Overactive bladder syndrome (Incontinence) Flashcards
Types of incontinence
Types of incontinence:
- Stress = Increased pressure on bladder -> incontinence [SMALL LOSSES]
- Urge = Strong urge to urinate and often don’t get to toilet in time -> incontinence [LARGE LOSSES]
- Mixed = ≥2 types (often stress and urge incontinence together)
- Overflow = Difficulty emptying bladder -> filling -> incontinence
- Functional = cannot get to the toilet in time (issues in mobility) -> incontinence
· Dribbling incontinence after having a child with a prolonged labour, suspect a vesicovaginal fistula à urinary dye studies
Define overactive bladder syndrome
Overactive Bladder Syndrome:
- Urinary urgency(+/- urge incontinence) which is usually associated with urine storage symptoms:
- Frequency- patient considers they void too often by day
- Nocturia- waking at night ≥ 1 times to void
Normal micturition
Micturition cycle: The bladder stores and then voids urine
- The detrusor muscle of the bladder is usually RELAXED, allowing STORAGE of increasing volumes with no increase in pressure
- As the bladder reaches its capacity, sensory signals from the stretch receptors in the bladder wall are sent, signalling stretch (and so the bladder is full).
- Voluntary delay of micturition occurs until it is SOCIALLY CONVENIENT. This is achieved by cortical inhibition of the spinal voiding reflex arc.
- Before voiding begins, this inhibition is REMOVED which allows the pelvic floor and urethral sphincters RELAX.
- The detrusor muscle is innervated by muscarinic cholinergic nerves of the PNS (which causes muscle contraction)
- The urethral sphincter is innervated by:
- Noradrenergic neurons of the SNS (causing sphincter contraction)
- Somatic fibres from the pudendal nerve (causing voluntary contraction and relaxation)
In women, the urethral sphincter mechanism includes the:
- INTERNAL sphincter (smooth muscle)
- EXTERNAL sphincter (striated muscle)
In premenopausal women, the urethral epithelium has a rich blood supply and contributes to continence by acting as a seal
Causes
Stress Incontinence
- Usually due to an incompetent urethral sphincter
- Urethral sphincter weakness is due to hypermobility, where the pelvic floor and ligaments cannot retain the urethra in position, and it falls through the urogenital hiatus during increases in abdominal pressure
- This leads to loss of pressure transmission to the urethra and therefore, leakage of urine
Intrinsic Sphincter Deficiency
- Less common
- Occurs when urethral closure pressure is low without any urethral mobility
- It is caused by weakness of the sphincter muscles and loss of the cushioning seal effect in the urethra
NOTE: urethral sphincter weakness is associated strongly with a history of vaginal childbirth.
Childbirth can lead to:
- Stretching/ damaging the pudendal nerves
- Overstretching/ avulsion of the pelvic floor muscles
- Direct muscle damage and result in loss of pelvic floor support (and so urethral hypermobility)
IMPORTANT: Pudendal nerve damage causes both weakening of the urethral sphincter and pelvic floor muscles.
Detrusor Overactivity- Overactive Bladder syndrome/ Urge Incontinence
- Involuntary detrusor contractions during the filling phase of micturition
- Women will be symptomatic but may not be incontinent unless the urethral sphincter function is compromised or the detrusor contractions are of very high amplitude and overcome urethral resistance.
- Infection/ neuro cause
Urinary Overflow Incontinence
Causes include:
- Nerve damage- causing a neurogenic bladder
- Diabetes
- Chronic alcoholics
- Pelvic surgery to the area
- Prostate problems (e.g. enlargement) in men
Symptoms
NOTE: Determine if symptoms are due to stress or urge incontinence (if mixed symptoms, assess which ones are predominant)
Stress incontinence: involuntary leakage on effort or exertion when intra-abdominal pressure rises
- e.g. coughing, laughing, sneezing
- Loss of small (but often frequent) amounts when coughing etc.
- Sudden urgency
- Check for mobility as may mean it is harder to cope
- Frequency
- Nocturia
Voiding difficulties- hesitancy, straining, slow or intermittent stream, incomplete emptying)
- Most commonly seen with neurological conditions in women (+ prostate enlargement in men)
- Constant leakage of urine
- May cause vulval irritation and dryness (esp post menopausal)
Associated symptoms:
- Prolapse
- Faecal incontinence
- Sexual difficulties
Determining severity
- Number of episodes per day of frequency, urgency and leakage
- Are continence pads needed and if so, how many and what size?
- Volume coming out during each situation
- Does the patient need to change underwear or outer clothes because of leakage?
- Changes in behaviour to accommodate for this issue?
