Urinary Incontinence Flashcards
What are the types of incontience?
- stress urinary incontinence
- urgency urinary incontinence
- mixed urinary incontinence
- overflow incontinence (chronic urinary retention)
- functional incontinence
- over active bladder
What is the most common type of incontinence?
Over active bladder
What is stress urinary incontinence?
The complaint of involuntary leakage on effort or exertion or sneezing or coughing
Due to an increase in intra-abdominal pressure/stress
What is urgency urinary incontinence?
The complaint of involuntary leakage of urine accompanied by or immediately proceeded by urgency
Due to involuntary contraction of bladder muscles
What is mixed urinary incontinence?
The complaint of involuntary leakage of urine associated with urgency and also with excretion, effort, sneezing or coughing
What is overflow incontinence (chronic urinary retention)?
The involuntary release of urine when bladder becomes overly full due to a weak bladder muscle or blockage
Causes of overflow incontinence
- anticholinergic meds
- fibroids
- pelvic tumours
- neurological conditions e.g. MS, diabetic neuropathy
What is over active bladder?
A frequent + sudden urge to urinate that may be difficult to control
Detrusor muscle contracts when it shouldn’t be
What is functional incontinence?
when a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a toilet
often due to cognitive impairment or behavioural problems
Prevalence of urinary incontinence with age
Urgency incontinence (most)
Mixed incontinence
Stress (least)
Gradual increase with age with peaks after child birthing age + menopause in women+ older age
Risk factors of incontinence
- pregnancy
- pelvic surgery
- race
- anatomical or neurological abnormalities
- menopause
- increased inta-abdominal pressure
- UTI
- increasing age
- obesity
Classifications of lower urinary tract symptoms
Storage
Voiding
Post micturition
List lower urinary tract storage symptoms
- increased frequency
- urgency
- nocturia
- incontinence
List lower urinary tract voiding symptoms
- slow stream
- spitting or spraying
- intermittency
- hesitancy
- straining
- terminal dribble
List lower urinary tract post micturition symptoms
- post-micturition dribble
- feeling of incomplete emptying
Why does menopause promote incontinence?
- less oestrogen
- oestrogen helps strengthen pelvic floor muscles > loss of tone in menopause
- urethra passes through pelvic floor
How much volume is polyuria?
More than 3L a day
Difference between increased frequency of urination and polyuria
- Polyuria is excreting > 3L per day
- Increased frequency is a normal volume but need the toilet more times.
NOT THE SAME THING
Specific history questions to determine the type of urinary incontience
- fluid intake (particularly tea + coffee)
- previous pelvic surgery
- history of large babies
- how long symptoms have occurred for
- symptoms of uterovaginal prolapse
+ faecal incontinence (relates to menopause)
If urinary incontinence is suspected to be due to neurological damage, what dermatomes need to be examined?
S2,3+4
‘S2,3,4 keeps the wee and poo off the floor’
Investigations of urinary incontinence
- urine dipstick: MANDATORY - UTI, haematuria, proteinuria, glucosuria
- midstream urine test
- frequency volume chart/bladder diary >3 days
- post micturition residual volume/bladder scan - catheterise (voiding dysfunction)
- urodynamic tests
- prostate assessment in men
- external genitalia review
What is assessed in an external genitalia exam for UI investigations?
- pelvic tone
- pelvic organ prolapse
- atrophic vaginitis
- urethral diverticulum
- pelvic masses
Outline urodynamic tests in assessing urinary incontinence
A catheter is inserted into the bladder + rectum. These two catheters measure pressures in both areas to compare. The bladder is filled with liquid + these are taken:
- cystometry: measures detrusor muscle contraction + pressure
- uroflowmetry: measures flow rate
- leak point pressure: the point at which the bladder pressure causes urine leakage (assesses SUI)
- post-void residual bladder volume
- video urodynamic testing
General + conservative management of urinary incontinence
- depends on symptoms + degree of bother to patient
- modify fluid intake
- weight loss
- stop smoking
- decrease caffeine intake > decaf coffee/tea (UUI)
- avoid constipation
- timed voiding
Management of stress urinary incontinence
- pelvic floor muscle training (8 contractions 3x a day for 3 months)
- duloxetine: combined noradrenaline + serotonin uptake inhibitor > increased sphincter activity (alternative to surgery, not first line treatment)
What is the next step for patients with urinary incontinence who have failed conservative or medical management?
