Urinary Incontinence Flashcards
Types of Urinary Incontinence
-Urinary Incontinence: involuntary leakage of urine
-Urge/ overactive bladder: complaint of involuntary leakage of urine accompanied/ preceded by urgency (sudden urge to pass urine with loss of control on the way to the toilet) , due to detrusor overactivity, urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
-Stress: the complaint of involuntary leakage of urine accompanied with exertion, coughing, or sneezing. Due to weakness of pelvic floor and sphincter muscles
-Mixed
-Functional incontinence: comorbid physical conditions impair the patient’s ability to get to a bathroom in time
=causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
-Overflow incontinence: chronic urinary retention due to obstruction to outflow of urine, common in men
4-5%. elderly females
Clinical definitions of urinary incontinence
-Overactive bladder (OAB): urinary frequency and urgency, with or without urge incontinence and nocturia
-Detrusor overactivity (DO): urodynamic observation characterised by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked
-Idiopathic detrusor overactivity (IDO): diagnosed in the absence of other pathologies
Risk Factors of urinary incontinence
Hysterectomy
Family history
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
Initial assessment of woman presenting with urinary incontinence
-History
=Caffeine, alcohol, medications, BMI, frequency of urination and incontinence, night-time urination, use of pads and change of clothing
-Physical exam: pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic masses
-Questionnaire optional
-Voiding diary
-Urinalysis
-Post void residual if voiding difficulty
-Pad test if quantification of leakage is desired
-ICIQ Structured Incontinence Questionnaire
-Urodynamics
Reasons for specialist referral for woman presenting with urinary incontinence
-Haematuria
-Pain
-Recurrent UTI
-Grade 3 or symptomatic prolapse
-Previous pelvic radiotherapy
-Previous surgery for UI
-Pelvic mass
-Suspicion of fistula
What to ask in UI history
-SUI
-UUI
-Mixed UUI
-Medication: alpha-blockers, diuretics
-Provocative manouevres: running tap, key in latch, standing
-Quantify: panty liners vs pads (how many?), changes of clothing
-RFs for UI: caffeine, MS, spinal injury, CVA, multiparity, obesity
-Enquire: BO - ?constipation, ?? Faecal incontinence
Urinary incontinence examination
-Abd:
=?palpable bladder, ?pelvic mass
-Perineum:
=Cough test positive?
=Vaginal tone (weak?): Oxford test
=Urethral diverticulum
=Prolapse
=Vaginal atrophy
=Fistula
Investigation of incontinence
-bladder diaries should be completed for a minimum of 3 days
-vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
-urine dipstick and culture
-urodynamic studies: urge
-Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
Management of urge incontinence
-PFME (Pelvic Floor Muscle Exercises)
-Lifestyle advice
=reduction to caffeine intake
=smoking cessation
=reduced alcohol intake
=weight loss
-Bladder training can improve urgency: Bladder Drill, lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding
-Pharmacotherapy either with an antimuscarinic (blocks the post-synaptic muscarinic receptor, oxybutynin immediate release/ tolterodine immediate release, or darifenacin once daily) or recent novel pharmacological agent a beta-3 adrenergic agonist mirabegron (Induce relaxation by increasing sympathetic tone).
-Intradetrusor Botulinum Toxin Therapy: If urodynamic assessment confirms the presence of an overactive bladder and medications fail to improve symptoms, intravesical injections of botulinum toxin should be considered (requires repeat injections 6-monthly).
-Neuromodulation e.g Posterior tibial nerve stimulation or implantation of sacral neuromodulator
-Major surgery is often a last option with CLAM ileocystoplasty, detrusor myomectomy or urinary diversion
Describe intra-detrusor botulinum toxin therapy
-Cystoscopic injection of Botox therapy into bladder muscle
-For Urodynamics-proven detrusor overactivity UI, that is refractory to PFME (pelvic floor muscle exercises) and antimuscarinics
-Success rates: variable typically >70-80%
Management of stress incontinence
-PFME (Pelvic Floor Muscle Exercises)
-Lifestyle modification
=Weight loss
=Avoiding caffeine, diuretics and overfilling of the bladder
=Avoid excessive or restricted fluid intake
=Smoking cessation
-Pelvic floor exercises (takes 12-18 months for maximal effect and requires continuation long term, at least 8 contractions performed 3 times per day for a minimum of 3 months)
-Duloxetine (a serotonin and noradrenaline re-uptake inhibitor – SNRI).Improves sphincter muscle tone) but with side effects of nausea and vomiting
-Surgery: For more severe cases/intractable cases, surgery with urethral bulking agents, or sling/suspension surgeries are effective (Autologous fascia pubo-vaginal sling); or AUS (Artificial Urinary Sphincter)
Describe Autologous fascia Pubo-vaginal sling, AUS (Artificial Urinary Sphincter)
-Autologous Fascia Pubo-Vaginal Sling, AUS (Artificial Urinary Sphincter)
=For Urodynamics-proven stress UI, that is refractory to PFME(pelvic floor muscle exercises)
=Success rates: variable typically >80%
Management of overflow incontinence
-Associated with BOO and chronic urinary retention, particularly in elderly men.
-The classical presenting complaint is of new nocturnal incontinence.
-Examination may reveal a palpable bladder
-These cases require catheterisation
-U&Es
-If U&Es deranged, the catheter will have to remain, or the patient performs ISC or undergoes TURP(men)
Factors affecting temporary incontinence
-Delirium
-Infection
-Atrophic vaginitis
-Pharmaceuticals (diuretics, opiates, ca antagonists. Anticholinergics)
-Psychological issues (depression, anxiety)
-Excess fluid (CCF, polyuria)
-Reduced mobility
-Stool (constipation)
What is detrusor instability?
Detrusor instability is characterised by spontaneous and uninhibited contraction of the detrusor muscle during bladder filling. The bladder pressure exceeds the urethral pressure resulting in incontinence (the urethral opening pressure is higher in women with detrusor instability than in those with stable bladders).
It may complicate multiple sclerosis or a stroke but in most cases, the cause is unknown.
The symptoms are those of urge incontinence.
Diagnosis can be made only on cystometry, spikes of increased intravesical pressure appearing without the specific instruction to void, and which cannot be inhibited.
