Urinary incontinence Flashcards
What is urinary incontinence?
Urinary incontinence refers to the involuntary loss of urine and can be categorised into stress, urge, overflow, functional, and mixed types
What causes UI?
- Neurological causes (multiple sclerosis, spinal injury)
- genitourinary causes (trauma to pelvic floor, sphincter deficiency, bladder outlet obstruction, pelvic floor weakness)
- reversible causes (diuretics, UTIs)
What investigations are used to diagnose/ monitor UI?
- Bladder Diaries → should be completed for minimum of 3 days to assess frequency and volume of micturition
- Vaginal Examination → exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
- Urine Dipstick & Culture → exclude UTI
- Urodynamic Studies (Bladder Outflow Obstruction) → increased detrusor pressure and reduced urine flow rate
- Dx of Acute Urinary Retention = bladder ultrasound
- Postvoid Residual Volume → may identify urinary retention
What is stress incontinence?
This involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.
What are the risk factors for stress incontinence?
- Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor
- Hysterectomy
What are some triggers for stress UI?
- coughing
- laughing
- sneezing
- exercising
can all increase abdominal pressure sufficiently
What are some causes of stress UI?
Any abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.
How is stress UI managed?
Non-surgical:
1. Lifestyle changes:
- weight loss
- smoking cessation
- Avoid excessive fluid intake
2. Supervised pelvic floor exercises
3. Bladder re-training
Medical:
1. Oestrogen therapy (if evidence of atrophy)
2. Duloxetine (increases spincter force- only recommended if conservative measures fail and the patient is not a surgical candidate)
Surgical: (if signficiant)
1. Occlusive:
- bulking agents are injectable materials placed at the bladder neck to improve continence- reserved for patients who are poor surgical candidates
- Compressive (artificial urinary sphicter AUS)
2. Supportive:
- Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper.
- Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures- minimally invasive
3. Ileal conduit diversion: An ileal conduit aims to divert urine produced from the upper urinary tracts to a newly formed reservoir created from the terminal ileum. The ureters are disconnected from the bladder and implanted into the conduit.
What is urge incontinence?
This involves the sudden and involuntary loss of urine associated with urgency.
What are the risk factors for urge UI?
Recurrent urinary tract infections
High BMI
Advancing age
Smoking
Caffeine
How is urge UI managed?
Non-surgical:
1. Lifestyle changes:
- weight loss
- smoking cessation
- Avoid excessive fluid intake
2. Supervised pelvic floor exercises
3. Bladder re-training
Medical:
1. Anticholingerics (inhibit the parasympathetic action on the detrusor muscle)
- Oxybutynin, Tolterodine, Fesoterodine, Solifenacin, Trospium
SE: dry mouth, temporary blurry vision, constipation
2. Beta-3-agonists
- betmiga
SE: raised bp, prolonged QT interval
Surgical:
1. Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder.
2. Sacral neuromodulation:
- Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.
What is functional incontinence? What can cause this?
This involves an individual having the urge to pass urine, but they’re unable to access the necessary facilities and as a result are incontinent.
- bladder func is ok
Causes
Functional incontinence associated with:
- Sedating medications
- Alcohol
- Dementias- cognitive impairment
- mobility limitations
What is overflow incontinence? what causes this?
Involuntary leakage of urine when bladder is full
causes:
- This occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.
- Usually due to chronic retention secondary to obstruction or atonic bladder
What is mixed incontinence?
More than 1 types of UI, usually seen in older patients
What is continuous incontinence?
Continuous loss of urine all the time
- could be due to vesicovaginal fistula (from injury, surgery, radiotherapy, etc), ectopic ureter