- indwelling catheter (urethral or suprapubic)
- sheath device (condom catheter)
- incontinence pads
Surgical management of stress urinary incontinence in women
permanent:
- open retropubic suspension procedure
- classical autologous sling procedures
- low-tension vaginal tapes
temporary: if further pregnancies are planned
- intramural bulking agent
Surgical management of stress urinary incontinence in men
Artificial urinary sphincter
Male sling procedure
Management of urgency urinary incontinence
Bladder training: schedule of voiding
- void every hour during day
- must wait or leak in between
- intervals increased by 15-30 mins each week until interval of 2-3 hours reached
- over 6 weeks
Pharmacological management of urgency urinary incontinence
-
anticholinergics: act on muscarinic receptors M2,3
(side effects due to M receptors at other sides) - avoid in older people oxybutynin - B3 adrenoceptor agonist: increases bladders capacity to store urine mirabegron
- butolism toxin
Why are should you avoid oxybutynin + anticholinergics in older people?
can cause postural hypotension > increased risk of falls
Contraindications of mirabegron
uncontrolled hypertension - BP must be monitored regularly during treatment
Surgical management of urgency urinary incontinence
- sacral nerve modulation
- botulinum toxin type A
- augmentation cystoplasty
- urinary diversion
What is botulism toxin?
What is it used for?
- intravescial injection
- inhibits release of Ach at pre-synaptic neuromuscular junction > targeted flaccid paralysis
- used in urgency urinary incontinence after other pharmaceuticals
What is enuresis?
Involuntary urination
(Particularly children at night - bed wetting)
Define bed wetting
Involuntary wetting during sleep at least 2x a week in children > 5 with no CNS defects
Managment of primary enuresis without daytime symptoms
- normally in primary care
- reassurance
- positive reward system
- desmopressin overnight to supplement ADH
What nerve maintains voluntary continence?
Pudendal nerve
Management of primary enuresis with daytime symptoms
- normally caused by disorder of lower urinary tract
- refer to secondary care
Managment of secondary enuresis
Treat underlying cause
e.g. UTIs, constipation, diabetes, psychological problems
What nerve matures during potty training?
Pudendal nerve
What hormone is released during the night to prevent bed wetting?
ADH
Compare the specific management of stress and urgency urinary incontinence including potential drugs given
Stress:
- pelvic floor muscle training
- duloxetine
Urgency:
- bladder training
- anticholinergics
- B3 adrenoceptor agonist
- botulism toxin
What drugs can be given to help with urgency urinary incontinence?
How do they help?
- anticholinergics: ACh acts on M3 receptors as part of the parasympathetic stimulation of detrusor muscle of the bladder which causes contraction | anticholinergics oppose this action
- B3 adrenoceptor agonists: NA acts on B3 receptors as part of the sympathetic inhibition of detrusor muscle which prevents contraction| B3 agonists promote this action (relaxes bladder + increases bladders capacity to store urine)
What is duloxetine used for?
How does it work?
- stress urinary incontinence
- combined noradrenaline + serotonin uptake inhibitor > increased sphincter activity
- alternative to surgery, not first line treatment
What antimuscarinic is given in urgency urinary incontinence?
Oxybutynin
What is normal functional bladder capacity?
400-500ml
What is the mechanism of action of oxybutynin?
antimuscarinic
Blocks M3 receptors in bladder > stops Ach from binding > inhibits contraction of bladder
Why can dementia patients have urinary incontinence?
- regulation of paracentral lobules to M centre lost
- or functional incontinence
Drugs used to treat overactive bladder
- anti muscarinic: e.g. oxybutynin
- B agonists: e.g. mirabegron
- botulinum toxin injection
Describe flow-volume charts
What can flow volume charts /bladder diary detect?
- frequency
- polyuria
- nocturia
- nocturnal polyuria
What is nocturnal polyuria?
Passing more than 35% of 24 hour urine production at night
