Incontinence Flashcards
Define Stress Incontinence
Complaint of involuntary leakage of urine on effort or exertion, sneezing or coughing etc
Define Urodynamic Stress Incontinence (USI)
Its a disorder diagnosed by Cystometry
Leaking with coughing in the absence of detrusor contraction
Define Urge Incontinence
Involuntary urine leakage accompanied by urgency of micturition
Define Overactive Bladder Syndrome
Urgency that occurs with (wet) or without (dry) incontinence (and freq & noturia usually)
Define Detrusor Overactivity
Diagnosis of cystometry if involuntary detrusor contraction occurs
Define Overflow Incontinence
Usually due to chronic bladder outflow obstruction
Define Functional Incontinence
Patient unable to reach toilet in time for functional reasons ie poor mobility/ unfamiliar surroundings
Define Detrusor Overactivity
Urodynamic diagnosis characterized by involuntary detrusor contractions during filing phase
Spontaneous or provoked (eg coughing)
Outline the Epidemiology of Incontinence
Of incontinent women;
- 50% Stress incontinence
- 35% Overactive bladder syndrome
Outline the Aetiology of Stress Incontinence
- Pregnancy & vaginal delivery
- Obesity
- Elderly [esp post-menopausal]
- Previous surgery/ prolapse
Outline the Aetiology of Urge Incontinence
- Detrusor instability or hyperreflexia leading to involuntary detrusor contraction
- Idiopathic
- Secondary to Neurological problem [cerebral/ spinal]
Outline the Aetiology of Overactive Bladder syndrome
- Idiopathic
- Following operations for Stress Incontinence
- Involuntary detrusor contractions in the presence of underlying neuropathy (MS/ spinal injury)
Outline the mechanism of Urinary Stress Incontinence
- Inrease in intra-abdominal pressure (‘stress’)
- Bladder compressed & pressure rises
- Bladder pressure exceeds urethral pressure (which should be maintained by pelvic floor & bladder neck)
- Incontinence
Outline the mechanism of Overactive Bladder Syndrome
Detrusor muscle contracts strong enough to overcome urethral pressure & patient leaks (urge incontinence)
Spontaneously or with provocation (eg coughing)
Outline the investigations for Incontinence
-
Urine dipstick
- for Leukocytes & Nitrites/ or symptomatic ⇒ MSU culture & sensitivities
-
Urodynamic Studies [prior to surgery & unsure]
- Frequency volume charts [to gain more info]
- Pad tests [to determine amount of fluid lost]
- Urinary flow rate [ml/s, assess voiding function]
- Residual volume
-
Multichannel cystometry
- Catheter: Vesicle pressure & flow rate
- Rectal pressure transducer: Abdominal pressure
- Detrusor pressure = Vesicle pressure - Abdominal pressure
- Leak point pressure = pressure during vesicle filling that it contracts
- Ambulatory urodynamics [cystometry while doing things]
- Electromyography [muscle activity around urethral sphincter
Outline the management of Stress Incontinence
- Lifestyle
- Loose weight
- Address chronic cough
- Conservative
- Pelvic floor muscle training (PEMT) for 3months by Physio
- Vaginal ‘cones’/ sponges
- Medical
- Duloxetine [SNRI] - enhances urethral striated sphinter activity via centrally mediated pathway
- Surgery
-
Tension-free vaginal tape (TVT)
- Synthetic polypropylene tape place in U-shape under mid-urethra via small vaginal ant. wall incision
- Tension then adjusted
-
Trans-obturator tape (TOT)
- Same as TVT except passed through transobturator foramen
- Retropubic space not entered & so bladder perforation rare
-
Injectable periurethreal bulking agents
- Not very good
-
Tension-free vaginal tape (TVT)
Outline the management of Overactive Bladder Syndrome/ Urge Incontinence
- Conservative (urge)
- Bladder retraining (inc time between voids)
- Medical
- Anticholinergics (antimuscarinics) [suppress detrusor overactivity]
- Oestrogens [in postmenopausal women]
-
Botulinum toxin A (BTX) [blocks neuromuscular transmission, weakening detrusor]
- Retention may require self-catheterisation
- Other
- Neuromodulation & S3 nerve stimulation [suppresses detrusor contraction]
