incontinence in women Flashcards
define incontinence
involuntary leakage of urine
- stress
- urgency
- mixed
- overflow - detrusor underactive or bladder outlet obstruction
risk factors of stress incontinence
Increasing age.
Pregnancy and vaginal delivery — muscles and connective tissue can be weakened during delivery, and damage may occur to pudendal and pelvic nerves.
Obesity — due to pressure on pelvic tissues and stretching and weakening of muscles and nerves from excess weight.
Constipation — straining may weaken pelvic floor muscles.
A deficiency in supporting tissues for example:
- Prolapse — not a cause of stress urinary incontinence but may be caused by the same underlying deficiency of supporting tissues.
- Hysterectomy — surgery may damage the pelvic floor muscles.
- Lack of oestrogen at the menopause — oestrogens keep tissues that influence normal pressure transmission in the urethra healthy and maintain urethral secretions that help to create a ‘seal’.
Family history — women whose mother or sisters are incontinent are more likely to develop stress urinary incontinence.
Smoking — smoking is associated with chronic cough which may contribute to stress urinary incontinence.
Drugs — for example angiotensin-converting enzyme (ACE) inhibitors (can cause cough and worsen stress incontinence).
risk factors of urgency incontinence
overactive bladder
- involuntary contraction of the detrusor muscle during filling phase
neurological - parkinsons
MS
injury to pelvic or spinal nerves
comorbidities
- obesity
type 2 diabetes
chronic urinary tract infection
medications - parasymapthomimetic
diuretics
HRT
antidepressants
usually idiopathic
drinks - acidic, alcoholic or caffeine
nerval supply for muicturtion
The lower urinary tract is innervated by 3 sets of peripheral nerves: pelvic parasympathetic nerves, which arise at the sacral level of the spinal cord, excite the bladder, and relax the urethra; lumbar sympathetic nerves, which inhibit the bladder body and excite the bladder base and urethra; and pudendal nerves, which excite the external urethral sphincter.
drugs that cause detrusor overactivity
parasympathomimetics
antidepressants
hormone replacement
diuretics cause increase in urinary frequency
causes of overflow incontinence
underactivity of the detrusor or bladder obstruction - urinary retention
drugs that decrease bladder contractility
Angiotensin-converting enzyme (ACE) inhibitors. Antidepressants. Antihistamines. Antimuscarinics. Antiparkinsonian drugs Beta-adrenergic agonists. Calcium channel blockers. Opioids. Sedatives and hypnotics.
complications of urinary incontinence
impairment in QoL - work and life psyhcological problems -depression, embarrassment social isolation sexual problems loss of sleep falls and fractures financial problems
what qs to ask about incontinence
If incontinence occurs when coughing, sneezing, or on effort or exertion (likely to be stress urinary incontinence), or
If there is sudden urgency, and if they have frequency and nocturia (likely to be urgency incontinence associated with overactive bladder syndrome).
Voiding difficulty (for example straining to void, sensation of incomplete emptying) — may suggest chronic urinary retention (overflow incontinence).
Constant leakage of urine (may be intermittent if position dependent) — suggestive of a fistula (for example vesicovaginal).
Post-void dribbling, pain, urgency, frequency, recurrent urinary tract infection, vaginal discharge, and dyspareunia — consider a urethral diverticulum.
fluid intake, caffeine, alcohol
childhood enuresis
drugs
previous history of Ix and Tx - UTI, spinal surgery, prolapse, hysterecomy
history of back pain or falls
prolapse
sexual dysfunction
bowel habit
how do assess pelvic floor muscle contraction
oxford classification
0 = no contraction. No discernible muscle contraction.
1 = flicker. A flicker or pulsation is felt under the examiner's finger. 2 = weak. An increase in tension is detected, without any discernible lift. 3 = moderate. There is lifting of the muscle belly and also elevation of the posterior vaginal wall. 4 = good. Increased tension and a good contraction elevate the posterior vaginal wall against resistance (pressure by the examining finger applied to the posterior vaginal wall). 5 = strong. Strong resistance is applied to the elevation of the posterior vaginal wall. The examiner's finger is squeezed and drawn into the vagina.
when do refer within 2 weeks
unexplained visible haematuria without UTI
visible haematuria - persistent or recurrent after successful treatment of urinary tract infection
when do refer within 2 weeks
aged 45 and over
unexplained visible haematuria without UTI
visible haematuria - persistent or recurrent after successful treatment of urinary tract infection
aged 60 and over
unexplained non-visible haematuria and dysuria or a raised white cell count on a blood test.
management for stress incontinence
1) lifestyle advise
2) pelvic floor muscle exercises - 8 types 3X day minimum 3 months
DULOXETINE
3) options - colposuspension, autologous rectus fascial sling, and retropubic mid-urethral mesh sling, intramural urethral bulking agents.
lifestyle advise for incontinence
Reducing caffeine intake — this may improve symptoms of urgency and frequency but not incontinence.
Fluid intake — advise the woman to avoid drinking either excessive amounts, or reduced amounts, of fluid each day.
Weight loss if the woman’s body mass index is 30 kg/m2 or greater.
Smoking if this is appropriate — for more information, see the CKS topic on Smoking cessation.
managing urgency incontinence
1) - bladder training for at least 6 weeks
FAILS 2) continue trianing PLUS antimuscarinic FIRST LINE - oxybutynin - tolterodine - darifenacin
new antimuscarinic - solifenacin
ANITMUSCARININC CONTRADICTED
- Mirabegron - B3 agonist - urinary retention
3) BOTOX
