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Obstetrics and Gynaecology > Tutorial 15: Urinary Incontinence > Flashcards

Tutorial 15: Urinary Incontinence Flashcards

1
Q

What is the definition of urinary incontinence?

A

“The involuntary loss of urine that represents a hygienic or social problem to the individual”

Urinary Incontinence is a problem with a huge impact on the quality of life of individuals, yet it is continually under-diagnosed and under-recognised, by patients, the public, and even physicians. Despite this, incontinence is eminently treatable and these have the potential to change lives.

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2
Q

What is urge incontinence?

A
  1. Sudden onset urge to pass urine urgently – but don’t have enough time to get to bathroom.
  2. Quickly followed by uncontrolled bladder emptying (~5-10 seconds later) –usually leak large amounts
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3
Q

What are some features of urge incontinence?

A

Incidence: Urge incontinence is the main type of incontinence seen in hospital patients

Aetiology: Detrusor overactivity, isolated (idiopathic) or associated with one or more of the following:

  1. GU conditions such as tumors, stones, diverticuli, or outflow obstruction
  2. CNS disorders such as stroke, dementia, parkinsonism, spinal cord injury
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4
Q

What is the pathogenesis of urge incontinence?

A

Widening of the intracellular space, and change in cell-cell junctions, results in:

  1. Increased spontaneous activity of detrusor smooth muscle
  2. Involuntary bladder contractions +/- impaired contractility
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5
Q

What are some symptoms of Urge incontinence?

A
  • Wets bed, leaves puddles on floor
  • Good emptying of bladder volume
  • Leakage – episodic but frequent
  • Urgency
  • Nocturia
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6
Q

How do you diagnosis Urge incontinence?

A

Leaking of urine with dynamic manoeuvres

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7
Q

What is the management of Urge incontinence?

A
  1. Correct underlying cause ie change frusemide to ACEi
  2. Behavioural Techniques
    • Bladder retraining
    • Pelvic floor exercises
    • Toileting Programme
  3. Medications
    • Smooth Muscle Relaxants
    • Anticholinergics
    • Oestrogen: Topical and Oral
  4. Other Methods
    • Bedside commode/urinal
    • Pads, intermittent catheterisation
  5. Males with Obstruction: Correct the obstruction (either surgically or medically)
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8
Q

What is stress incontinence?

A

Incontinence (usually small amounts) with increases in intra-abdominalpressure I.e. cough, sneeze, laugh

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9
Q

What are some features of stress incontinence?

A
  • It is very common, occurring in 50% of postmenopausal women.
  • Rare in men, occurring only when the sphincter mechanism has been damaged secondary to extensive prostatic resection.
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10
Q

What is the pathogenesis behind stress incontinence?

A

Stress incontinence is the leakage of urine 2o to an incompetent sphincter.

  • Weakness of pelvic floor musculature and urethral hypermotility
  • Bladder outlet or urethral sphincter weakness
    • Congenital, childbirth (instrumental delivery - forceps), post- menopausal, pelvic surgery, pelvic masses, alpha blockers.

Pathogenesis: Coughing/Laughing –> Intra-abdominal Pressure –> Urine leakage

Other mechanisms:

  1. Stress incontinence may be caused by nerve damage (usually 2o to an operation) or due to sphincter mechanism damage
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11
Q

What are some risk factors for developing stress incontinence?

A
  1. Bladder outlet or uretheral sphincter weakness:
  • Congenital
  • childbirth (instrumental delivery - forceps)
  • post- menopausal
  • pelvic surgery
  • pelvic masses
  • alpha blockers.
  1. Nerve damage: secondary to an operation
  2. Sphincter mechanism damage
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12
Q

How do you diagnose Stress incontinence?

A

Observation of urine leakage upon coughing

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13
Q

What is the management of Stress Incontinence?

A
  1. Behavioural Techniques
  • Pelvic floor exercises: Mainstay of management especially if due to pelvic floor laxity.
  • Often combined with exercises to increase pelvic awareness to encourage tightness on exertion
  1. Pharmacotherapy
  • Imipramine: Helpful, but side-effects are common
  • ?Efficacy of oestrogen
  1. Surgery: Severe stress incontinence. Often contraindicated in frail old women
  • For urethral hypermobility (bladder neck suspension or sling, anterior vaginal repair)
  • For sphincter deficiency (artificial sphincter, sling procedures)
  • Other (urinary diversion, removal of obstruction or pathological lesion)
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14
Q

What is overflow incontinence?

A
  • Impaired detrusor contractility
    • usually neurogenic (e.g. MS, spinal injuries, diabetes) or
    • due to outlet obstruction.
  • In ability to contract causes overfilling and eventual loss of urge to go.
  • Chronic overfilling causes incontinence.
  • Incidence: 10-15% of UI in the elderly
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15
Q

What is the pathogenesis of overflow incontinence?

