U-WIN-ary incontinence Flashcards
stress urinary incontinence
leakage on effort or exertion, sneezing or coughing.
occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
urine leaks whenever urethral resistance is exceeded by increased abdominal pressure
urge urinary incontinence
leakage accompanied by or immediately preceded by urgency
may be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone)
mixed urinary incontinence
combo of SUI and MUI
bedwetting in elderly men (NOT incontinence)
usually indicating high-pressure chronic retention
post-micturition dribble (NOT incontinence)
happens in men immediately after leaving toilet and is due to urine pooling in bulbar urethra
other types that arent incontinence
- a constant leak of urine suggests a fistulous communication between the bladder (usually) and vagina (e.g. due to surgical injury at the time of hysterectomy or Caesarian section) or rarely the presence of an ectopic ureter draining into the vagina
risk factors of incontinence
gender – female > male
race – caucasian > afro-caribbean
genetic predisposition
neurological disorders – spinal cord injury, stroke, MS, parkinson’s
anatomical disorders – vesicovaginal fistula, ectopic ureter in girls, urethral diverticulum, urethral fistula, bladder extrophy, epispadias
childbirth – vaginal delivery, increasing parity, pregnancy
pelvic, perineal and prostate surgery – radical hysterectomy, prostatectomy, TURP leading to pelvic muscle and nerve injury
radical pelvic radiotherapy
diabetes
promoting factors of incontinence
smoking – causing cough
obesity (higher BMI puts more pressure on pelvic floor)
infection – UTI
increased fluid intake
poor nutrition
ageing
cognitive deficit
poor mobility
oestrogen deficiency
incontinence history
the type, triggering factors, frequency and degree of bother
risk factors, previous surgery, bowel symptoms, symptoms of sexual dysfunction or pelvic organ prolapse in women
red flags in incontinence
pain, haematuria, recurrent UTI, significant voiding/obstructive symptoms, history of pelvic surgery/radiotherapy
physical exam in women for incontinence
pelvic examination (chaperoned)
ask patient to cough or strain and look for anterior and posterior vaginal wall prolapse, uterine or vaginal vault descent, and urinary leakage.
internal pelvic examination can be performed to assess voluntary pelvic floor muscle strength and bladder neck mobility.
inspect the vulva for oestrogen deficiency – causing vaginal atrophy
physical examination in both sexes for incontinence
examine abdomen for palpable bladder (urinary retention).
neurological examination to assess gait, anal reflex, perineal sensation and lower limb function.
DRE to exclude constipation, a rectal mass and to test anal tone
incontinence red flags to look out for in examination
new neurological deficit, haematuria, urethral, pelvic or bladder mass and suspected fistula
basic investigations for incontinence
bladder diary (frequency/volume chart)
urinalysis +- culture
flow rate and post-void residue
pad testing
further investigations for incontinence
blood tests, imaging, cystocopy - for complex cases
how cystometry works
urodynamics - seeing pressure to identify whether bladder obstruction etc.
conservative treatment for incontinence
pelvic floor exercises – at least 8 contractions, 3x day for min. 3months. Improvement in 30% of women w/ mild SUI
**!! MOST IMPORTANT IMPACT lifestyle – weight loss, stop smoking, avoid constipation, modify fluid intake
biofeedback – ability & strength of pelvic floor contraction is fed back to patient as visual or auditory signal
medication – duloxetine (inhibits reuptake of both serotonin and noradrenaline) acts to increase sphincteric muscle activity during bladder filling
electrical stimulation of pelvic floor – no proven benefit in SUI
surgical treatment for incontinence
injection therapy - bulking materials into the bladder neck and periurethral muscles to increase outlet resistance.
main indication is for female stress incontinence secondary to demonstrable intrinsic sphincter deficiency in the presence of normal bladder muscle function, e.g Macroplastique (silicone – polydimethyl siloxane elastomer) or Teflon (polytetrafluoroethylene paste).
how injection therapy acts for urinary incontinence
injected submucosally under endoscopic guidance – aim is to achieve urethral mucosal apposition and closure of the lumen. Success rate 50-80% but tends to deteriorate with time and repeat treatments often needed
contraindications for injection therapy for urinary incontinence
UTI, untreated bladder overactibity, bladder neck stenosis
complications of injection therapy for urinary incontinence
temporary urinary retention (2-15%), de novo urge incontinence (6-12%), UTI (5%), haematuria (5%)
retropubic suspension
treat sfemale stress incontinence predominantly caused by urethral hypermobility.
elevates and fixes the bladder neck and proximal urethra in a retropubic position in order to support the bladder neck and regain continence.
lower chance of benefit in presence of significant ISD
burch colposuspension
requires good vaginal mobility as the vaginal wall is elevated and attached to the lateral pelvic wall.
also an option in patients with concurrent SUI and anterior vaginal wall prolapse.
success rate of 70% at 5 years
suburethral tapes and slings
(synthetic tape)
e.g. the retropubic tension-free vaginal tape (TVT).
