Urinary Incontinence Flashcards
the complaint of any involuntary leakage of urine
Urinary Incontinence
true or false incontinence can almost always be improved and frequently can be cured, often using relatively simple, nonsurgical interventions
true
true or false
If the leakage is distressing to the patient, evaluation and treatment should be offered.
true
– peak at 5th decade of life and the most common subtype of urinary incontinence
stress incontinence
– the most dominant subtype in late adulthood
mixed urinary incontinence
the key urethral support responsible for continence was considered to be at the
bladder neck and proximal urethra
were thought to be structurally important to maintain continence
pubourethral ligaments, extending from the undersurface of the pubic bone down to the urethra
current most accepted theory of stress urinary incontinence pathogenesis
- loss of integrity of structures intrinsic to the urethra, and, to a lesser extent, the
- pelvic support structures in close proximity, but extrinsic, to the urethra
proposed that the primary support of the bladder neck and urethra to be an intact vaginal wall at the base of the bladder
Hammock Theory by DeLancey
- condensation of the levator ani muscles - the vagina was shown to act as a hammock to support the bladder neck, compress the urethra, and maintain continence
- Loss of integrity of the hammock resulted in stress urinary incontinence
stress urinary incontinence occurs as a result of connective tissue laxity in the vagina and its supporting ligaments (pubourethral, cardinal/uterosacral, and arcus tendineus fascia pelvis)
Integral Theory
by Petros and Ulmsten
highlighted the role of the suspensory ligaments supporting the proximal vagina that supports the mid-urethra
Integral Theory by Petros and Ulmsten
multidirectional movement of the pelvic floor muscles coordinated the urethral continence mechanism
- the forward direction of the pubococcygeus muscle stretches the mid-vagina forward against the pubourethral ligament to close the urethra from behind;
- the backward direction of the levator plate stretches the upper vagina and bladder base backward and downwards in a plane around the pubourethral ligament to close off the proximal urethra
Integral Theory by Petros and Ulmsten
Maintains a positive urethral closure pressure during bladder filling
Normal urethral closure mechanism
Pathophysiology is not well developed; often used interchangeably with overactive bladder (OAB)
Urgency urinary incontinence
SYNDROME associated with urgency, usually accompanied by frequency, nocturia, with or without urgency urinary incontinence, and in the absence of a urinary tract infection or other obvious pathology
OAB “overactive bladder”
Theories for nonneurogenic OAB or idiopathic urgency urinary incontinence
- Epithelial hypersensitivity theory
- Myogenic theory
proposes presence of chemosensitizing agents leading to bladder instability which are believed to be inflammatory substances such as nerve growth factor, prostaglandins, and acetylcholine that increase detrusor muscle sensitivity and neuronal excitability
Epithelial hypersensitivity theory
suggests that the pelvic floor sustains a physical strain during the developmental years
Myogenic theory
-Myogenic dysfunction ensues secondary to altered structure or disordered function of a group of myocytes within the detrusor smooth muscle independent of its nerve supply
the most common incontinence subtype in later adulthood
Mixed urinary incontinence
may represent a combination of bladder storage conditions of different etiologies
Mixed urinary incontinence
occur mostly in the distal urethra of women between the ages of 30 and 60 years
Urethral diverticuli
a congenital anomaly where the ureter opens distally into the urethra or more commonly into the vagina
Ectopic urethra
rare condition that involves a congenital absence of the anterior vaginal wall and base of the bladder/urethra
Bladder extrophy
an acquired condition where there are one or more direct communications between the vagina and the following adjacent organs:
Fistula (traumatic)
Fistula that is most common and usually arises from a prolonged obstructed labor, in younger and poorly developed women in rural, underdeveloped regions of the world
Vesicovaginal fistula
Causes of genitourinary fistula in developed countries
Gynecologic causes
-pelvic malignancies
-gynecologic surgeries such as HYSTERECTOMY, AND PELVIC IRRADIATION
What type of urinary incontinence are at higher risk to developed in
- White women
- Black women
- White women—STRESS urinary incontinence
- Black women—URGENCY urinary incontinence
Prevalence for STRESS urinary incontinence peaks in the
5th decade and then declines thereafter
-vaginal birth is strongly associated with stress urinary incontinence in the FIRST 2 DECADES after childbirth, but has little to no effect beyond that
-ADVANCING AGE IS A STRONG PREDICTOR OF BOTH URGENCY AND MIXED URINARY INCONTINENCE
major risk factor for urinary incontinence and its subtypes
OBESITY
- Previous hysterectomy
- Surgery for prolapse
- Surgery for stress incontinence
- Stress and urgency urinary incontinence
- New onset stress urinary incontinence
- De novo or worsening urgency urinary incontinence
REVERSIBLE CAUSES OF URINARY INCONTINENCE
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmacologic causes
Excessive urine production
Restricted mobility
Stool impaction
DIAGNOSIS FOR URINARY INCONTINENCE
-2 to 3 day diary
-cystoscopy—rarely an indication for uncomplicated urinary incontinence
-urodynamics—no longer necessary prior to treatment
Urine loss associated mostly with activities such as coughing, sneezing, or laughing is suggestive of
stress urinary incontinence;
Symptoms associated with or immediately preceded by an urgency episode are indicative of
urgency urinary incontinence.