A
  • Underactive detrusor muscle
  • Outlet obstruction: Common in older males: due to prostatic hypertrophy. But rare in females
  • Functional obstruction: Spinal cord damaged above the sacral root
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16
Q

What are the symptoms of overflow incontinence?

A

o Post void dribbling
o High residual volume – usually > 100ml

o Often associated with exertion
o Often associated urgency symptoms

17
Q

How do you diagnose overflow incontinence?

A
  • USS/Catheterisation, looking for excess residual urine post-voiding
  • Flow voiding studies to detect prostatism
18
Q

What is the management of overflow incontinence?

A

Treat underlying cause – eg stop reversible causes

  1. If due to BPH: treat accordingly
  2. If due to underactive bladder
  • Catheterise
    • Intermittent – underactive or partially obstructed bladder
    • Indwelling - last option e.g. terminal care, sacral pressure ulcers
  • +/- augmented voiding techniques
  • +/- distigmine (PSNS stimulator –> increases bladder tone)
  1. If due to an outlet obstruction:
    * Surgery: If due to outlet obstruction in men TURP (transurethral resection of prostate) has a good outcome
19
Q

What is occult stress incontinence?

A
  • Incontinence only observed after anterior repair
  • Prolapse of surrounding tissues into the vagina causes kinking of the urethra, hiding the incontinence
  • Repair straightens out the urethra, unmasking the incontinence
20
Q

What is functional incontinence?

A

The inability to hold urine due to reasons other than neuro-urologic and lower urinary tract dysfunction.

Things like physical or psychological pathology preventing them from reaching the toilet in time, or environmental problems

21
Q

What are some causes of functional incontinence?

A

DIAPPERS

  • Delerium
  • Infection e.g. UTI
  • Atrophic urethritis or vaginitis
  • Pharmacological Agents
  • Psychiatric illnesses
  • Endocrine
  • Reduced mobility
  • Stool impaction
22
Q

What is reflex incontinence?

A
  • From disruption of higher centers of micturition
  • Brain lesion or disease disrupts normal control of micturition –-> therefore, bladder control becomes controlled by reflex arcs –-> first overflow incontinence (urinary retention), then detrusor hyperreflexia.
23
Q

What is continuous incontinence?

A

Continual leakage of urine
Represents a significant abnormality in bladder/urethral function

  • e.g. urogenital fistula
  • complete non-functional urethra
  • pelvic irradiation
24
Q

What is nocturnal enuresis?

A
  • Incontinence while asleep.
  • Most common in children, but some are adult-onset and some are children whose incontinence continues into adulthood.
  • Responds very well to behavioural modification and synthetic ADH
25
Q

What is nocturia?

A

Waking up at night to go.
Usually associated with excessive fluid intake or a general medical condition

26
Q

What are some neurological causes of urinary incontinence?

A
  • Cortical lesions – loss of social awareness, sensation, etc.
  • Spinal lesions – alteration of sympathetic/parasympathetic tone
  • Metastatic carcinomas – cause back pain as primary symptom
  • Cauda equina syndrome
27
Q

What are some pharmacological causes of urinary incontinence?

A
  • Anticholinergics – urinary retention –> overflow incontinence α-agonists – urinary retention
  • α-antagonists – urethral relaxation
  • Diuretics – overwhelming bladder capacity
  • Ca-blockers – decreased smooth muscle contractility –> urinary retention
  • Sedatives – immobility –> functional incontinence
  • ACEi & ARBs – diuretic effect, as well as pelvic floor relaxation + cough – exacerbation of stress incontinence
  • Dopaminergics – urinary urgency & constipation Antihistamines
28
Q

What are some risk factors for urinary incontinence?

A
  • Age
  • Female gender
  • Multiparity
  • European background
  • Overweight
  • Smoking
  • Inactivity
  • Depression
  • Diabetes
  • Incontinence/enuresis as a child
  • Recurrent UTI - pelvic inflammation
  • Neurological disorders
  • Pelvic surgery
  • Constipation
29
Q

What should you include when taking a hx for a patient with urinary incontinence?

