Incontinence Flashcards
Bladder nerve supply: which nerves affect storage, voiding and voluntary function?
- Storage - hypogastric nerve (sympathetic)
- Storage of urine requires relaxation of the detrusor muscle and simultaneous contraction of both the internal and external urethral sphincters. The bladder and IUS are primarily under the control of the sympathetic nervous system.
- Voiding - pelvic splanchnic nerve (parasympathetic)
- Causes the detrusor muscle to contract and the internal urethral sphincter to relax
- Voluntary - Pudendal nerve (somatic)
What happens as the bladder empties?
- The detrusor muscle found in the wall of the bladder remains relaxed to allow the bladder to store urine, and contracts during urination to release urine.
- Urethral relaxation
- Sphincter co-ordination
Normal bladder emptying only occurs in the absence of obstruction or anatomical shunts (Cystocele, Diverticulum)
How does the brain control bladder emptying?
- Cortical influence is important - makes sure that we only urinate when and where it is appropriate.
- Urination is partly controlled by reflexes and is partly under conscious control.
- As the bladder fills, it sends sensory information to the pontine micturition centre in the CNS, and when the bladder is full, these signals indicate that it must be emptied soon.
- Activation of parasympathetic pathway (voiding) & Inhibition of Sympathetic pathway (storage)
- remember there is still the EUS under voluntary control to hold pee in
What happens as the bladder fills?
- Accommodate increasing volume at constantly low pressure.
- Cortical activity: Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
- Activates Sympathetic pathway & reciprocal inhibition of the Parasympathetic pathway
- Mediates contraction of bladder base and proximal urethra.
Define Stress urinary incontinence
Involuntary leakage on effort or exertion, on sneezing or coughing
Define urge urinary incontinence
Involuntary leakage accompanied by or immediately preceded by urgency
Mixed urinary incontinence
Involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing
Risk factors of urinary incontinence (8)
- Age
- Parity
- Menopause
- Smoking
- Increased intra-abdominal pressure
- Pelvic floor trauma
- Denervation
- Connective tissue disease
- Surgery
What is the main risk factor for stress incontinence?
Pregancy and childbirth
When taking a history from a patient who has presented with urinary incontinence what sorts of things do you want to ask them?
- 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 and anti-psychotics
- Previous Pelvic floor muscle training (PFMT), surgical treatment of stress urinary incontinence or Pelvic Organ Prolapse
- Impact on QOL (0-10)
- Fluid intake
- Prolapse symptoms - Vaginal Lump/ Dragging sensation in vagina
- Bowel symptoms - anal incontinence, constipation, faecal evacuation dysfunction, IBS
What symptoms may a patient complain of due to being irritating?
- Urgency ; Sudden compelling desire to void that is difficult to defer.
- Increased daytime frequency (>7)
- Nocturia (>1)
- Dysuria
- Haematuria
What incontinence related symptoms may a patient complain of?
Stress UI
Urgency UI
Coital Incontinence
Severity: How many incontinence pads/day
What would a patient record if asked to do a 3 day Urinary diary?
- Fluid intake - quantity and quality
- Urine output
- Daytime frequency
- Nocturia
- Average voided volume
What urinary investigations/examinations may be done to assess a patient?
- 3 day urinary diary
- Urine dipstick
- Urinalysis - multistix + MSSU
- Post voiding residual volume assessment - only if have voiding difficulties
- Urodynamics -
- Examinations:
- General, abdominal, neurological, gynae, pelvic floor assessment (oxford scale)
What are you looking for during a pelvic floor assessment?
- Prolapse
- Stress incontinence
- Uro-genital atrophy changes
- Pelvic mass
- Pelvic floor tone, strength, awareness
What does the management of incontinence involve?
- Lifestyle changes i.e smoking, weight loss, diet (constipation), alcohol and caffeine
- Physio - reinforce cortical awareness of muscle groups, hypertrophy of existing muscle fibres and general increase in muscle tone and strength
- Medical treatments
- Surgery
What is the gold standard drug for treatment of moderate to severe stress urinary incontinence?
Yentreve (Duloxetine) +/- pelvic floor muscle training - this is a selective serotonin and norepinephrine reuptake inhibitor (anti-depressant) - it increases urethral sphincter contraction during the storage phase of urination cycle.
It should be given if PFMT has failed or if the patient is in secondary care and does not want or fit surgery/ has had failed surgery
What is Culposuspension?
- An operation to treat stress incontinence (leakage of urine when you exercise, sneeze or strain).
- Involves lifting the neck of your bladder, and stitching it in this lifted position
What anatomical defect do stress and urge incontinence arise from in females?
Defect in the anterior vaginal wall and pubo-urethral ligament - Urethral/bladder neck closure dysfunction and USI
What is tension-free transvaginal tape used for?
- An operation used in the treatment of stress urinary incontinence.
- It is the first choice procedure in the surgical treatment of Sress UI
- In this procedure, a synthetic tape is placed around the urethra to form a sling – this supports the urethra to prevent leakage.
- 80% Cure at 11 years follow-up.
Conservative management of overactive bladder symptoms - stress/urge incontinence?
- Lifestyle
- Normalise fluid intake
- Reduce caffeine, fizzy drinks, chocolate
- Stop smoking + alcohol
- Weight loss
- Bladder training programme with continence nurse
- Timed voiding with gradually increasing intervals
Pharmacological treatment of overactive bladder symptoms
- Antimuscarinic
- Oral - solifenacin, fesoteridine
- Transdermal - Kentera patches
- Tri-cyclic antidepressants
- Imipramine
What is ‘overactive bladder’?
- Overactive bladder (OAB) is the name for a group of urinary symptoms. It is not a disease.
- The detrusor muscle contracts before the bladder is full
Symptoms:
- Frequency
- Urgency
- Urgency incontinence
Types of incontinence
What do anti-cholinergics do?
- Anticholinergic drugs block the action of the neurotransmitter acetylcholine.
- This inhibits nerve impulses responsible for involuntary muscle movements and various bodily functions.
- These drugs can treat a variety of conditions, from overactive bladder to chronic obstructive pulmonary disorder.