Medications that May Affect the Function of the Urinary Tract
- Sedatives
- Alcohol
- Anticholinergic drugs
- Alpha agonists
- Alpha blockers
- Calcium channel blockers
- Angiotensin-converting enzyme inhibitors
May cause confusion and secondary incontinence, particularly for elderly patients
Sedatives such as benzodiazepines
May have similar effects to benzodiazepines and also impair mobility and causes diuresis
Alcohol
May impair detrusor contractility and may lead to voiding difficulty and overflow incontinence.
Anticholinergics
Increase outlet resistance and may lead to voiding difficulty
Alpha agonists
Decrease urethral closure pressure and leads to stress incontinence
Alpha blockers
(Prazosin, teazosin)
Reduce bladder smooth muscle contractility and lead to voiding problems or incontinence; they may also cause peripheral edema, which may lead to nocturia or nighttime urine loss
Calcium channel blockers
Result in a chronic and bothersome cough that can result in increasing stress urinary incontinence in an otherwise asymptomatic patient
ACE inhibitors
involves introducing a cotton-tipped swab into the urethra and asking the patient to Valsalva to measure the angle deviation of the urethra from baseline
Q-tip test
More than a 30-degree deviation is consistent with hypermobility of the urethra, and/or urethrovesical angle.
• Minimal to no angle deviation in a woman with stress urinary incontinence may indicate intrinsic sphincter deficiency, also known as stove-pipe urethra
Done During the pelvic examination
• can be done either with a full or an empty bladder
Cough stress test
the amount of urine remaining in the bladder within 10 minutes from voiding
Postvoid residual
Normal value of PVR
< 50 ml
PVR > 150 ml is abnormally elevated
can be administered before (bladder diary), during (urinalysis), or after (pad test) a clinical encounter - to assist the clinician in making a firm diagnosis
Simple bladder testing
represent the total amount of fluid intake, by type, in a 24-hour period done within 2- to 3- days
Bladder diary/voiding diary
helpful to rule out a urinary tract infection, especially in the presence of irritative lower urinary tract symptoms such as urgency, frequency, nocturia, and dysuria.
Urinalysis
The hallmark of advanced bladder testing
Urodynamics
Simple urodynamics consists of
- Uroflowmetry
- PVR
- Simple filling cystometry
First becomes aware of bladder filling
Bladder sensation
-First sensation
Feeling that would lead the person to void at next convenient moment, but voiding can be delayed if necessary
First desire to void
Persistent desire to void without the fear of leakage
Strong desire to void
Detrusor function:
-allows bladder filling with little or no change in pressure; no involuntary phasic contractions
Normal detrusor function
Involuntary detrusor contractions during filling
Detrusor overactivity
Characteristic wave form; may or may not lead to incontinence
Phasic detrusor overactivity
Single involuntary detrusor contractions occurring at cystometric capacity, which cannot be suppressed, and results in incontinence usually resulting in bladder emptying
Terminal detrusor overactivity
Incontinence that is due to an involuntary leakage episode
Detrusor overactivity incontinence
There is a relevant neurologic condition (replaces term detrusor hypereflexia)
Neurogenic detrusor overactivity
No definite cause
Replaces term detrusor instability
Idiopathic detrusor overactivity
Fill volume/change in detrusor pressure (Pdet)
Bladder compliance
Volume at the end of cystometrogram; capacity is c volume voided together with any residual urine
Cystometric capacity
Volume at which person feels she can no longer delay voiding
Maximum cytometric capacity
Allows leakage of urine in the absence of a detrusor contraction
Incompetent urethral closure mechanism
Leakage that is due to urethral relaxation in the absence of raised abdominal pressure or detrusor overactivity
Urethral relaxation incontinence
Involuntary leakage of urine during increased abdominal pressure, in the absence of detrusor contraction
-replaces the term genuine stress incontinence
Urodynamic stress incontinence
Fluid pressure needed to open a closed urethra
Urethral pressure
Pressure along length of urethra
Pressure profile
Increment in urethral pressure on stress as percentage of simultaneously recorded increment in intravesical pressure
Pressure transmission ratio
Intravesical pressure at which urine leakage occurs because of increased abdominal pressure
Abdominal leak point pressure
Volume voided/unit time
Flow rate
Total volume voided
Voided volume
Time over which measurable flow actually occurs
Flow time
Voided volume/flow time
Average flow rate
Pressure measured at the end of measured flow
Closing pressure
Contraction of reduced strength resulting in prolonged bladder emptying an/or failure to achieve complete bladder emptying
Detrusor underactivity
Cannot be demonstrated to contract
Acontractile
Normal urethral function during voiding
Continuously relaxed
Intermittent and/or fluctuating flow rate that is due otherwise involuntary intermittent contractions of the periuethral striated muscle during voiding in neurologically normal people
Dysfunctional voiding
Detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle
Detrusor sphincter dyssynergia
Usually occurs in people with a neurologic lesion
Nonrelaxing urethral sphincter obstruction
A study that assessed voiding function
Uroflowmetry
A normal uroflow
- Continuous bell-shaped configuration
- A short time to peak flow
- A high peak flow
An obstructed flow may
- Have two or more lower peaks with an interrupted flow pattern or a prolonged tail
After completion of the uroflowmetry, the patient is placed in a lithotomy position and a catheter is placed to measure the PVR volume
Filling cystometry
NORMAL IS LESS THAN 50 ML
several sensory parameters that are measured during the filling phase (with
their typical normal values)
- FIRST filling sensation - 50 ML
- First DESIRE to void - 150 ML
- STRONG desire to void - 250 ml
- Maximum cystometric capacity- 400 ML
Loss of urine associated with an increased abdominal pressure is indicative of
Stress urinary incontinence
suited for women with predominant urgency urinary incontinence, mixed or complex symptoms, with previous failed incontinence surgery, or neurologic conditions
• includes complex filling cystometry, urethral pressure profilometry, and pressure flow studies
Complex urodynamics
False NEGATIVE test of complex urodynamics can occur in
woman with subjective stress urinary incontinence where no urine loss is observed even with a full bladder in the lying or standing position;
• it can also occur with urgency urinary incontinence where a patient may report sensory urgency, but no detrusor activity is visible.
