URINARY Flashcards
Urinary incontinence (UI)?
Involuntary urine (ur) loss; common in women; few seek care despite effective options; may affect quality of life (QoL)
Stress UI?
increased intra-abdominal pressure (coughing, exertion); most common in younger women
Urge UI?
Sudden uncontrollable ur loss, preceded or accompanied by urgency;
from overactive bladder (OAB)
detrusor overactivity (DO);
most common in older adults
Mixed UI?
> 1 type of UI, often a combo (stress and urge UIs); overall most common type
Overflow UI?
High-residual volume from inadequate bladder emptying (chronic ur retention), causing frequent dribbling; predisposes to recurrent infections, vesicoureteral reflux, autonomic dysreflexia
Functional UI?
urine loss due to deficits in cognition or mobility with normal ur system function
Continuous UI?
Sustained slow leakage in between regular voiding; may have no awareness nor bladder fullness
Urinary Incontinence: Basics
ETIOLOGY AND PATHOPHYSIOLOGY
Stress UI:?
2 types—anatomic (urethral hypermobility from lack of pelvic support) and intrinsic sphincter deficiency (impaired urethral closure);
stress UI is secondary to surgical scarring, radiation, hormonal, or age-related changes.
Urinary Incontinence: Basics
ETIOLOGY AND PATHOPHYSIOLOGY
Urge UI: ?
DO (usual cause) or OAB from neuro causes (SCI), abd trauma, infection, Rx, certain fluids, or idiopathic; DO could be idiopathic or neurogenic (MS).
- Overflow UI: detrusor underactivity (“neurogenic bladder”), increased bladder ur volume (DM or Rx), or bladder outlet obstruction (fibroids, pelvic organ prolapse [POP], masses)
Urinary Incontinence: Basics
ETIOLOGY AND PATHOPHYSIOLOGY
Overflow UI ?
detrusor underactivity (“neurogenic bladder”), increased bladder ur volume (DM or Rx), or bladder outlet obstruction (fibroids, pelvic organ prolapse [POP], masses)
Urinary Incontinence: Basics
ETIOLOGY AND PATHOPHYSIOLOGY
Mixed UI:
aggregate of etiologies from each type of UI present
- Functional UI: cognitive impairment (dementia, delirium, intellectual disabilities); unable to recognize need for toilet; psychological issues and mental illness (decreased awareness); medical conditions (arthritis) and physical disability impairing mobility; poor vision; and environmental barriers
Continuous UI
constant involuntary ur loss; ectopic ureters in females usually open in urethra distal to sphincter or in the vagina, causing sustained leakage through the urethra or extra-urethral (urogenital fistulas: vesicovaginal [most common], ureterovaginal, and urethrovaginal).
What are the risk factors for urinary incontinence?
-Advanced age
-vaginal atrophy
-impaired cognition-function
-obesity
-medical conditions
-multiparity
-pelvic floor dysfunction
-neuro diseases
-smoking
-constipation
-caffeine
-high-impact exercises
What is included in the history for urinary incontinence?
- Any other urinary symptoms like dysuria?
- Surgical history
- Comorbidities: DM, changes in cognition
- Medications
- 3-day voiding diary
- The International Consultation on Incontinence Questionnaire (ICIQ)
What do you see on the physical exam for urinary incontinence?
- Neuro Exam
- Pelvic Exam/Genital Exam
- Abdominal Exam
- Anorectal Exam
TESTING - Urinalysis
- Urine Culture if suspicious for infection
- Renal Function
- Imaging is unnecessary in uncomplicated UI; renal US for hydronephrosis if suspicious for obstruction (microhematuria)
- Urodynamic testing: for complicated UI or if surgery is considered.
- Bladder scan if overflow UI is suspected (PVR >200 mL)
Urinary Incontinence: Treatment
GENERAL MEASURES
- Stepwise approach: conservative (first line), medications or mechanical devices (second line), invasive interventions (third line)
- Tx correctable causes (infection, constipation
Stress UI treatment?
6- to 8-week trial of behavioral modification and pelvic floor training; if no improvement, refer to urology.
Urge UI treatment?
-behavior modification
-pelvic floor muscle training (PFMT), and medication; —–behavior modification plus medication: > effective versus —medication alone
Mixed UI treatment?
directed at predominant Sx (stress or urge UI)
Stress UI
no FDA-approved Rx
- Topical estrogen may be beneficial for urgency and frequency Sx in postmenopausal women with vaginal atrophy (transdermal or oral may worsen UI
Rx: for urinary incontinence
can be used for both urge and mixed UIs; combo Tx (Rx-behavior) is more effective than either modality alone.
- If behavior Tx is unsuccessful, anticholinergic agents (selective: darifenacin, solifenacin; nonselective: oxybutynin, tolterodine, trospium) and β3-AR agonists (mirabegron, vibegron) are FDA-approved.
Treatment for urinary incontinence?
Dual Tx (mirabegron and low-dose anticholinergic agents) can be considered
Treatment for urinary incontinence?
Anticholinergic agents inhibit involuntary detrusor contractions; effective for urge UI and OAB (significant improvement and modest >QoL).
No single anticholinergic agents is shown to be overall superior (higher doses: more effective but more side effects); extended release and transdermal prep have fewer
side effects (dry mouth and eyes, constipation, impaired cognition).
Treatment urinary incontinence?
β3-AR agonists: no associated significant cognitive decline; avoided in ESRD, ESLD and uncontrolled HTN
REFERRAL: Urologist
