urinary incontinence Flashcards
what is stress urinary incontinence (SUI)?
leakage on effort or exertion, sneezing or coughing. Occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency.
what is urge urinary incontinence (UUI)?
leakage accompanied by or immediately preceded by urgency. May be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone)
what is mixed urinary incontinence (MUI)?
a combination of SUI and MUI
what are risk factors for urinary incontinence?
female
Genetic predisposition
Neurological disorders – spinal cord injury, stroke, MS, Parkinson’s
Anatomical disorders – vesicovaginal fistula, ectopic ureter in girls, urethral diverticulum, urethral fistula, bladder extrophy, epispadias
Childbirth – vaginal delivery
Pelvic, perineal and prostate surgery – radical hysterectomy, prostatectomy, TURP leading to pelvic muscle and nerve injury
Radical pelvic radiotherapy
diabetes
what are red flags in urinary incontinence?
pain, haematuria, recurrent UTI, significant voiding/obstructive symptoms, history of pelvic surgery/radiotherapy
what investigations do you do for urinary incontinence?
Bladder diary (frequency/volume chart)
Urinalysis +/- culture
Flow rate and post-void residue
Pad testing
what is the management of stress urinary incontinence?
pelvic floor exercises
lifestyle modification - weight loss, stop smoking, avoid constipation, modify fluid intake
biofeedback - a technique whereby ability and strength of pelvic floor contraction is fed back to patient as visual or auditory signal
medication - duloxetine - increases sphincteric muscle activity
what is injection therapy for SUI?
the injection of bulking materials into the bladder neck and periurethral muscles to increase outlet resistance. Main indication is deficient sphincter activity
describe suburethral tapes and slings
Synthetic tapes – e.g. the retropubic tension-free vaginal tape (TVT). Small mid-line anterior vaginal incision. The tape has long trochars on each end which are inserted either side of the urethra and perforate through the endopelvic fascia. They are then pushed up behind the symphysis pubis and out onto lower abdominal wall in the midline, just above the pubic bone. Once the tape is positioned loosely (tension-free) over the mid-urethra its covering is removed and the ends cut flush to the abdomen. Vaginal epithelium is closed over the top
describe artificial urinary sphincter
A closed pressurised system with three components:
- An inflatable cuff placed around the bulbar urethra or bladder neck
- A pressure-regulating balloon placed extraperitoneally in the abdomen
- An activating pump in the scrotum or labia majora
what is overactive bladder?
A symptom syndrome that includes urgency, with or without urge incontinence, usually with frequency and nocturia. Usually caused by bladder (detrusor) overactivity.
what is the management of overactive bladder?
- A MDT approach – urologists, urogynaecologists, continence nurse specialists, physiotherapists
- Pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy
- Behavioural modification – modify fluid intake, avoid stimulants (caffeine, alcohol), bladder training
what is the action of acetylcholine?
Acetylcholine acts on muscarinic receptors on the bladder smooth muscle to cause involuntary contractions and provoke the symptoms of bladder overactivity. These receptors are the targets of anticholinergic (antimuscarinic) drugs which inhibit contractions and increase bladder capacity.
when would you use anticholinergics in urinary incontinence?
as a last resort
what is augmentation “Clam” ileocystoplasty
relieves intractable frequency, urge and UUI in 90% patients. Bladder dome is bivalved and a detubularised segment of ileum is anastomosed, creating a larger bladder volume
