Incontinence Flashcards
What is stress urinary incontinence (SUI)?
Complaint of involuntary leakage on effort or exertion, or on sneezing/coughing
Define urinary incontinence
Complaint of any involuntary leakage of urine
What is urge urinary incontinence (UUI)?
Involuntary leakage immediately proceeded by or accompanied by urgency
What is mixed urinary incontinence?
Involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
What is overflow incontinence?
Involuntary release of urine from an overly full bladder, often in the absence of any urge to urinate
Which is the most common type of urinary incontinence?
Stress urinary incontinence
Prevalence with age of urinary incontinence?
Gradually increases
10% age 20-24
40% age 90+
Risk factors for urinary incontinence?
Pregnancy Pelvic surgery Hysterectomy Pelvic prolapse Bowel dysfunction Obesity Dietary factors eg caffeine, alcohol Multiparity Drugs Menopause
In general, what increases your risk of urinary incontinence?
Anything that weakens the pelvic floor
What history if urinary incontinence is suspected would you take from the patient?
Categorise type
Ask patient to keep a voiding diary
No. of pads used a day
Determine if leakage is continuous or intermittent
Intravesicular inflammatory condition eg UTIS, stone, tumour - these can make it worse
Any previous surgery of pelvic floor? Denervation of parts of bladder?
Childbirth? -indicate SUI due to sphincter damage
What should be recorded in a voiding diary?
Volume of urine produced
Frequency
Precipitating factors
Number of pads used each day
What examinations would you do of the patient?
Weight
Height
Abdominal exam to exclude palpable bladder
Digital rectal exam - prostate/constipation
In females, examine external genitalia and a vaginal exam (for prolapse, fistulae)
Check perianal sensation and reflexes as this is supplied by same nerve root as sphincter muscles
What does management of urinary incontinence depend on?
Symptoms
Degrees of nuisance
Effects of treatment on other symptoms
Previous/current treatment
What lifestyle changes can be made in managing urinary incontinence?
Modify fluid intake Stop smoking Avoid constipation Weight loss Decrease caffeine Have timed voiding on a fixed schedule
What investigations would you do for urinary incontinence?
Urine dipstick to check for UTIS, haematuria, proteinuria, glucosuria
Frequency - volume chart and bladder diary (at least 3 days)
Post-micturition residual volume in patients with voiding dysfunction
Optional
- invasive urodynamics
- pad tests
- cystoscopy
What are urodynamics? What can it measure?
Term for investigating lower urinary tract symptoms
Measure electrical activity of external urethral sphincter - muscle tone
Post void residual volume
Peak flow rate
What can be used to strengthen pelvic floor muscles?
Pelvic floor muscle training - 8 contractions, 3x a day for at least 3 months
Duloxetine - NA and serotonin uptake inhibitor
Void bladder and stop mid-stream - uses muscles of pelvic floor
What specific management is there of urge urinary incontinence?
Bladder training
- schedule voiding every hour
- don’t void in between - wait or leak
- increase intervals by 15-30 mins a weak until interval is 2-3 hours
- 6 weeks of training needed
How would you manage patients who are unsuitable for surgery and have failed other methods of incontinence management?
Indwelling catheter - urethral/suprapubic
Sheath device
Incontinence pads
What pharmacological management is there of incontinence?
Duloxetine - combined NA and serotonin uptake inhibitor. Increase activity of external urethral sphincter during filling phase. Offered as an alternative to surgery
Anticholinergics - act on M3 receptors that cause detrusor muscle to contract.
Botulinum toxin - inhibits Ach release. Prevents detrusor muscle contraction ad pelvic nerve cannot release Ach to act on M3 receptors
What surgical management is there for females (permanent intention)?
- low tension vaginal tapes are most common. Minimally invasive technique with success rate >90%. Support the mid urethra with a polypropylene mesh
- open retropubic suspension procedure supports the urethra and increases bladder outflow resistance. Involves autologous transplantation of fascia lata/rectus fascia
What surgical management is there for treatment of females with temporary intention?
Intramural bulking agents improve ability of urethra to resist abdominal pressure by improving urethral coaptation
Inject autologous fat, silicone, collagen, or hyaluron-dextran polymers
What is the gold standard surgical management for males?
How does it work?
Risks?
Artificial urinary sphincter - gold standard in urethral sphincter deficiency
Cuff is a mechanic (hydraulic) device that stimulates action of a normal sphincters to circumferentially close the urethral.
Problems include infection, erosion, device failure.
What other surgical management is there for males?
Male sling procedure corrects SUI in men from iatrogenic cause
It is an emerging treatment using bone-anchored tape
Long term results unknown
What are some iatrogenic causes of urinary incontinence (in males)?
Radical prostatectomy
Colorectal surgery
Radical pelvic radiotherapy
