Urinary Incontinence

Question 1

How is continence in women maintained in the urethra?

Answer 1

external sphincter and pelvic floor muscles maintain a urethral pressure higher than the bladder pressure

Question 2

Describe how micturition occurs

Answer 2

Pelvic floor muscles and external sphincter relax and bladder detrusor muscle contracts to allow voiding

Question 3

Define incontinence

Answer 3

Involuntary leakage of urine

Question 4

Thinking about normal bladder function, describe what happens in the storage phase

Answer 4

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

Question 5

Thinking about normal bladder function, describe what happens in the voiding phase

Answer 5

Removal of higher centre suppression
There is coordinated activity:
* sphincters relax
* detrusor muscle contracts
* normal position of ureter creates sphincter effect

Question 6

Define urgency

Answer 6

Overwhelming desire to void

Question 7

Define urge incontinence

on bb

Answer 7

Associated with leak

Question 8

Define stress incontinence

on bb slide

Answer 8

leak with increased intraabdominal pressure - e.g. coughing

Question 9

Define frequency

Answer 9

Voids >8x per day
Also includes voiding that is “troublesome” for the pt

Question 10

Define nocturia

Answer 10

Voids >2x per night
(If less than 2x, due to physiological ageing)

Question 11

Define hesitancy

Answer 11

Delay in commencing stream

Question 12

Define dysuria

Answer 12

Burning discomfort while/after voiding

Question 13

What questions would you ask in Hx of someone presenting with incontinence?

Answer 13

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)

Question 14

What to look for on examination of pt presenting with incontinence?

Answer 14

• 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

Question 15

What quantitiative tools can be used to assess incontinence?

Answer 15

• Urinalysis
• Diaries
• Pad tests
• Ultrasound/IVP for renal tract abnormalities
• Cystoscopy

Question 16

Why do we do urinalysis?

Answer 16

• 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

Question 17

Why do we investigate incontinence with urinary diaries?

Answer 17

• 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

Question 18

Why do we do pad tests when investigating incontinence?

Answer 18

• Objective measure of amount of leakage
• do this for 1-24hrs
• 24hour pad test at home is best

Question 19

Why are pad tests done for a short time regarded as uncertain/dubious?

Answer 19

Shorter tests = poor reproducibility
= poor correlation with other measures

So pad tests done for 24hrs are better

Question 20

A pad test outcome can vary from:
0-20g
21-50g
51-75g
>75g

What do these outcomes mean?

Answer 20

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)

Question 21

Reason for doing renal tract imaging and cystoscopy?

Answer 21

To investigate:
* recurrent UTI
* haematuria
* pain / painful bladder
* “sensory urgency” aka overactive bladder

Question 22

For investigations for incontience:

What does cystometry look at?

Answer 22

• 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.

Question 23

Main issue with cystometry?

Answer 23

Can get fasle +ves and false -ves

Question 24

Describe how cystometry is done

Answer 24

• 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

Question 25

Why do pts with UTIs/bacterial cystitis have urgency and frequency?

Answer 25

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!

Question 26

What are causes of incontinence?

i.e. how can it be classified

Answer 26

• Urodynamic stress incontinence
• Detrusor overactivity / OAB
• Mixed incontinence
• Other - overflow (due to injury or insult e.g. postpartum)

Question 27

What are the reasons women get urodynamic stress incontinence?

Answer 27

• Incompetent urethral sphincter:
  – childbirth
  – menopause
  – prolpapse
  – chronic cough
• positional displacement (most common - bladder neck falls during cough)
• intrinsic weakness

Question 28

On examination, what findings would support a Dx of urodynamic stress incontinence?

Answer 28

• mobile bladder neck - e.g. when cough it moves, causing leakage
• prolapse present: cystocoele, urethrocoele

Question 29

On cystometry, what findings would support a Dx of urodynamic stress incontinence?

Answer 29

• normal bladder capaity
• leakage in ABSENCE of detrusor pressure rise
• provoked by cough test
• usually small to moderate loss
  *

Question 30

What may be present in Hx of pt who has suspected detrusor overactivity?

Answer 30

• uncontrolled or unprovoked detrusor muscle activity (pressure generated exceeds sphincter tone)
• PMH of childhood UTIs
• a recent probelm after incontinence surgery
• neurological disease - MS

Question 31

On examination, what findings would support a Dx of detrusor overactivity?

Answer 31

• 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)

Question 32

On cystometry, what findings would support a Dx of detrusor overactivity?

Answer 32

• Reduced capacity bladder
• leakage with detrusor pressure rise
• often large loss
• triggers include running water, washing hands, key in door

Question 33

What are some general continence measures to discuss with pts to conservatively manage their continence?

Answer 33

• 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

Question 34

Treatment options for urodynamic stress incontinence

(i.e. after general measures)

Answer 34

• Physiotherapy
• medications
• surgery

Question 35

Adv and disadv of physiotherapy for urodynamic stress incontinence?

Answer 35

• simple, no side effects
• requires pt motivation, commitment and perserverance
• only has success rate 50-75%

Question 36

Medication used for urodynamic stress incontinence?

Answer 36

Duloxetine 40mg
80% of women report 50%+ improvement in incontinence

Question 37

Side effects of duloxetine used for urodynamic stress incontinence?

Answer 37

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

Question 38

Benefits of surgery for urodynamic stress incontinence?

Answer 38

Effective - cure rate of 95%
Long term success 85%

Question 39

Types of urodynamic stress incontinence surgery?

Answer 39

Tension free vaginal tape
Burch colosuspension
Transobturator tapes
Single incision tapes

Question 40

For urodynamic stress incontinence: Which type of surgery has poorer cure rate?

Answer 40

Single incision tape - as there is no exit wound and less tape in body to hold organs in place

Question 41

Risks with having surgery (such as burch colposuspension or tension free vaginal tape) for urodynamic stress incontinence?

Answer 41

Voiding difficulty
Bladder injury
Detrusor overactivity

For burch colposuspension - risk of posterior prolapse

Question 42

Advantage of periurethral injections for urodynamic stress incontinence?

Answer 42

Squashes neck of bladder together
A day case (woo)
can be repeated if needed

Question 43

Treatment options for detrusor overactivity?

Answer 43

• v tricky
• behaviour therapies - bladder retraining, alarms and timers
• electrical stimulation - high frequency to pudendal nerve.
• medications

Question 44

Drug treatment options for detrusor overactivity?

Answer 44

Oxybutynin
Tolterdine
Trospium
Propiverine
Solifenacin - no longer recommended by NICE as not cost effective
Mirabegron

Question 45

Why does drug treatment for detrusor overactivity have poor compliance?

Answer 45

Anticholinergic - so have side effects of dry mouth, blurred vision, constipation -not v nice

Question 46

For detrusor overactivity:
Dose of oxybutynin?
Side effects of oxybutynin?

Answer 46

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.

Question 47

For detrusor overactivity:
Dose of tolterodine?
Side effects of tolterodine?

Answer 47

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

Question 48

Apart from conservative and oral drug treatments, what are other options to treat detrusor overactivity?

Answer 48

• 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

Question 49

How is mixed incontinence managed?

Answer 49

individualised discussions
conservative meaures for stress incont
can consider surgery as urgency persists in up to 70%