, broad
Indwelling catheter - urethral or suprapubic
Sheath device - similar to condom attached to catheter tubing and bag
Incontinence pads
Risk with indwelling catheter
Urinary tract infection
Specific management for stress incontinence
Pelvic floor muscle training - 8 contractions 3x daily, for 3 months at least
Weight loss
Duloxetine
What does duloxetine do in general?
Noradrenaline and serotonin uptake inhibitor - remains at receptor for longer and has prolonged action
What does duloxetine do specifically in bladder?
Increases inhibitory effect of noradrenaline on B3 receptor at detrusor muscle - continued relaxation during storage phase, preventing increases in pressure
Increase stimulaotry effect of NA at alpha 1 receptor causing contraction and closure of internal urethral sphincter
When is duloxetine offered?
Not first or second line routinely but if surgery is not an option/alternative to surgery
Surgery for stress urinary incontinence female
Permanent intention:
- open retropubic suspension procedures (colposuspension) (bladder, urethra and vagina sutured to pelvic bones/ligaments, lifts them which helps them close easier)
- autologous sling procedure (sling under urethra using own tissue)
- low tension vaginal tapes (less popular now, sling under urethra using mesh)
Temporary:
Intramural bulking agents (into neck of bladder)
Why do some surgeries for stress incontinence have temporary intention?
Women may still want to have further pregnancies - no point doing permanent surgery when it could damage it again
Surgery for stress incontinence for males
Artificial urinary sphincter
Male sling
Describe male artificial sphincter
GOLD STANDARD for urethral sphincter deficiency - neurological or post dxt (radiotherapy) or surgery
Cuff lies around circumference of urethra- stimulates action of normal sphincter to close urethra. Males can switch on and off by switch in scrotum
Initial management of urgency urinary incontinence
Bladder training - schedule voiding eg every hour of the day. MUST NOT void in between - wait or leak
Intervals are then increased by 15-30 mins until interval of every 2-3 hrs is reached
6 weeks long
Pharmacological management of urgency incontinence
Anticholinergics - act on M1, M2 and M3 eg Oxybutynin, Solifenacin
B3 adrenoreceptor agonist eg Mirabegron
What do anticholinergics do?
Act on M3 receptor in detrusor muscle
Stop Ach causing contraction of detrusor from parasympathetic pathway
What does B3 adrenoreceptor agonist do?
Bind to B3 adrenoreceptor
Replicate NA’s normal effect here - relaxation of detrusor muscle despite increased stretch
Therefore increase bladder capacity to store urine
What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?
Botulism toxin intravesicle injection (into bladder(
What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?
Botulism toxin intravesicle injection (into bladder)
Actions of botulism toxin
Biological neurotoxin
Inhibits release of Acetylcholine at presynaptic neuromusclar junction
Causes flaccid paralysis - detrusor doesn’t contract
(eg in bladder M3 contraction of detrusor muscle is inhibited)
Duration of botulism toxin effects
3-6 months - type A in uk under general anaesthetic or local
Problem with using anticholinergics in UUI management
NON SELECTIVE - act on all M1, 2, 3 4 and 5 receptors
Eg these are present in smooth muscle in heart ocular and intestinal, salivary glands, CNS, eyes
Example of anticholinergic
Oxybutynin
Solifenacin
Surgery for urgency urinary incontinence (if pharmacological doesnt work)
Sacral nerve neuromodulation - alter nerve activity
Autoaugmentation - removal of detrusor muscle
Augmentation cystoplasty - makes bladder larger
Urinary diversion - new route for urine
Examples of ADLs
- Getting dressed
- Feeding yourself
- Washing
- Control over bladder/bowels
Examples of intermediate ADLs
- Cooking
- Shopping
- Cleaning house
- Finances
What are higher ADLs?
Societal role of patient - can they fulfil these eg mother, volunteer at local shop etc
