Lecture 14 - urinary incontinence Flashcards
Lower motor neuron lesion
E.g. cauda equina
- PS affected at S2,3,4
- can’t void
- reduced perianal sensation
- lax anal tone
- Low detrusor pressure as can’t contract
- Large residual urine - overflow incontinence
Upper motor neurone lesion
The PS aren’t inhibited as much
- Detrusor sphincter dyssynergia
- High pressure detrusor contractions
- Poor coordination with sphincters
Detrusor muscle hypertrophy - dilates ureter and kidneys due to back pressure
Stress incontinence
Involuntary leaking on effort or exertion as well as:
- cough
- laugh
- sneezing
Urgency incontinence
Involuntary leaking associated with immediate urgency - can’t hold it in
Mixed urinary incontinence
Involuntary leaking associated with urgency, exertion, effort and sneezing or coughing
Overflow incontinence
Involuntary leaking due to
- lower urinary tract lesion
- chronic retentionq
Most common type of incontinence
Stress incontinence
Risk factors for incontinence
Family predisposition Pregnancy and vaginal delivery Pelvic prolapse Menopause - decreased oestrogen so less anal tone Obesity Age
Examination for incontinence
BMI
Abdominal exam - palpable bladder in chronic retention
Male: DRE
Females:
- external genitalia stress test
- vaginal exam - atrophic after menopause
Investigations for incontinence
Urine dipstick:
- UTI
- haematuria
- proteinuria
- glucosuria
Non invasive urodynamics
- voiding patterns - bladder diary
- frequency - volume chart
- post micturition residual volume
Optional:
- invasive urodynamics - pressure flow studies +/- video
- pad tests
- cystoscopy - if haematuria
Pressure flow studies
Detrusor pressure and function
Residual volume
Abdominal pressure
Bladder pressure
Detrusor pressure
= Total pressure - abdominal pressure
Coughing increases abdominal pressure but destrusor pressure stays the same
Management of incontinence
Modify fluid intake Weight loss Stop smoking Decrease caffeine intake Routine voiding schedule every 4 hours Avoid constipation
Pelvic floor muscle training - 8 contractions 3x a day for atleast 3 months
Failed conservative management
Indwelling catheter
Sheath device
Incontinence pads
Pharmological management
Duloxetine
= combined noradrenaline and serotonin uptake inhibitor
- Increased activity in striated sphincter during filling phase
- Not first line as feel nauseous
