Incontinence Flashcards
What is the prevalence of urinary incontinence?
20% of adult women
Increases with: Age Parity Obesity Smoking
What are the two main types of incontinence? What are some less common types?
Common:
Stress incontinence = sphincter weakness
Detrusor overactivity/overactive bladder = involuntary bladder contractions
Less common: Overflow - when bladder becomes overly full, muscles cannot hold Functional - ? psychological origins Neurological - due to nerve damage Mixed
How does detrusor overactivity present?
Urgency symptoms: Urge incontinence Frequency Nocturia >2x (1x is normal) Nocturnal enuresis Latch key incontinence Hand-washing incontinence Intercourse
How does stress incontinence present?
Involuntary leakage on: Coughing Laughing Lifting Exercise Movement
How do you use a frequency volume chart to assess incontinence?
Daily chart of fluid intake and urinary passing - voluntary and leakage
Looks at volume, frequency, quantity, diurnal variation (more at night might be a heart failure picture)
Stress picture:
Normal volume bladder - often understood by first void of the day (400mls+) with small volume leakage
Detrusor overactivity picture:
Smaller volume bladder with large volume leakage, frequency, nocturia etc
How and why would you test for residual urine in the bladder?
May be useful to see if bladder is retaining urine - especially after surgery or catheter removal
Use an in/out catheter - can be taught to self catheterise like this if retention is a recurrent issue
USS bladder
What is an electronic personal assessment questionnaire? (ePAQ)
Questionnaires that can be answered before or during gynae clinic to gauge the symptom picture across 4 dimensions and several domains:
Urinary symptoms: Pain Voiding Overactive bladder Stress incontinence QoL
Vaginal symptoms: Pain Capacity (??) Prolapse QoL
Bowel symptoms: IBS Constipation Evacuation Continence QoL
Sexual: Urinary Bowel Vaginal Dyspareunia Overall sex life
Will get scores /100 for each so doctor will know where areas of concern are greatest
Can also be reassessed with same questions after management to see if have improved
What is urodynamics and how does it work?
Used as an adjunct to Hx taking/examination to confirm diagnosis in some women
Uses urinary and rectal catheters to measure intra-abdominal and intra-vesicular pressures to give an overall picture of detrusor pressure
Stress incontinence = detrusor pressure increases when asked to cough (should normally not change)
Detrusor overactivity = detrusor pressure increases in response to specific triggers e.g. water flowing, or after a certain amount of time
What are some conservative methods for managing incontinence?
These are the 1st line treatments for any bladder issue
Stress:
Pelvic floor exercises/Kegels - train the levator ani muscles and coccygeus - surround and pinch on the bladder neck and urethra and with training will be stronger to effectively retain urine; can be given vaginal cones to hold in vagina to strengthen muscles; must have tried physio for 6+wks before surgery
Urge:
Bladder training/drill - simply practising resisting the urge to go to the toilet
Weight reduction (even bariatric surgery can help), smoking cessation (as damages tendons/muscles), caffeine cessation (esp. for overactive), manage any bowel dysfunction better e.g. IBS control, no straining for constipation
What are some containment options for incontinence?
Bladder bypass - catheter - in/out or permanent suprapubic/urethral
Leakage barriers - pads and pants
Vaginal support devices - pessaries
Skin care (as urine is an astringent and can damage skin if left)
Odour control - for wellbeing
Why might you give oestrogens?
There are oestrogen receptors in the bladder, bladder neck, urethra, vagina etc
Treatment with local oestrogen creams has shown to reduce frequency, urgency and incontinence
HRT similarly will improve skin and muscle quality in postmenopausal women
How do you mange detrusor overactivity
medically?
Drugs:
1st - Oxybutynin
2nd - Mirabegron
Botox:
Using cystoscope - several injections into the bladder in different places, blocks ACh release from nerves so no contraction; if done just right will have good control (though a risk of being put into retention), will need repeating 6 monthly
How do antimuscarinics work? What are their side effects?
Key drug:
Oxybutynin - 2.5-5mg BD/TDS (also Tolterodine; trospium - fewer CNS effects)
They are atropine-like agents (from Atropa belladonna, would combat muscarine poisoning)
Are M2 and M3 receptor antagonists - acting on receptors in the detrusor muscle that would otherwise be activated by ACh from the sacral parasympathetic fibres from S2-S4 (and lead to bladder contraction and voiding)
SE are common (60-90%): dry mouth, blurred vision, drowsiness, constipation, tachycardia
Large placebo effect
What is the mechanism of action and side effects of Mirabegron?
Beta-3 adrenergic receptor agonist
Relaxes smooth muscle of the detrusor - increases bladder capacity
SE: palpitations, HTN, headache
What is a surgical option for stress incontinence?
Colposuspension - lifting the neck of the bladder and stitching it in this lifted position; SE: incomplete emptying, recurrent UTI and sex pain
Urethral sling - sling (made of your own tissue/another persons tissue/animal tissue) can be placed around the neck of the bladder to support it and prevent urine leaking; SE: incomplete emptying
