Urinary incontinence Flashcards
Define stress urinary incontinence
- The complaint of involuntary leaking on effort or exertion, or on sneezing or coughing
Define urgency urinary incontinence
- The complaint of involuntary leakage of urine accompanied or immediately proceeded by a feeling of urgency
Define mixed urinary incontinence
- The complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
Define overflow incontinence (chronic urinary retention)
- The involuntary release of urine when the bladder becomes overly full - due to a weak bladder muscle or to blockage
Define over active bladder
- A frequent and sudden urge to urinate that may be difficult to control
Outline the prevalence of urinary incontinence/OAB
- The presence of of OAB (wet & dry) is much higher than the prevalence of UUI
- UI increases with age
What are the O&G risk factors for UI?
- Pregnancy and childbirth
- Pelvic surgery/DXT
- Pelvic prolapse
- History of large babies/difficult deliveries/instrumental deliveries
What are the predisposing risk factors for UI?
- Race
- Family predisposition
- Anatomical abnormalities
- Neurological abnormalities
What are promoting risk factors of UI?
-Co-morbidities
- Obesity
- Age
- Increased intra-abdo pressure
- UTI
- Drugs
- Menopause
- Cognitive impairment
What are storage symptoms of the lower urinary tract?
- Increased frequency
- Urgency
- Nocturia
- Incontinence
What are voiding symptoms of the lower urinary tract?
- Slow stream
- Splitting or spraying
- Intermittency
- Hesitancy
- Straining
- Terminal dribble
What are post-micturition symptoms of the lower urinary tract?
- Post-micturition dribble
- Feeling of incomplete emptying
What other factors are important to consider with UI?
- Fluid intake habits, particularly in relation to tea coffee
- Any symptoms of uterovaginal prolapse and faecal incontinence
- How long have the problems been going on for
If UI is due to neurological damage, which dermatomes should we examine?
- S2, S3, S4
What would we examine in a patient with UI?
- BMI
- Abdominal exam to exclude palpable bladder
- Examination of S2, S3, S4 dermatomes
- DRE (prostate in males)
- In females, external genitalia (stress test) and vaginal exam
What are the mandatory investigations for suspected UI?
- Dipstick for UTI, haematuria, proteinuria, glucosuria
What are the basic non-invasive urodynamics investigations done for UI?
- Frequency-volume chart
- Bladder diary (>3 days)
- Post-micturition residual volume
- Optional tests include invasive urodynamics, pad tests, cystoscopy
Outline how urodynamic testing works
- Pt voids and is then catheterised
- Catheter used to measure residual volume
- Infuse set volume (300-400mls) saline into bladder
- Pressure probe (placed in uterus or rectum) measures pressure in bladder
- Need abdominal pressure value (ask pt to cough to obtain value)
- Intravesical pressure - abdominal pressure = detrusor pressure
How does the female pelvic floor affect continence?
- Urethra passes through pelvic floor
- Reduced tone of pelvic floor reduces function of EUS to stay closed and maintain continence
What factors determine how UI is managed?
- Depends which symptoms a patient has
- The degree to which symptoms bother the patient
- Management should be individualised and have a systematic approach
What are the conservative management suggestions for UI?
- Modify fluid intake
- Weight loss
- Stop smoking
- Decrease caffeine intake (UUI)
- Avoid constipation
- Time voiding - fixed schedule
What contained incontinence methods can mange UI?
- For patients unsuitable for surgery and who have failed conservative and medical management
- Indwelling catheter (urethral or suprapubic)
- Sheath device (condom attached to catheter and bag)
- Incontinence pads
What management is specific to SUI?
- Pelvic floor muscle training
- Duloxetine (offered as an alternative to surgery but not first-line)
How is pelvic floor muscle training carried out?
- 8 contractions 3x/day
- At least 3 months duration
What is duloxetine?
- Combined noradrenaline and serotonin uptake inhibitor
- Lengthens storage phase (NA)
- Keeps IUS closed (serotonin)
- Increased activity in striated sphincter during filling phase
What surgery can be done for SUI in females?
- Permanent intention
- Open retropubic suspension procedures
- Classical autologous sling procedures
- Low-tension vaginal tapes
- Temporary intention e.g. if further pregnancies are planned
- Intramural bulking agents
What surgery can be done for SUI in males?
- Artificial urinary sphincter - gold standard
- Male sling procedure
How does an artificial urinary sphincter work?
- Cuff stimulates action of normal sphincter to circumferentially close urethra
- Switch is present in scrotum
- Given to patients with urethral sphincter deficiency (neurological, post DXT/surgery)
What is the initial management of UUI?
- Bladder training
How does bladder training work?
- Schedule of voiding:
1. Void every hour during the day
2. Must not void in between - wait or leak
3. Intervals increased by 15-30 minutes each week until interval of 2-3 hours is reached - At least 6 weeks duration
What is the pharmacological management of UUI?
- Anticholinergics that act on muscarinic receptors (M2, M3)
- Reduces reflex that stimulates detrusor to contract
- Many brands e.g. Oxybutynin, Solifenacin
- Beta 3 adrenoceptor agonist called Mirabegron
- Increases bladder’s capacity to store urine
What are the side effects of the anticholinergics used to treat UUI?
- Affect M receptors at other sites
- M1 - CNS, salivary glands
- M2 - heart smooth muscle
- M3 - ocular and intestinal smooth muscle, salivary glands
- M4 - CNS
- M5 - CNS, eye
How does the botulism toxin treat UUI?
- Treats UUI unresponsive to anticholinergics and B3 adrenoceptor agonists
- Intravesical injection of botulism toxin
- Inhibits release of ACh at presynaptic neuromuscular junction causing targeted flaccid paralysis
- Lasts 3-6 months
What surgery can be done to treat UUI?
- Sacral nerve neuromodulation
- Autoaugmentation
- Augmentation cytoplasty
- Urinary diversion
What is enuresis in children?
- Involuntary wetting during sleep at least 2x/week in children aged >5 years with no CNS defects
What is the difference between primary and secondary enuresis?
- Primary = child never achieved sustained continence at night
- Secondary = stayed dry at night initially (6+ months) but then started bedwetting
What key questions would you ask the parent of a child with enuresis?
- Age?
- Primary or secondary?
- Do they have daytime symptoms
- Do they have pain passing urine?
- How frequently do they pass urine?
- Are they constipated
How is primary enuresis without daytime symptoms treated?
- Usually managed in primary care
- Reassurance, alarms with positive reward system, desmopressin
How is primary enuresis with daytime symptoms treated?
- Usually caused by disorders of lower urinary tract
- E.g. anatomical, OAB
How is secondary enuresis treated?
- Treat underlying cause if it has been identified
- E.g. UTIs, constipation, diabetes, psychological problems, family problems, physical or neurological problems
- Primary/secondary care
What causes enuresis?
- Children have to wait until they have enough ADH to stay dry overnight
