Urinary Incontinence Flashcards
Urinary incontinence is when
there is an involuntary loss of urine
Urinary incontinence presentation
near constant dribbling or intermittent voiding with or without awareness of need to void
extreme urgency with little or no warning; may be unable to hold urine until reaching bathroom
worsens with maneuvers that increase intra-abdominal pressure
pt engages in bathroom mapping
Urinary incontinence types:
- Urge incontinence (m.c in elderly)
- Stress incontinence (2nd m.c in women d/t childbirth)
- Overflow incontinence (m.c in men)
Urge incontinence is
most common in older people
uncontrolled urine leakage (mod-large volume) immediately after urgent, irrepressible need to void
Stress incontinence is:
2nd most common type in women
urine leakage due to abrupt increase in intra-abdominal pressure (coughing, sneezing, laughing, bending, jumping or lifting)
Leakage volume usually low to moderate (depending on fullness)
Overflow incontinence is:
2nd most common type in men
dribbling of urine from overly full bladder
volume usually small, but leaks may be constant
Functional incontinence is
urine loss due to cognitive or physical impairments or environmental barriers that interfere with control of voiding
Mixed incontinence is
any combination of other types
Urinary incontinence pathophysiology in older patients:
with aging bladder capacity decreases and ability to inhibit urination declines, detrusor overactivity occurs more often and bladder contractility is impaired
Urinary incontinence pathophysiology of postmenopausal women
decreased estrogen leads to atrophic urethritis/ vaginitis, decreased urethral resistance and closure pressure
Urinary incontinence pathophysiology in men
prostate size increases partially obstructing urethra leading to incomplete bladder emptying and strain on detrusor muscle, facilitate incontinence but does not cause it
Urinary incontinence pathophysiology in younger pts
often begins suddenly, may cause little leakage and usually resolves quickly with little or no treatment, one cause in younger pts but several in older pts
Transient urinary incontinence causes:
delirium
infection
atrophic urethritis/vaginitis
pharmaceuticals
psych disorders
excess urine output (DI)
restricted mobility
stool impaction
Transient urinary incontinence is
something that comes up quickly and if we address it the issue can usually be resolved - correctable
Established Urinary incontinence is
caused by persistent problem affecting nerves or muscles:
bladder outlet incompetence or obstruction
detrusor overactivity or underactive
detrusor-sphincter dyssynergia
combination
Established Urinary incontinence is a common cause of
stress incontinence
Outlet obstruction leads to
chronically overdistended bladder, loses ability to contract, bladder does not empty resulting in overflow
detrusor overactivity and urge incontinence - detrusor muscle loses its ability to contract
Detrusor overactivity is
“overactive bladder” - urgency, frequency, a weak flow rate, urinary retention
often accompanied by urinary frequency and nocturia
Detrusor underactivity is
urinary retention and overflow incontinence
Detrusor-sphincter dyssynergia is
loss of coordination between bladder contraction and external urinary sphincter relaxation
rather than the sphincter relaxing when bladder contracts, sphincter contracts obstructing bladder outlet
What must be excluded before beginning treatment for incontinence
urinary retention
Physical exam for urinary incontinence needs to consist of
neurologic, pelvic and rectal exams are focus
Urinary incontinence: stress testing is
on exam table with full bladder, patient sits upright with legs spread, relaxes perineal area and coughs vigorously
immediate leakage that starts and stops with cough means
confirmed stress urinary incontinence
Delayed or persistent leakage suggests detrusor overactivity
detrusor overactivity triggered by cough
If cough triggers incontinence in the urinary stress test you should
repeat while examiner places 1-2 fingers inside the vagina to elevate the urethra (marshall-bonney test) incontinence that is corrected by this maneuver may respond to surgery
Postvoid residual volume results
< 50 ml is normal
<100 ml is usually acceptable > 65 yo but abnormal in younger
> 200 ml suggests detrusor underactivity or outlet obstruction
What is peak urinary flow rate testing used for
to confirm or exclude outlet obstruction in men
Electromyography of perineal muscle is used for
assessing the sphincter innervation and function
Urinary incontinence treatment:
specific causes are treated, drugs that cause or worsening D/C’d or dosing is altered
general - limit fluid intake at certain times, avoid fluids that irritate the bladder
portable commode, absorbent pads or undergarments
timed voiding or prompted voiding
kegel exercises, relaxation techniques, bladder training
Urinary incontinence treatment: Drugs
oxybutynin and tolterodine most common (make sure they do not have retention because this will make it worse)
Onabotulinum toxin A - administered via cystoscopic injection into detrusor muscle
Urge incontinence treatment procedures:
sacral nerve stimulation - implanted neurostimulator
posterior tibial nerve stimulation
surgery - last resort, usually younger pts with severe urge incontinence refractory to other treatments
stress incontinence behavioral treatment
bladder training
kegel exercises
avoiding physical stresses that provoke incontinence
losing wt
exercise regimens using vaginal cones (retained for 15 min twice a day)
stress incontinence drugs
pseudoephedrine
Duloxetine, imipramine
if due to atrophic urethritis - topical estrogen
Urinary stress incontinence devices
various mesh slings
pessaries
silicone suction caps over urethral meatus
