Urinary Incontinence Flashcards
urinary incontinence, including UTI, overactive bladder, genuine (urodynamic) stress incontinence, retention with overflow Signs on examination, first line and further incestigations Interpret results Conservative and operative mangement Drugs used + side effects
How is continence in women maintained in the urethra?
external sphincter and pelvic floor muscles maintain a urethral pressure higher than the bladder pressure
Describe how micturition occurs
Pelvic floor muscles and external sphincter relax and bladder detrusor muscle contracts to allow voiding
Define incontinence
Involuntary leakage of urine
Thinking about normal bladder function, describe what happens in the storage phase
Sphincters contracted
Get active relaxation of the detrusor muscle
Sensory efferents are continuously supplied for first desire (ie when a pt has their 1st sensation that bladder is filling)
At capacity (of bladder volume), there is voluntary reinforcement of sphincter tone
Have altered behaviours at capacity to higher centres - i.e brain decides whether to void or not (e.g. if not in socially acceptable place) - if needing to store, higher centres suppress voiding
Thinking about normal bladder function, describe what happens in the voiding phase
Removal of higher centre suppression
There is coordinated activity:
* sphincters relax
* detrusor muscle contracts
* normal position of ureter creates sphincter effect
Define urgency
Overwhelming desire to void
Define urge incontinence
on bb
Associated with leak
Define stress incontinence
on bb slide
leak with increased intraabdominal pressure - e.g. coughing
Define frequency
Voids >8x per day
Also includes voiding that is “troublesome” for the pt
Define nocturia
Voids >2x per night
(If less than 2x, due to physiological ageing)
Define hesitancy
Delay in commencing stream
Define dysuria
Burning discomfort while/after voiding
What questions would you ask in Hx of someone presenting with incontinence?
1.Presenting Symptoms
- stress or urge symptoms predominat (even if have both, which are predominantly troublesome)
- frequency of the episodes - how often do you have episodes of leakage?
2.Severity measures
- amount of leakage
- pad size (size and number worn per day)
- lifestyle modifications - e.g. do they only visit shops they know have a toilet
3.Fluid intake
4.Associated symptoms
- prolapse
- faecal symptoms (up to 75% have feacal leakage)
5.Obstetric Hx
- birthweight (large babies put more strain on pelvic floor muscles)
- forceps delivery
- perineal trauma
- duration of second stage (of labour)
6.Previous surgery
- hysterectomy
- any pelvic floor repair?
- incontinence operations
7.Medical and FHX
- chronic lung disease (bronchiecstasis known to be related to incontinence)
- connective tissue disease - more prone to incontinence and prolapse
- DM (get polyuria)
- hypertension and if they are on drugs for it (pt may be on doxazosin which is an alpha blocker, and can cause incontinence symptoms)
What to look for on examination of pt presenting with incontinence?
- Obesity - stress incontinence and detrusor overactivity are related to this
- scars
- abdo/pelvic massess
- visible incontinence - see any leakage? e.g. when coughing
- prolapse
- pelvic floor tone - as pt to squeeze/cough during bimanual exam
- CNS features - may fit illness script of neurological condition e.g. MS
- Are there signs of vulval/vaginal atrophy?
Oxford book - check weight, BMI, BP and signs of systemic disease
What quantitiative tools can be used to assess incontinence?
- Urinalysis
- Diaries
- Pad tests
- Ultrasound/IVP for renal tract abnormalities
- Cystoscopy
Why do we do urinalysis?
- Screen for infection - exclude UTI
- recurrent infections may be sign of underlying abnormality - stone, tumour
- Also can do OGTT if DM is suspected from urine
Why do we investigate incontinence with urinary diaries?
- it is a pt completed record
- allows an accurate estimate of intake, functional bladder volume and frequency (so can see if they are having excessive intake >2L, and can confirm symptoms)
- used as an adjunct to bladder retraining
Why do we do pad tests when investigating incontinence?
- Objective measure of amount of leakage
- do this for 1-24hrs
- 24hour pad test at home is best
Why are pad tests done for a short time regarded as uncertain/dubious?
Shorter tests = poor reproducibility
= poor correlation with other measures
So pad tests done for 24hrs are better
A pad test outcome can vary from:
0-20g
21-50g
51-75g
>75g
What do these outcomes mean?
These outcomes relate to how well the pt will repsond to conservative treatment
0-20g = excellent (conservative will help them)
21-50g = good
51-75g = moderate
>75g = likely to reqire surgery ( conservative will not make them better, so need surgery)
Reason for doing renal tract imaging and cystoscopy?
To investigate:
* recurrent UTI
* haematuria
* pain / painful bladder
* “sensory urgency” aka overactive bladder
For investigations for incontience:
What does cystometry look at?
- Funtional test of bladder function
– capacity
– flow rate and voiding function
– demonstrate leakage with intravesical pressure - Provides objective diagnosis - either urodynamic stress incontience or detrusor overactivity. Can see what detrusor is doing during micturition.
Main issue with cystometry?
Can get fasle +ves and false -ves
Describe how cystometry is done
- Put bladder pressure catheter through the urethra to look at pressure in bladder
- Put balloon device in rectum to measure pressure in the abdomen.
To find the pressure of the detrusor muscle = Pressure in the bladder - pressure of the abdomen
