Lecture 15 - Urinary Incontinence Flashcards
What are the 4 main types of incontinence?
Stress Urinary Incontinence
Urgency Urinary Incontinence
Mixed Urinary Incontinence
Overflow Incontinence
What is Stress Urinary Incontinence (SUI)?
When there’s involuntary leakage on effort or exertion, coughing or sneezing due to increased ABDOMINAL PRESSURE
What is Urgency Urinary Incontinence?
Involuntary leakage associated with urgency
What is Mixed Urinary Incontinence?
The complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing.
Stress + Urinary
What is overflow incontinence?
Involuntary release of urine when the bladder becomes overly full, can be due to a weak bladder muscle or blockage
What is an Over Active Bladder?
Frequent and sudden urge t urinatte that may be difficult to control due to overactive detrusor muscle
Why is the prevelance of Urgency Urinary Incontinence much higher than it actually is measured to be?
Lots of people dont seek medical help for it
What are the risk factors for Urinary Incontinence?
Pregnancy and childbirth
Pelvic surgery
Pelvic prolapse
Anatomical/neurological abnormalities
Obesity
Age
Inc Abdomen pressure
Menopause
UTIs
Drugs
Why does menopause increase risk of urinary incontinence?
Lack of oestrogen after menopause
Oestrogen maintains the tone of the pelvic floor muscles which the urethra passes through
Look at slide 7:
What type of incontinence does the patient most likely have?
Mixed Urinary Incontinence
What factors based on her history support the diagnosis?
What is the incontinence likely due to?
Urgency
Inc freq
Nocturia without UTI
LIkely weakness of pelvic floor due too menopause
What are some lower urinary tract symptoms to do with storage?
Increased frequency
Urgency
Nocturia
Incontinence
What are some lower urinary tract symptoms to do with voiding?
Slow stream
Splitting or spraying
Intermittency
Hesitancy
Straining
Terminal dribble
What are some lower urinary tract symptoms to do with post-micturition?
Post-micturtiion dribble
Feeling of incomplete emptying
How does caffeine intake affect urinary continence?
Acts as a diuretic
Caffeine irritates bladder leading to the need to go
What dermatomes should be examined if Urinary Incontinence is thought to be due to neurological damage?
S2, S3 and S4
What examinations are done in a person with urinary incontinence?
BMI
Abdominal exam + able to palpate bladder (not normally able to)
Neuro exam of S2,S3 and S4
DRE (prostate)
Females (external genitalia + vaginal exam)
What investigations are done on someone with Urinary incontinence?
Mandatory Urinary dipstick
Frequency vol chart
Bladder diary
Post micturition residual volume
Can do pad tests or cytoscopy
What is the urine dipstick testing for?
Ruling out UTI also diabetes
Haematuria
Proteinuria
Glucosuria
How do you measure post-micturition residual volume?
After the patient has voided you Catheterise them then drain the urine left in the bladder
When doing urodynamics testing what pressures are important?
Intravesicle pressure
Abdominal pressure
Detrusor pressure
Where is a probe inserted in order to measure intravesical pressure?
Bladder probe
Where is a probe inserted in order to measure abdominal pressure?
Rectal probe
How do you work out detrusor pressure?
Bladder (intravesical pressure) - Abdominal pressure
What structures can prolapse through the pelvic floor if it become weak in women?
Uterus
Rectum
Bladder
What are the pelvic floor muscles?
Coccygeus
Levator ani
Iliococcygeus
Pubococcygeus
Puborectalis
Puborectalis
Obturator internus
What are some conservative management techniques for urinary incontinence?
Modify fluid intake (caffeine)
Weight loss (inc Abd Pressure)
Stop smoking (irritate detrusor)
Avoid constipation (Inc abdominal pressure)
Timed voiding
What is contained incontinence?
When devices like in dwelling catheters, sheath device (catheter condom) and incontinence pads are used to catch any urine
What can be trained as a part of management for Stress Incontinence?