Small mid-line anterior vaginal incision.
tape has long trochars on each end which are inserted either side of the urethra and perforate through the endopelvic fascia.
pushed up behind the symphysis pubis and out onto lower abdominal wall in the midline, just above the pubic bone.
tape is positioned loosely (tension-free) over the mid-urethra its covering is removed and the ends cut flush to the abdomen.
vaginal epithelium is closed over the top.
success rates up to 80% at 5 years
complications of suburethral tapes and slings
voiding dysfunction (retention or de novo bladder overactivity - vaginal, urethral and bladder perforation/erosion
- pain
- damage to bowel or blood vessels
pubovaginal (autologous) slings
use segment of rectus fascia 10-20cm in length harvested via a Pfannenstiel approach, long non-absorbable sutures on both ends.
sling placed under mid-urethra and sutures placed through the endopelvic fascia to the remaining rectus fascia where the suture ends are tied using the minimal amount of tension to prevent urethral movement.
artificial urinary sphincter
closed pressurised system with three components:
1.inflatable cuff placed around the bulbar urethra or bladder neck
2. pressure-regulating balloon placed extraperitoneally in the abdomen
3. activating pump in the scrotum or labia majora
how artificial urinary sphincterworks
The cuff provides a constant circumferential pressure to compress the urethra. To void, the pump is squeezed, which transfers fluid to the reservoir balloon, thereby deflating the cuff. The cuff then automatically re-fills within 3 minutes
Used for moderate to severe SUI secondary to urethral sphincter deficiency in patients with normal bladder capacity and compliance.
Long-term success 70-90%
complications of artifical urinary sphincter
urethral atrophy, mechanical failure, urethral erosion, bladder overactivity or reduced compliance, infection
overactive bladder (OAB)
symptom syndrome that includes urgency, with or without urge incontinence, usually with frequency and nocturia. usually caused by bladder (detrusor) overactivity.
affects 40% of the population >40y in Europe
conservative treatment of overactive bladder
MDT approach – urologists, urogynaecologists, continence nurse specialists, physiotherapists
pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy may provide some benefit
behavioural modification – modify fluid intake, avoid stimulants (caffeine, alcohol), bladder training
anticholigernic medication
acetylcholine acts on muscarinic receptors on the bladder smooth muscle to cause involuntary contractions and provoke the symptoms of bladder overactivity
receptors are the targets of anticholinergic (antimuscarinic) drugs which inhibit contractions and increase bladder capacity.
(e.g: Oxybutynin, Solifenacin, Tolterodine, Fesoterodine, Trospium, Propiverine)
contraindications of anticholinergic medicatIon
uncontrolled narrow-angle glaucoma, myasthenia gravis, BOO, bowel disorders (active ulcerative colitis, bowel obstruction)
common side effects of anticholinergic medicatIon
dry mouth, constipation, blurred vision, urinary retention, cognitive impairment
β-Adrenoreceptor agonists
β-ARs induce detrusor relaxation and it is the β3 sub-type that is predominant in human detrusor.
β3-AR agonists increase bladder capacity with no change in micturition pressure and the residual volume
Mirabegron (Betmiga)
Contraindication: uncontrolled hypertension
oab - options for failed conventional therapy
Intravesical Botulinum toxin-A: injected at multiple (20) sites under the bladder mucosa or into detrusor, sparing the trigone
neuromodulation
sacral nerve stimulation involves electrical stimulation of the bladder’s nerve supply to suppress reflexes responsible for involuntary detrusor contrcation.
device stimulates the S3 afferent nerve, which then inhibits detrusor activity at the level of the sacral spinal cord. initial percutaneous nerve evaluation is performed, followed by surgical implantation of permanent electrode leads into the sacral foramen, with a pulse generator which is programmed externally
augmentation “Clam” ileocystoplasty:
relieves intractable frequency, urge and UUI in 90% patients. bladder dome is bivalved and a detubularised segment of ileum is anastomosed, creating a larger bladder volume
- bladder opened laterally and incised down to the trigone
- segment of ileum + its mesentery are sutured onto the bladder
ileal conduit urinary diversion
for intractable cases only – both ureters anastomosed and connected to a short length of ileum which is brought out cutaneously as a stoma (urostomy)
