Session 8 B Flashcards
Types of incontinence
Stress, Urgency, mixed, overflow, over active bladder
What is stress urinary incontinence
Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What is urgency urinary incontinence
The complaint of involuntary leakage of urine accompanied by or immediately proceeded by urgency
What is mixed urinary incontinence
The complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
What is overflow incontinence (chronic urinary retention)
The involuntary release of urine when the bladder becomes overly full- due to a weak bladder muscle or to blockage
What is overactive bladder
A frequent and sudden urge to urinate that may be difficult to control
Prevalence of urinary incontinence/OAB
OAB is higher than UUI
SUI is most common incontinence compared to UUI
3 factors of risk factor
Obs and gyn.
Predisposing
Promoting
O and G risk factors
Pregnancy and childbirth
Pelvic surgery/DXT
Pelvic prolapse
Predisposing risk factors
Family predisposition
Race
Anatomical abnormalities
Neurological abnormalities
Promoting risk factors
Co-morbidities
Obesity
Age
Increased intra abdominal pressure
Cognitive impairment
UTI
Drugs
Menopause
3 classes of classification for lower urinary tract symptoms
Storage, voiding, post-micturition
What do we need to rule out
Diabetes
Storage symptoms of LUTs
Increased frequency
Urgency
Nocturia
Incontinence
Voiding symptoms of LUTs
Slow stream
Splitting or spraying
Intermittency
Hesitancy
Straining
Terminal dribble
Post-micturition LUTs
Post micturition dribble
Feeling of incomplete emptying
Additional factors to consider when determining type of UI
Fluid intake habits, particularly tea and coffee
Previous pelvic surgery
History of large babies
Symptoms of uterovaginal prolapse and faecal incontinence
Examinations needed when investigating for Urinary incontinence
-BMI
-Abdo exam to exclude palpable bladder
-Examination of S2,3,4 dermatomes if suspecting neurological disease
-Digital rectal examination DRE (prostate if male)
- Females external genitalia (stress test), vaginal exam
Investigations for urinary incontinence
Mandatory- urine dipstick, UTI, haematuria, proteinuria, glucosuria
Basic non-invasive urodynamics- frequency-volume chart, bladder diary over 3 days, post micturition Residual volume (in patients with voiding dysfunction)
Optional- invasive urodynamics (pressure flow studies and or video), pad tests, cystoscopy
Conservative management of urinary incontinence
Modify fluid intake
Weight loss
Stop smoking
Decrease caffeine intake (UUI)
Avoid constipation
Timed voiding- fixed schedule
Contained incontinence systems
For patients unsuitable for surgery who have failed conservative or medical management
Indwelling catheter- urethral or suprapubic
Sheath device- analogous to an adhesive condom attached to catheter tubing and bag
incontinence pads
Specific management of SUI
Pelvic floor muscle training (PFMT)
- 8 x contractions (x3 a day)
- 3 months duration at least
Duloxetine
Features of Duloxetine
Combined noradrenaline and serotonin uptake inhibitor
Increased activity in the striated sphincter during filling phase
Not recommended by NICE as first line or routine second line treatment but may be offered as alternative to surgery
Surgery in females for SUI
Permanent intention
- open retropubic suspension procedures
- classical autologous sling procedures
- low tension vaginal tapes
Temporary if further pregnancies planned
- Intramural bulking agents
Males surgery interventions for SUI
artificial urinary sphincter
Male sling procedure
Features of a male artificial urinary sphincter
Gold standard
Urethral sphincter deficiency- neurological, post DXT or surgery
Cuff stimulates action of normal sphincter to circumferentially close the urethra
What is DXT
Deep x ray therapy
Overview of initial management of UUI
Bladder training
Schedule of voiding:
- void every hour during day
- must not void in between, wait or leak
- Intervals increased by 15-30 minutes a week until interval of 2-3 hours reached
- at least 6 weeks duration
Pharmacological management of UUI
Anti cholinergic (acts on muscarinic receptors M2 and m3)
Many brands e.g. Oxybutynin, Solifenacin
B3 adrenoreceptor agonist- Mirabegron
What does Mirabegron do
B3 adrenoreceptor agonist
Increases bladders capacity to store urine
Side effects of anti cholinergics
M1- CNS, salivary glands
M2- heart smooth muscle
M3- smooth muscle (ocular and intestinal), salivary glands
M4- CNS
M5- CNS, eye
Features of botulism toxin
Refractory to anticholinergics and B3 adrenoreceptor agonist
Intravesical injection of Botulinum toxin (potent biological neurotoxin, inhibits ACh release at pre-synaptic neuromuscular junction causing targeted flaccid paralysis)
Lasts 3-6 months
Surgery refractory to pharmacological management
Sacral nerve neuromodulation
Autoaugmentation
Augmentation cytoplasty
Urinary diversion
What constitutes Enuresis in children
Bedwetting = involuntary wetting during sleep at least 2x a week in children aged >5 years with no CNS defects
Key questions for children with enuresis
Age
Primary or secondary (after 6 months of dry nights)
Daytime symptoms
Pain passing urine
Pass urine infrequently
Are they constipated
Management in primary enuresis without daytime symptoms
Primary care
Reassurance, alarms with positive reward system, desmopressin
Management in primary enuresis with daytime symptoms
Usually caused by disorders of the lower urinary tract e.g. anatomical, OAB
Referral to secondary care
Management of secondary enuresis
Treat underlying cause if it has been identified
E.g. UTIs, constipation, diabetes, psychological problems, family problems, physical or neurological problems
Primary/secondary care
