Pelvic floor disorders - incontinence Flashcards
What is the incidence of urinary incontinence
1 in 3 women ≥ 55 have urinary incontinence
What are the risk factors for developing urinary incontinence ?
- Female
- Increasing age
- Obesity
- Smkoing - chronic cough, COPD can all cause episodes of incontinence or worsen it
- Other conditions - Kidney disease, Diabetes
Describe the 4 classifications of urethral urinary incontinence and there cause
- Overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- Stress incontinence: leaking small amounts when coughing or laughing
- Mixed incontinence: both urge and stress
- Overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
What are the 2 main causes of extraurethral urinary incontinence ?
Ectopic ureter draining straight into the urethra or a fistula
Define what stress incontinence is
This is involuntary urine leakage on effort/extortion or on sneezing or coughing
Define what overactive bladder (OAB) is
This is defined as urgency that occurs with or without urgency UI & usually with frequency & nocturia.
- OAB that occurs with urgency UI is known as ‘OAB wet’
- OAB that occurs without incontinence is known as ‘OAB dry’
Define what urge UI is
- This is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)
==> think OAB as being the urge which can then occur with (OAB wet) urge UI or without (dry OAB)
Define mixed UI
- This is involuntary urine leakage associated with both urgency & effort/exertion, sneezing or coughing
Define what overflow incontinence is
- This is UI due to bladder outflow obstruction causing a build up resulting in chronic retention, then eventually the person is incontinent (usually due to prostate enlargement)
What are the investigations done for someone presenting with UI ?
- History & physical exam - categorise the woman’s UI as SUI, mixed urinary incontinence or UUI/OAB. Start initial treatment on this basis.
- Bladder diaries should be completed for a minimum of 3 days
- Vaginal examination to exclude pelvic organ prolapse (prolapse associated with 50% of stress UI) and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- Urine dipstick and culture - to exclude UTI or diabetes cause
- Measure post-void residual volume by bladder US in women with symptoms suggestive of voiding dysfunction or recurrent UTI
- Urodynamic studies may be done - to differentiate between OAB/urge & stress UI
Describe the signs/symptoms of urge UI/OAB
- You have an urgent desire to pass urine and sometimes urine leaks before you have time to get to the toilet
- Sometimes provoked by things e.g. putting the key in the door, sound of running water etc
What is urge UI/OAB often due to ?
Detrusor muscle overactivity - which is essentially due to overstimulation by nerves
What are some of the causes of detrusor overactivity ?
- Tumours or bladder stones causing irritation in the bladder
- Pelvic surgery or fractures causing damage to the parasympathetic supplying the bladder
- Paraplegia - loss of central inhibition
- Destruction of S2,3 segment
- Infection
How can urodynamics be used to differentiate between urge UI/OAB & stress UI?
- OAB/ UUI is due to bladder (detrusor) overactivity causing frequent involuntary contractions. On urodyanmics this is seen as an increase in detrusor pressure causing a rise in intravesicular pressure with no increase in abdominal pressure
- In SUI urodynamics will show increased abdominal pressure corresponding to increased filling without increased detrusor pressure
Note - don’t do before primary surgery if SUI or stress-predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary incontinence at examination.
What are the signs/symptoms of stress incontinence ?
- Urine leaks during increased intra abdominal pressure, without a detrusor contraction
- e.g. when coughing can get leaks, can be due to weak pelvic floor muscle due to pregnancy
What is the most common type of urinary incontinence ?
SUI
Describe the symptoms/signs of overflow incontinence
- It is due to bladder flow obstruction causing urine to build up resulting in chronic retention then eventually the person is incontinent
- Large palpable bladder
- Usually don’t feel that they are incontinent
- Often wet at night
Who is usually affected by overflow incontience ?
Men - as can be caused commonly by enlargement of the prostate
Describe the 2 phases which make up the micturation cycle/ micturation reflex
- Filling phase - bladder pressure (intravesicular) has a slight rise as it fills. The internal urethral sphincter remains tense & detrusor muscle relaxed by sympathetics
- Voiding phase - Adequate filling of bladder occurs, which is sensed by stretch receptors (which send signals to S2,3 & the brain), these receptors have increased firing now to the point where thy stimulate pelvic parasympathetic nerves to cause detrusor muscle contraction & internal urethral sphincter relaxation
Voluntary control via the peudendal nerve (conscious thought) can stimulate perineal muscles & external urethral sphincter to contract to prevent voiding
On urodyanmics what does a very high detrusor muscle pressure in the context of UI indicate ?
Obstruction (overflow) e.g. prostate enlargement
What is the treatment of UUI/ OAB wet
- 1st line = dietary (avoid caffeine, sensible fluid intake & decrease weight) + bladder training (min 6weeks) + pelvic floor strengthening by physio
- 2nd line = Antimuscarinics - (e.g. oxybutynin, tolterodine, darifenicin)
- 3rd line = Beta 3 adrenergics (mirabegron)
Why do you need to review someone 4 weeks after putting them on an anti-muscarinic ?
Due to potential unacceptable side effects:
- Dry mouth
- Constipation
- Blurred vision
- Somnolence
What is the treatment of stress UI?
- 1st line = lifestyle (weight loss, stop smoking) and physio (pelvic floor exercises) - physio for min of 3 months
- 2nd line = Surgical correction is the mainstay - either colposusspension or tape procedures (preferred as less invasive)
What is the treatment of mixed UI ?
Management depends on whether urge or stress UI is the predominant picture. Focus on treating the predominant problem
What is the treatment of overflow incontinence/voiding symptoms?
Conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
- 1st line = alpha-blocker (tamulosin, doxazosin)
- 2nd line = 5-alpha reductase inhibitor (finasteride, dutasteride)
If storage symptoms which arent responding to tamulosin then can add in a antimuscarinic (anticholinergic)
What should you stop/ avoid in overflow UI?
Anticholinergics - as there is obstruction so you don’t want to promote detrusor muscle contraction
What are the common side effects of finasteride ?
Sexual dysfunction & gynaecomastia
What are the indications of multi-channel urodyanmics (cystomethogram)
- Uncertain diagnosis
- Failure to respond to treatment
- Prior to surgery for UI & prolapse
When should mirabegron be avoided ?
If someone has sustained uncontrolled hypertension
