Overactive bladder Flashcards
What are the types of incontinence?
o Stress = Increased pressure on bladder -> incontinence [SMALL LOSSES]
o Urge = Strong urge to urinate and often don’t get to toilet in time -> incontinence [LARGE LOSSES]
o Mixed = ≥2 types (often stress and urge incontinence together)
o Overflow = Difficulty emptying bladder -> filling -> incontinence
o Functional = cannot get to the toilet in time (issues in mobility) -> incontinence
What investigations do you do for overactive bladder?
o Speculum examination -> exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises) -> ask patient to cough (Valsalva) during exam to check for fluid leakage
o 1st: Urine dipstick, urine MC&S – rule out DM or UTI
o 1st: Bladder diaries (minimum 3 days) -> if inconclusive move to 2nd line…
o 2nd: Urodynamic Testing (if mixed incontinence) – 3 pressures* measured from inside rectum and urethra
§ Bladder pressure = detrusor + IAP
§ Detrusor = bladder – IAP
What is voiding?
Men can hold 400mL and void at a rate of 10-15mL/s
Women can hold 500mL and void at a rate of 15-20mL/s
What is the management of stress incontinence?
§ CHECK NEED FOR REFERRAL TO SPECIALIST (i.e. trigone tumour -> needs to be checked)
§ 1st line = lifestyle advice, WL (only if BMI >30), pelvic floor exercises (8 contractions, TDS, 3 months)
· Can refer to physiotherapist if difficulty with pelvic floor exercises
§ 2nd line = surgical treatment (see below) or SNRI duloxetine (if does not want surgical treatment)
· Burch colposuspension -> stitching the neck of the bladder higher (Cooper’s ligaments)
o SE of surgery – any paravaginal plexus damage can lead to lots of bleeding
· Autologous rectus fascial sling -> a sling placed around the neck of the bladder
· Bulking agents -> put bulking agents into urethral wall to provide more force
What happens in stress incontinence?
Increased pressure on bladder -> incontinence [SMALL LOSSES]
What are the RFs for stress incontinence?
o Age
o Children
o Traumatic delivery
o Pelvic surgery
o Obesity
What are the RFs for urge incontinence?
o Age
o Obesity
o Smoking
o FHx
o DM
What is the management of urge incontinence?
§ CHECK NEED FOR REFERRAL TO SPECIALIST (i.e. trigone tumour -> needs to be checked)
§ 1st line (conservative) = lifestyle advice, bladder training:
· Bladder training (6 weeks) -> progressively hold off going to the toilet (up to 25 minutes)
· Other:
o Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles)
o Control any diabetes well (avoid diabetic nephropathy)
§ 2nd line (medical) = antimuscarinic (oxybutynin, tolterodine), ADH analogues (desmopressin)
· Antimuscarinics (DOT; darifenacin, oxybutynin, tolterodine)
o Don’t give if the patient has closed angle glaucoma
o Oxybutynin = increased risk of falls – do not give if frail and elderly
o Darifenacin = M3 receptor antagonist
· ADH analogues (desmopressin) NOT oxytocin
NOT terbutaline
§ 3rd line (medical)= mirabegron (beta-3 agonist)
· Used if concerns about using anticholinergics in older, frail women
§ 4th line (surgical) = Botox injection, sacral nerve stimulation, cystoplasty, urinary diversion
What is the management of overflow incontinence?
Difficulty emptying bladder -> overflowing -> incontinence
§ Refer to specialist urogynaecologist
§ 1st line = timed voiding
Dribbling incontinence after having a child with a prolonged labour, suspect a vesicovaginal fistula -> urinary dye studies
Dribbling incontinence after having a child with a prolonged labour, suspect a vesicovaginal fistula -> urinary dye studies
How do you counsel someone with incontinence?
o Risk Factors:
§ Stress: age, traumatic delivery (forceps), obesity, previous pelvic surgery, children
§ Urge: age, obesity, smoking, family history, diabetes mellitus
o Explain diagnosis and mechanism
o Explain lifestyle measures (e.g. controlling fluid intake, avoiding caffeine, losing weight)
o Explain treatment:
§ Urge: bladder retraining (6 weeks) – trying to gradually increase the time in between going to the toilet
§ Stress: pelvic floor training (3 months, TDS, 8 contractions)
o Explain further medical and surgical options