Pelvic floor muscles
What drug can be used to treat Stress Urinary Incontinence?
Duloxetine
How is Duloxetine used to treat Stress Urinary Incontinence?
Noradrenaline reuptake inhibitors
Meaning prolongs the action of Noradrenaline at the Internal Urethral Sphincter so it remains contracted
What surgery can be done in females for Stress Urinary Incontinence?
Permanent:
Open retro pubic suspension procedures
Low tension vaginal tapes
Temporary (if further pregnancy planned):
Intramural bulking agents into sphincter to make it bigger
What surgery can be done in males to treat Stress Urinary incontinence?
Artificial urinary sphincter
Male sling procedure
What is an open retropubic procedure?
Mesh put inside vagina at midurethral level and is passed retroppubiclaly supporting the bladder preventing urine from being squeezed out
What is the gold standard surgical treatment for men in SUI?
Male artificial urinary sphincter (cuff)
How does the male artificial urinary sphincter work?
Cuff put around urethra
Urine from bladder drains into it allowing it to swell and occlude urethra
Turn off mechanism to allow urine through
How is Urgency Urinary Incontinence initial managed?
Bladder training:
-schedule of voiding
-eventually time period between voiding increases
How is urgency Urinary incontinence treated Pharmacologically?
Anticholinergics/antimuscarinics
B3-adrenoceptor agonist
What is the problem with Anticholinergics?
They have many side effects due to them acting on Muuscarinic Receptors (mainly M2,M3) but act on all of them
M1 = CNS salivary glands
M2 = heart
M3 = smooth muscle (ocular and intestinal), salivary glands
What is the function of Anticholinergics in treating UUI?
Inhibits the parasympathetic action of ACh at the M3 receptor on the detrusor muscle preventing it contracting
What is an example of antihcholinergics for UUI?
Oxybutynin
Solifenacin
What is the function of a B3-adrenoceptor agonist?
Stimulates the sympathic actions of detrusor muscle contraction
How can botulism Toxin be used to treat UUI?
Injected into bladder (intravesical injection)
Its a neurone toxin inhibiting release of ACh at presynaptic neuromuscular junction causing flaccid paralysis allowing the bladder to fill more
What surgery can be done t treat UUI?
Sacral nerve modulation
Autoaugmentation
Augmentation cystoplasty
Urinary diversion (into a port like a stoma bag)
What managements can be done to treat a post menopausal woman’s UUI without surgery?
Reduced fluid intake
Reduced caffeine intake
Bladder training
HRT (helps strengthen pelvic floor)
Pelvic floor exercises
Anticholinergics drugs
B3 agonists
What managements can be done to treat a post menopausal woman’s SUI without surgery?
Duoloxtine hydrochloride
Pelvic floor muscles
What is enuresis?
Bedwetting
What is considered Enuresis/bedwetting?
Involuntary wetting during sleep at least twice per week in children aged over 5yrs with no CNS defects
What is primary enuresis?
Nerve achieved sustained continence at night
What is secondary enuresis?
Restarted having been dry at night for over 6months
What nerve maintains voluntary continence?
Pudenal nerve
What hormone is usually produced in large quantities at night to help prevent enuresis?
ADH
How is primary enuresis managed without daytime symptoms?
Reassurance
Alarms with positive reward system to wake up once start to wet bed
Give desopressin when not enough ADH is being made
How is primary enuresis managed with daytime symptoms?
Usually caused by disorders of lower urinary tract so refer to secondary care
How is secondary enuresis treated?
Treat underlying cause:
UTIs
Constipation
Diabetes
Psychological problems
Family problems
Physcial or neuro problems
What is a urinary stress test?
Fill bladder then cough to see if there’s any incontinence
What are some investigations done when suspecting stress incontince?
Urinalysis
Stress test
Bladder scan
Bladder diary
