Urinary Incontinecne

Question 1

What contributes to urinary continence?

Answer 1

External urethral sphioncter

Pelvic floor muscles maintaining urethral pressure higher than bladder pressure

Question 2

What should you ask about in urinary history?

Answer 2

Daytime voids (normal 4-7)
Nocturia (up to 70yo >1 is abnormal)
Noctural enuresis
Urgency - due to detrusor overactivity
Voiding difficulties: (most commonly neurological)
- Hesitancy
- Straining
- Slow/intermittent stream
Feeling of incomplete emprying
Bladder pain
Dysuria
Haematuria
Recurrent UTI

Prolpase
Bowel symptoms

PMHx
Ddx

QOL

Frequency/volume charts - information about fluid intake and voiding

Question 3

What does continuous urinary leakage indicate?

Answer 3

Vesicovaginal fistula or congenital abrnomality such as ectopic ureter

Question 4

What examination for urinary incontinence?

Answer 4

Neurological examination - most common cause of neurogenic bladder in woman is MS
Abdominal or pelvic mass 
Vulval/vaginal skin atrophy?
Prolaspe?
Urinary leakage on coughing?

Question 5

What investigations in urinary incontinence?

Answer 5

Urinalysis:
MSU for MC&S to exclude UTI
OGTT if diabetes suspected

Imaging
Check residual volume post-micturition to exclude incomplete emptying

Cystoscopy:
Visualise urethra, bladder mucosa, trigone, ureteric orifices
Biopsies can be taken
Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour or interstitial cystitis

Urodynamics:
Combination of tests which look at ability of bladder to store and void urine

Question 6

What are indication for cystoscopy?

Answer 6

Recurrent UTI, haematuria, bladder pain, suspected fistula, tumour or interstitial cystitis

Question 7

What is uroflowmetry?

Answer 7

Screens for voiding difficulties and the patient voids in private onto a commode with a urinary flow meter, measuring voided volume over time and plotting it on a graph

Question 8

What is cystometry?

Answer 8

Measuring pressure and volume within bladder during filling and voiding - test of bladder funciton
Bladder is filled with saline via a catheter and an intravesical and rectal probe measure differences in pressure to give to detrusor pressure
Patient is asked for first desire to void, strong desire to void and to cough

Question 9

What are the classifications of urinary incontinence?

Answer 9

Stress urinary incontinence: involuntary leakage of urine on effort or exertion or on sneezing/coughing

Urge urinary incontinence: Involuntary leakage of urine with a strong desire to pass urine - commonly coexists with frequency and nocturne - forms overactive bladder syndrome

Mixed urinary incontinence - combination of stress and urge

Overflow incontinence:
Due to bladder outlet obstruction or injury or insult
Treat with catheter

Question 10

When does stress urinary incontinence occur?

Answer 10

When detrusor pressure exceeds the closing pressure of the urethra

Question 11

What are risk factors for stress urinary incontinence?

Answer 11

Pregnancy
Menopause - oestrogen deficiency leads to weakening of pelvic upper and thinning of the urothelium
Radiotherpay
Congenital weakness
Trauma from radical pelvic surgery (e.g. for gynaecological cancer)
Obesity

Question 12

What investigations in stress urinary incontinency?

Answer 12

Urinarlysis to exclude UTI
Frequency/volume chart shows normal frequency and functional bladder capacity
Urodynamics indicated when surgery is considered
Check for detrusor overactivity
Check for voiding dysfucntion

Question 13

What is conservative management for stress urinary incontinence?

Answer 13

Optimising control of other medical problems: Smoking cessation, weight loss, diabetes, chronic cough, constipation
Pelvic floor exercises for 3 months and continued long tern - refer to pelvic floor physiotherapy

8 contractions 3 times per day for 3 months

Question 14

What is surgical management for stress urinary incontinence?

Answer 14

Periurethral injection of bulking agents - better for frail older women or younger women yet to complete family

Tension-free vaginal tape
- risks: bladder injury, voiding difficulty, tape erosion

Burch colposuspension

Question 15

What is overactive bladder syndrome?

Answer 15

Urge urinary incontinence
Nocturia
Frequency

Implies underlying detrusor overactivity

Symptoms may be provoked by cold weather, opening front door, or coughing/sneezing leading to confusion with stress incontinence

Question 16

What investigations in overactive bladder?

Answer 16

Exclude UTI
Frequency volume chart
Urodynamics - show involuntary detrusor contractions during filling

Question 17

What is management for urge incontinence?

Answer 17

Avoid excess fluid, caffeinated, carbonated drinks and alcohol

Bladder retraining: gradually increase intervals between voiding for 6 weeks

Antimuscarinics are first line
Block parasympathetic nerves and relax the detrusor
Oxybutinin (immediate release)
Tolterodine
Darifenacin/solifenacin

Mirabegron (beta-3 agonist) may be useful if there is a concern about anticholinergic side effects

Intravaginal oestrogen cream can help those with vaginal atrophy

Question 18

What are side-effects of oxybutinin? What can be used if this is a concern?

Answer 18

Dry mouth
Constipation
Nausea
Blurred vision

Mirabegron (beta-3 agonist)

Question 19

What can be used if anticholinergics do not work?

Answer 19

Botulinum toxin A injected cystoscopically into the detrusor

Question 20

What medical management for stress incontinence? MOA? SE?

Answer 20

Duloxetine
SNRI
Increased NA concentration in pudendal nerve increases contraction of external urethral sphincter

SE: Dry mouth, nausea, headache, dizziness, discontinuation syndrome (dysphoria, irritability, lethargy, insomnia - withdraw gradually)

Question 21

What are complications of surgery for stress incontinence?

Answer 21

Bladder perforation
Damage to pelvic blood vessels or viscera - haemorrhage
Failure
GRoin pain
Urgency/frequency
Vaginal tape erosions