Urinary incontinence Flashcards
What is urinary incontinence?
Complaint of involuntary loss of urine
What are the 3 main types of urinary incontinence?
Stress urinary incontinence
Urgency urinary incontinence
Overactive bladder syndrome
What is stress urinary incontinence?
Complaint of involuntary loss of urine on effort or physical exertion including sporting activities, or on sneezing or coughing.
What is urgency urinary incontinence?
Complaint of involuntary loss of urine associated with urgency.
What is overactive bladder syndrome?
Urinary urgency, usually accompanied by increased daytime frequency and/or nocturia (nighttime urination), with urinary incontinence (OAB-wet) or without (OAB-dry), in the absence of urinary tract infection or other detectable disease
What are some of the risk factors for urinary incontinence in women?
- Age
- Obesity
- Parity and mode of delivery
- HRT
- Hysterectomy
- Diet
- Smoking
- Exercise
- UTI
How does stress urinary incontinence occur?
Occurs when intravesical pressure exceeds urethral closing pressure
What is intravesical pressure?
The pressure that occurs due to contraction of the detrusor muscle, this is the driving force behind the fluid in the bladder.
This force/pressure known as the intravesical pressure is maintained until urine is completely voided
What are the 2 main mechanisms for stress urinary incontinence?
Urethral hypermobility (impaired pelvic floor support)
Intrinsic sphincter deficiency (denervation or weakness of sphincter mechanism)
Typical feature in history of stress urinary incontinence?
Leakage provoked by activity, coughing, laughing, sneezing, penetration etc
An overactive bladder usually has a cause that is idiopathic in origin. true/false?
True
Usually idiopathic
Apart from being mainly idiopathic, what else could mainly cause an overactive bladder?
Neurogenic eg multiple sclerosis
Secondary to pelvic floor/incontinence surgery
What is the typical history features of an overactive bladder?
Frequency
Urgency with or without incontinence
Nocturia (waking up at night to urinate)
Nocturnal enuresis (wetting bed whilst sleeping at night)
Provoked by cold, running taps, key in lock (detrusor contraction can increase when arriving home and putting key in lock)
When assessing a patient with urinary incontinence, what factors of patient history should be taken into account?
Storage symptoms: Frequency, Nocturia, Urgency, UUI (urge), SUI (stress)
Voiding symptoms: Hesitancy, straining to void, poor flow
Post micturition symptoms: Incontinence, incomplete emptying
Establish most bothersome symptom(s)
Red flags ie haematuria
Obs history
Previous medical history
Previous pelvic surgery
Review medications
Bowel symptoms
When assessing a patient with urinary incontinence, what factors of patient examination should be taken into account?
BMI
Mobility
Abdominal palpation
Inspection external genitalia
Assess for prolapse
Assess pelvic floor squeeze
Neurology exam if appropriate
Typical baseline investigations for urinary incontinence?
Urinalysis and culture
Frequency/volume chart: 3 days
In cases of urinary incontinence, what can ultrasound check for and when can it be used?
Post void residual problems
Pelvic mass
Assess kidneys
In cases of urinary incontinence, what can cystoscopy check for and when can it be used?
Haematuria
Recurrent UTI
Bladder pain
Fistula
Mesh complication
Post SUI (stress urge incontinence) procedures
What is a vesicovaginal fistula and when does it most commonly occur?
Vesicovaginal fistula is an anomalous communication between the bladder and vagina, resulting in continuous urine leakage through the vagina.
This condition occurs most commonly after obstetrical and gynecological injury.
What is urodynamics?
The diagnostic study of pressure in the bladder, in treating incontinence.
When should urodynamic studies be carried out?
Mixed or complex symptoms
Prior to surgical intervention for SUI
OAB unresponsive to medical
treatment
OAB in neurological disease
Voiding dysfunction
Management of OAB (overactive bladder) using conservative, medical and surgical methods?
Conservative: Fluid management, Weight management, Bladder retraining.
Medical: Vaginal oestrogen, Anti-muscarinics (tolterodine, soliphenacin), Beta-3- adrenoceptor agonist (mirabegron), Desmopressin (nocturia)
Surgical: Botox, Percutaneous posterior tibial nerve stimulation (after MDT and failed botox) , Augmentation cystoplasty (last resort)
Mechanism of action in urinary incontinence for Anti-muscarinics such as tolterodine and soliphenacin?
Antagonise the effects of acetylcholine at muscarinic receptors on the detrusor muscle and are known as antimuscarinic agents.
By blocking anti-muscarinic receptors, these drugs inhibit involuntary detrusor contractions and result in delayed voiding.
Mechanism of action for Beta-3-adrenoceptor agonists such as mirabegron in urinary incontinence?
Beta-3 receptor agonist activates receptor present on the wall of the detrusor muscle which increases relaxation of detrusor muscle.
Results in increased storage capacity and decreased voiding frequency.
Conservative, medical and surgical management for stress urinary incontinence?
Conservative: Lifestyle (weight), Pelvic floor muscle training, Incontinence ring (acts as a pessary by being inserted into vagina to treat stress incontinence).
Medical: Vaginal oestrogen, Duloxetine (last line - SNRI can treat stress incontinence).
Surgical: Bulking agents, fascial slings, colposuspension
How can vaginal oestrogen treat stress urinary incontinence?
Helps in supporting sides of bladder, relaxing wall and decreasing stress incontinence.
What are bulking agents for stress urinary incontinence?
Bulking agents such as bulkamid, it involves injecting the bladder neck (through the urethra) with a bulking substance which obstructs the flow of urine.
What is an autologous fascial sling for stress urinary incontinence?
An operation to treat stress urinary incontinence.
In this operation a strip of tissue (rectus fascia) is taken from the lower abdomen (tummy) and used as a sling or hammock around the bladder neck and urethra.
What is culposuspension for stress urinary incontinence?
Stitches inserted into the pelvis either through an incision (cut) across the lower abdomen (tummy) or laparoscopically (keyhole surgery) through a series of small abdominal incisions.
The stitches pull up the vagina around the area of the bladder opening.
