Urinary Incontinence Flashcards
What are some urine storage symptoms
FUN:
* Frequency, Urgency (a sudden compelling desire to pass urine), Nocturia
* Urge incontinence (involuntary leakage accompanied/preceded by urgency)
* Stress incontinence (involuntary leakage on effort, exertion, sneezing or coughing)
* Nocturnal enuresis
What are some urine voiding symptoms
HIPST:
* Hesitancy (difficulty in initiating micturition), Intermittent stream, Poor stream (perception of reduced urine flow), Spitting or spraying, Terminal dribble
What is the micturition cycle
- The storage and voiding of urine from the bladder is called the micturition cycle: As the bladder fills, it is able to expand and contract due to the detrusor muscle layer lining it and the layer of transitional epithelial cells lining it (which are abe to physically stretch out)
- The detrusor muscle is innervated by muscarinic cholinergic nerves of the PNS
How much can the adult bladder hold
Around 750ml
What are the functions of the internal and external sphincter muscles
- Internal sphincter muscle: Smooth muscle with involuntary control- opens when bladder is around half full (innervated by NA neurons of the SNS)
- External sphincter muscle: Skeletal muscle under voluntary control (somatic fibres from pudendal nerves)
What happens as the bladder reaches capacity
- Sensory signals from stretch receptors in the bladder wall send the impulses to spinal cord at levels S2 and S3 (micturition centre) and to the pons (pontine storage centre and pontine micturition centre)
- Micturition reflex then occurs whereby internal sphincter relaxes
- The pons then allows for voluntary delay of micturition until socially convenient (via cortical inhibition of spinal voiding reflex arc). To delay urination, pontine storage centre overrides micturition reflex, and to urinate, pontine micturition centre allows for micturition reflex to happen
- In pre-menopausal women, the urethral epithelium has a rich blood supply and contributes to continence by acting as a seal
Important aspects of a general assessment of urinary incontinence
- Ask about fluid intake and amount and type of fluids (e.g caffeine and alcohol)
- Screen for red flag symptoms including: haematuria, persisting bladder or urethral pain, recurrent UTI, constant leakage (suggests fistula)
- Ask about drugs that could be causing or exacerbating incontinence:
- E.g Alpha-1 adrenoceptor antagonists, antipsychotics, anticholinergics, antidepressants, benzos, diuretics, HRT
- Ask about previous history of Ix and Tx (urinary tract disorders, lower spinal surgery, prolapse or hysterectomy, gynaecological and obstetric Hx)
- Consider and look for cognitive impairment
- Perform urine dipstick analysis in all women presenting with urinary incontinence to test for blood, glucose, protein, leucocytes, and nitrites (then consider MSU if either nitrates or leukocytes or both are positive- can offer Abx in the meantime if symptomatic)
- Perform a general examination noting factors such as weight, abnormalities of gait and indicators of neurological disease
- Examine the abdomen for a palpable bladder or mass
How can the strength of the pelvic floor be graded (based on digital examination)
- 0 = no contraction. No discernible muscle contraction.
- 1 = flicker. A flicker or pulsation is felt under the examiner’s finger.
- 2 = weak. An increase in tension is detected, without any discernible lift.
- 3 = moderate. There is lifting of the muscle belly and elevation of the vaginal wall.
- 4 = good. Increased tension and a good contraction elevate the posterior vaginal wall against resistance (pressure by the examining finger applied to the posterior vaginal wall).
- 5 = strong. Strong resistance is applied to the elevation of the posterior vaginal wall. The examiner’s finger is squeezed and drawn into the vagina.
How can we assess for the severity of urinary incontinence
- Ask how often the woman is incontinent, at what times, and during which activities
- Ask about the use of pads (including size) or changing of clothing
- Ask the woman to keep a bladder diary for a minimum of 3 days
Investigations for urinary incontinence
- Urine Dipstick
- Urinary diary
- Post-micturition USS (preferred) or catheterisation to exclude chronic urine retention
- Urodynamic testing (cystometry)
- USS- exclude incomplete emptying, also checks for congenital abnormalities, calculi, tumours and detects cortical scarring of kidneys
- CT urograms
- Methylene dye test- leakage from places other than the urethra is seen e.g fistulae
- Cystoscopy- inspection of the bladder cavity- exclude tumours, stones, fistulae, cystitis
Describe the process of urodynamic testing
- Used to be done in all patient but high false-negative and carries risk of UTI
- Based on recreating a micturition cycle whilst recording abdominal and bladder pressure
- 1 Catheter placed into the bladder through the urethra and a second into the rectum
- Bladder is filled with warm water and a commode measures leakage
- Detrusor pressure = bladder pressure -abdominal pressure
- When urgency is reported, filling is stopped and the patient performs various actions to provoke leakage (e.g. coughing, star jumps) before voiding
- Stress incontinence= leakage is seen when abdominal pressures are increased with no change in detrusor pressure
- Overactive bladder= detrusor contractions are seen in the filling phase
- Should be reserved for patients who fail to respond to conservative treatment
- DO NOT perform before primary surgery if stress incontinence is suspected
What might be identified on urodynamic testing
- Detrusor Overactivity: presence of a detrusor contraction, with or without sensation, during the filling phase of urodynamics
- Detrusor Overactivity Incontinence: leakage from the urethra in associated with a detrusor contraction and increase in bladder pressure
- Urodynamic Stress Incontinence: leakage from the urethra in association with a rise in abdominal pressure (e.g. coughing) without a detrusor contraction (a sign of urethral sphincter weakness)
- Mixed Incontinence: presence of both urodynamic stress incontinence and detrusor overactivity
Indications for referral of incontinence to a specialist
- Persisting bladder or urethral pain
- Palpable bladder on bimanual or abdominal examination after voiding
- Clinically benign pelvic masses
- Associated faecal incontinence
- Suspected neurological disease or symptoms of voiding difficulty
- Previous urology surgery
Definition of overactive bladder syndrome
Urgency, with or without urge incontinence, usually with frequency or nocturia, in the absence of proven infection. Characterised by involuntary detrusor contractions during the filling phase of micturition (either spontaneous or provoked by actions which increase abdominal pressure.)
Definition of urgency urinary incontinence
Involuntary leakage accompanied by, or preceded by, a sudden compelling urge to pass urine which is difficult to defer. UUI is part of the larger symptom complex of overactive bladder syndrome.