- E.g. reduced fluid intake, limiting social activities
- If issues during long walks and climbing stairs, it may indicate high severity
- Red flags: haematuria, rectal bleeding, significant pain
NOTE: continuous dribbling incontinence after prolonged labour may suggest vesicovaginal fistulae -> urinary dye studies should be performed to identify presence of fistula
Signs O/E
- General examination- weight, gait abnormalities, neurological disease indicators
- Abdominal examination
- Bimanual examination- assess pelvic tone and contraction (squeeze examining finger)
- Visible leakage during coughing or Valsalva
- Ability of the patient to contract and hold the contraction of pelvic floor muscles is essential (grade strength from 0-5 (strongest))
- Pelvic organ prolapse
- Atrophic vaginitis
- Palpable bladder after voiding (i.e. full bladder)- think RETENTION with urinary overflow à due to bladder outlet obstruction
Investigations
- Urine dipstick and MC&S - rule out UTI and DM is v imp
In patients over 65 years old, urinalysis is not performed to assess for UTIs as asymptomatic bacteriuria is common in this population and therefore urinalysis will not be reliable.
Urine pregnancy test
1. Bladder diary (usually about 3 days)
- Record amount, type and frequency of drinks taken
- Record timing, frequency and volume of voids
- Record episodes of incontinence and urgency
Pad test
- Patient wears a pre-weighed sanitary pad for a variable length of time (e.g. 1 hour in clinic or 24 hours at home) whilst performing provocation tests (e.g. handwashing, climbing stairs, coughing)
- The change in weight is a measure of the amount of urine lost
Bloods if indicated
Speculum to rule out prolapse
Pelvic or renal USS- if there are symptoms of pelvic pain , pelvic mass, haematuria, bladder pain or recurrent UTI
2. Urodynamic studies
Indicated when surgery is considered in order to:
- Confirm the diagnosis
- Check detrusor overactivity
- Check for voiding dysfunction
- Urge-predominant mixed or symp suggest voiding dysfunction
Hx of prev surgery for stress incontinence
Discuss with the MDT (gynaecologist, urologist, continence nurse, continence physiotherapist and maybe medicine for the elderly consultant)
Management of stress incontinence
1st Line: CONSERVATIVE Treatment - can manage this bit in GP
- Fluid balance
- Avoid excessive intake or reduced intake
- Women should drink 1.5-2.5 L of water per day
NOTE: reducing fluid intake can result in an increased sensation of urgency due to the more concentrated urine
Avoid caffeinated drinks and artificially sweetened or carbonated drinks
- Weight loss- if BMI ≥ 30kg/m2
- Optimise other medical problems- DM, smoking cessation, chronic cough or constipation
Pelvic Floor Muscle Exercise (Supervised) for ≥ 3 months
- The woman contracts the pelvic floor muscles by direct coaching whilst being examined vaginally
- Minimum of 8 contractions 3 x day
- Programmes are developed to increase the duration of the hold of the contraction and to increase the number of contractions that can be performed consecutively
- Pelvic floor exercises work for both incontinence and overactive bladder
2nd Line: SURGICAL Treatment
Burch Colposuspension
- Suture areas around the bladder neck to secure the area
- Done under GA or spinal anaesthesia
Autologous Rectus Fascial Sling
- A strip of tissue is taken from the lower abdomen and used as a sling around the bladder neck and urethra
MOT REALLY DONE
Urethral Sphincter Bulking Injections
- Bulk up the bladder neck and coat the urethral mucosa (e.g. macroplastique)
- Usually used for women deemed unfit for general anaesthesia
- Not as effective as colposuspension and midurethral tape
3rd Line: Duloxetine (SNRI)
- Review in 2-4 weeks if unsuitable for surgery or prefer this over surgery
- MoA: Increases sympathetic output to the urethral sphincter, increasing sphincter tone
C/I: uncontrolled hypertension, Caution: bleeding disorders, open-angle closure glaucoma, elderly,history of mania or epilepsy
Management of urge incontinence
CONSERVATIVE Treatment
1st LINE: Bladder Retraining for 6 weeks
- Available from local continence nurse, continence physiotherapist or urology clinic
- Involves re-educating the woman to increase the interval between voids to re-establish normal frequency
- The urgency and fear of leakage associated with overactive bladder leads to the woman wanting to void whenever they are aware of bladder filling sensations
- Teach the woman about normal bladder sensation, rate of urine production and normal bladder capacity (350-500 mL)
- The woman should be encouraged to delay voiding for several minutes after when she would normally void
MEDICAL Treatment
2nd Line: Antimuscarinics (Bladder Stabilising)
(DOT; darifenacin, oxybutynin, tolterodine), ADH analogues (desmopressin)
- Don’t give if the patient has closed angle glaucoma
- Oxybutynin = increased risk of falls – do not give if frail and elderly
- 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
Management of overflow incontinence
Difficulty emptying bladder à overflowing à incontinence
- Refer to specialist urogynaecologist
- 1st line = timed voiding
Complications
Anticholinergic Side effects:
- Dry mouth
- Constipation
- Blurred vision
Botulinum toxin- can lead to voiding difficulties, bleeding, infection
Midurethral tape (and Burch Colposuspension) side effects:
- Voiding dysfunction
- Bladder injury (perforation)
- New OAB symptoms
Burch Colposuspension can also result in long-term risk of posterior vaginal prolapse
UTI from urodynamic studies
Prognosis
Prognosis
Depends on:
- The type of urinary incontinence
- Severity
- Underlying cause
- Any contributory factors
- Motivation of treatment
PACES
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
Summary of management