False POSITIVE test of complex urodynamics can occur in
uncommon with stress but may happen with urgency urinary incontinence where the presence of the catheter or patient’s anxiety may provoke an iatrogenic bladder contraction
performed to assess bladder and urethral function during the filling phase
Filling cystometry
a measure of the detrusor pressure (Pdet) plus the pressure of the abdomen and surrounding organs (Pabd)
Intravesical pressure (Pves)
Pves = Pdet + Pabd
Pdet = Pves - Pabd
a measure of the function of the urethra
The pressure inside the bladder (Pves), and that of the urethra (Pure) are noted
Urethral pressure profilometry
What is the result of Pure and Pves in a healthy normal bladder and urethra
Pure is HIGHER than Pves during FILLING
Pves is HIGHER than Pure during VOIDING
test of urethral integrity which represents the value of the intra-abdominal or intravesical pressure at which point urine loss occurs
Valsalva leak point pressure (VLPP)
What is the value VLPP that is used as a cut-off representing normal urethral function
> 60 cm of H2O
leads are usually placed around the external anus to indirectly assess the activity in the urethral sphincter
Electromyography (EMG)
generally represents a good estimation of the urethral striated muscle activity.
EMG
Since the anal sphincter and urethra are primarily innervated by the pudendal nerve,
Result of EMG during filling and voiding phase
Filling phase - INCREASED EMG ACTIVITY
Voiding phase - DECREASED EMG ACTIVITY
Also called voiding cystometrogram
• Here the Pves, Pabd, and Pure are measured concurrently as the patient is asked to void.
• This study offers information on the voiding mechanism of the bladder, presence of dysfunctional voiding, and the potential risk for retention or incomplete bladder emptying after surgery for incontinence
Pressure flow studies
sometimes used, but generally not recommended, in conjunction with urodynamics (also referred to as video urodynamics) to assess for a cystocele and hypermobility of the urethrovesical junction
Fluoroscopy
A typical office-rigid cystoscope consists of a 17-French caliber sheath, through
which the endoscope is introduced
• attached to a fiber-optic light source, camera, and distending medium (sterile water or normal saline).
• The lenses on the endoscope are 0, 12, 30, 70, or 120 degrees.
Cytoscopy
Normal values of female bladder function
-residual volume < 50 mL
-first desire to void occurs: 150-250 mL infused
-strong desire to void: > 250 mL
-cystometric capacity: 400-600 mL
-bladder compliance: 20-100 mL/cm H2O measured 60 sec after reaching cystometric capacity
-no uninhibited detrusor contractions during filling, despite provocation
-no stress or urge incontinence demonstrated, despite provocation
-voiding occurs as a a result of a voluntarily initiated and sustained detrusor contraction
-flow rate during voiding is > 15 mL/sec with a detrusor pressure of < 50 cm H2O
Indications for cystoscopy
-stones
-BLADDER tumors
-foreign bodies
-CHRONIC cystitis
Other indications in women include:
a) microscopic hematuria (presence of red blood cells in the urine) that is unrelated to a urinary tract infection;
b) OAB that is refractory to conservative or medical treatment, especially in older women;
c) urinary incontinence with suspected vesicovaginal fistula;
d) symptoms such as frequency, urgency, dysuria, in the absence of a urinary tract infection;
e) women presenting with recurrent urinary tract infections;
f) recurrent urinary incontinence or OAB symptoms following previous anti-incontinence surgery;
g) complications from previous vaginal mesh or sling procedures
can help assess changes in morphology of the urethra, bladder neck mobility, pelvic support structures at rest or with Valsalva, and to quantify these changes
Ultrasound
used mostly in research to better understand the anatomy of the pelvis and the organs
MRI
• to study the normal function and pathophysiology of the neuromuscular system:
Neurophysiologic testing