A
  1. Presenting complaint: What is the problem? Why is it a problem?
  2. Incontinence
    • Duration
    • Severity – pads, brand of pads, how often change is needed, nocturnal symptoms Precipitating factors
    • Affect on quality of life
  3. Fluid-intake
  4. Associated symptoms
    • Storage – frequency / nocturia
    • Voiding – urinary flow; incomplete emptying? UTI
    • Bladder pain
    • Genital prolapse
    • Bowel symptoms
  5. QoL: Physical, Emotional, Social, Role performance, Symptoms
  6. Obstetric history
    • Birth weight, Parity, Mode of delivery, Problems
  • PMHx
    • Medical problems: esp. asthma / cough / DM / neuro
    • Past surgery esp. bladder / vaginal
    • Radiotherapy
    • Medications: anticholinergics; alpha-blockers; diuretics Smoking
  1. Gynae history: bleeding; smears
  2. Environmental factors
    • Distance to toilet
    • Access to toilet
    • Need for assistance and response time
    • Clothing, access, dexerity
    • Mobility in chairs
    • Bed
    • Toilet identification
30
Q

What should you include in the Ex of a patient with incontinence?

A
  1. CNS: Rule out spinal cord compression Affect, motivation, dementia
  2. Abdomen: Mass? Ovary, uterus, bladder, bowel mass, stool
  3. Pelvic
    • External female genitalia oestrogenisation
    • Prolapse
    • Tenderness
    • D/C
  4. Pelvic floor assessment: flick contractions; long contractions
  5. PR: Stool, pelvic mass, prostate size, symmetry, consistency
31
Q

What Ix would you perform on a patient with incontinence?

A
  1. Bloods
  2. MSU/Urinalysis: Rule out UTI
  3. Post-void residual urine
    • – Bladder scanner
    • – “In-out” catheter
  4. Bladder diary
    • – mL @ each void: maximum and minimum
    • – Fluids taken: type and volume
    • – Pads used
    • – Incontinence episodes
  5. Cystoscopy and bladder stretch biopsy: Exclude interstitial cystitis if refractory to medical therapy
    1. The most important differential diagnoses of incontinence to rule out are neurological conditions that may also cause incontinence as part of their clinical syndromes e.g. multiple sclerosis, cord lesions/infection, etc. The other main differential in women is urinary tract infection; in males, prostatitis may also cause incontinence.
  6. Urodynamic studies
    1. Looking at the pressure of the bowel as a proxy for the peritoneal cavity compared to the pressure of the bladder
    2. Also looking at residual volume, sphincter pressure, urethral pressures, etc.
32
Q

What are the main management options for urinary incontinence?

A
  1. Pads
  2. Catheterisation
  3. Medication: mainly drugs that cause urinary retention such as α-agonists, anticholinergics, tricyclics, etc.
  4. Pelvic floor exercises: Repeated contraction of the levator ani muscles. Should be coached on this rather than given pamphlets – many just do valsalva or gluteal contraction instead of pelvic floor activation.
    • 6-12wks at least for signs of improvement, and must be performed long-term for maintenance of results.
    • Better on younger women (who can more accurately and identify the correct muscles to activate)
    • Can also be done electrically with probes
  5. Weight loss (modification of risk factors) – the more weight people lose, the better their symptoms. This also applies to modification of other risk factors e.g. smoking, depression
  6. Behavioural changes
    1. Timed voiding (e.g. on 2-hour schedule)
    2. Fluid restriction
    3. Diet – spicy foods tend to worsen urge incontinence. Other food groups to avoid include chocolate and citrus fruits.
  7. Surgery - TVT
33
Q

What are the primary treatments for stress, urge, overflow and functional incontinence?

A

Stress

  1. Pelvic muscle exercises
  2. Tension free vaginal tape
  3. Surgical bladder neck suspension

Urge

  1. Bladder retraining
  2. Antimuscarinic agents

Overflow

  1. Treat BPH
  2. Catheterisation: Intermittent or Indwelling

Functional

  1. Behavioural interventions
  2. Incontinence undergarments and pads
34
Q

What is prolapse?

A

Pelvic organ prolapse is the herniation of various intra-abdominal structures into the pelvis. A variety of factors cause damage to the endopelvic fascia and muscles of the pelvic floor, allowing structures to push through with appropriate pressure. These factors include:

  • childbirth
  • surgery
  • menopause
  • tumours
  • neuropathies (particularly diabetic neuropathy)
  • and chronic conditions that increase intra-abdominal pressure (e.g. obesity, COPD, constipation, etc.)
  • reduce connective tissue strength (e.g. connective tissue diseases).
35
Q

What are some risk factors for prolapse?

A
  • childbirth
  • surgery
  • menopause
  • tumours
  • neuropathies (particularly diabetic neuropathy)
  • chronic conditions that increase intra-abdominal pressure (e.g. obesity, COPD, constipation, etc.)
  • reduce connective tissue strength (e.g. connective tissue diseases).
36
Q

What are the treatment options for prolapse?

A
  1. Pelvic Floor exercises
  2. Pessaries
  3. Repair

Obstetrics and Gynaecology (20 decks)

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