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
Why do pts with UTIs/bacterial cystitis have urgency and frequency?
With an infection, there is inflammation in the urinary tract.
In the presence of inflammation, sensations (first desire, second desire) occur at a lower volume.
As a result, pts get frequency + urgency more often!
What are causes of incontinence?
i.e. how can it be classified
- Urodynamic stress incontinence
- Detrusor overactivity / OAB
- Mixed incontinence
- Other - overflow (due to injury or insult e.g. postpartum)
What are the reasons women get urodynamic stress incontinence?
- Incompetent urethral sphincter:
– childbirth
– menopause
– prolpapse
– chronic cough - positional displacement (most common - bladder neck falls during cough)
- intrinsic weakness
On examination, what findings would support a Dx of urodynamic stress incontinence?
- mobile bladder neck - e.g. when cough it moves, causing leakage
- prolapse present: cystocoele, urethrocoele
On cystometry, what findings would support a Dx of urodynamic stress incontinence?
- normal bladder capaity
- leakage in ABSENCE of detrusor pressure rise
- provoked by cough test
- usually small to moderate loss
*
What may be present in Hx of pt who has suspected detrusor overactivity?
- uncontrolled or unprovoked detrusor muscle activity (pressure generated exceeds sphincter tone)
- PMH of childhood UTIs
- a recent probelm after incontinence surgery
- neurological disease - MS
On examination, what findings would support a Dx of detrusor overactivity?
- not much found !
- may demonstrate some leakage on coughing - giving differential of stress incontinence too
- signs of NS involvement e.g MS (red desaturation, RAPD etc)
On cystometry, what findings would support a Dx of detrusor overactivity?
- Reduced capacity bladder
- leakage with detrusor pressure rise
- often large loss
- triggers include running water, washing hands, key in door
What are some general continence measures to discuss with pts to conservatively manage their continence?
- sensible fluid intake
–(1.5-2.5L/day)
–informing that tea,coffee, alohol are all diuretics - mobility aids or downstair toilets –> v good for elderly who may have functional incontinence as well
- pads, bedpans, commodes etc
Treatment options for urodynamic stress incontinence
(i.e. after general measures)
- Physiotherapy
- medications
- surgery
Adv and disadv of physiotherapy for urodynamic stress incontinence?
- simple, no side effects
- requires pt motivation, commitment and perserverance
- only has success rate 50-75%
Medication used for urodynamic stress incontinence?
Duloxetine 40mg
80% of women report 50%+ improvement in incontinence
Side effects of duloxetine used for urodynamic stress incontinence?
Anxiety; palpatations, sweat changes, tremors
GI disorders, Constipation + diarrhoea
Dizziness; drowsiness, falls
Fatigue, headache; muscle complaints/ parasthesia
Nausea + vomiting
Sexual dysfunction
Skin reactions
Sleep disorders
Tinnitus
Urinary disorders; vision disorders
Appetitie decreased and weight changes
Benefits of surgery for urodynamic stress incontinence?
Effective - cure rate of 95%
Long term success 85%
Types of urodynamic stress incontinence surgery?
Tension free vaginal tape
Burch colosuspension
Transobturator tapes
Single incision tapes
For urodynamic stress incontinence: Which type of surgery has poorer cure rate?
Single incision tape - as there is no exit wound and less tape in body to hold organs in place
Risks with having surgery (such as burch colposuspension or tension free vaginal tape) for urodynamic stress incontinence?
Voiding difficulty
Bladder injury
Detrusor overactivity
For burch colposuspension - risk of posterior prolapse
Advantage of periurethral injections for urodynamic stress incontinence?
Squashes neck of bladder together
A day case (woo)
can be repeated if needed
Treatment options for detrusor overactivity?
- v tricky
- behaviour therapies - bladder retraining, alarms and timers
- electrical stimulation - high frequency to pudendal nerve.
- medications
Drug treatment options for detrusor overactivity?
Oxybutynin
Tolterdine
Trospium
Propiverine
Solifenacin - no longer recommended by NICE as not cost effective
Mirabegron
Why does drug treatment for detrusor overactivity have poor compliance?
Anticholinergic - so have side effects of dry mouth, blurred vision, constipation -not v nice
For detrusor overactivity:
Dose of oxybutynin?
Side effects of oxybutynin?
Dose - 2.5mg bd to 5mg tds in steps of 2.5mg
Side effects - dry eyes, dry mouth, diarhorea, constipation, dizzy, drowsy, urinary disorders, vision disorders (for all antimuscarinics). For oxy specifically - dry eyes, diarrhoea.
For detrusor overactivity:
Dose of tolterodine?
Side effects of tolterodine?
Dose: 2mg bd (only 1mg if have liver disease)
Side effects: specific for tolterodine - Abdominal pain; bronchitis; chest pain; diarrhoea; dry eye; fatigue; gastrointestinal disorders; paraesthesia; peripheral oedema; vertigo; weight increased.
Also note side effects that are common with all antimuscarinics
Apart from conservative and oral drug treatments, what are other options to treat detrusor overactivity?
- Botulinum toxin = large durable reductions in Sx
- Posterior tibial nerve stimulation = external stim of S3 via posterior tibial nerve. 12 weekly sessions of 30mins
- Sacral nerve stimulation = internal stimulation of S3 via implanted electrode
How is mixed incontinence managed?
individualised discussions
conservative meaures for stress incont
can consider surgery as urgency persists in up to 70%