Urinary Incontinence

Question 1

Urinary incontinence

Answer 1

Involuntary leakage of urine

Question 2

Types of incontinence

Answer 2

Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence

Question 3

Urge incontinence

Answer 3

Overactive bladder or infection causes involuntary contractions of bladder muscles
-> Sudden compelling desire to pass urine that is difficult to defer
- Usually idiopathic
- No warning before incontinence episodes
- A/w increased urinary frequency

Question 4

Stress incontinence

Answer 4

Involuntary loss of urine due to:
- Increase in intrabdominal pressure
- Weak pelvic floor muscles
-> urethra too weak to stay closed

Question 5

Mixed incontinence

Answer 5

Mix of urge and stress incontinence
*Determine predominant sx

Question 6

Overflow incontinence

Answer 6

Associated with incomplete emptying of bladder due to:
- Underlying systemic neurological disease
- Chronic obstruction of bladder neck

“Continuous dribbling with a full bladder that is unable to empty completely “

Question 7

What type of incontinence is more common in women?

Answer 7

Stress incontinence

Question 8

Risk factors of stress urinary incontinence

Answer 8

Think: weakened pelvic floor muscles
1. Pregnancy >20 weeks ++ (full term?)
2. Increase number of parity
3. Vaginal delivery (assisted/instrumental, weight of baby)
4. Congenital/ Genetic (FHx of prolapse)
- Ehler Danlos, Marfans
5. Aging/ Menopause
6. Chronic raised intra-abdominal pressure
- Obesity
- COPD/Asthma, chronic cough
- Smoking
- Chronic constipation
- Occupations requiring manual labour (Avoid carrying >5kg)
7. Previous pelvic surgery
++ 8. Uncontrolled DM - polyuria, polydipsia
++ 9. Hx or current POP

Question 9

How does increasing age increase risk of SUI / Why is SUI more prevalent in menopausal women?

Answer 9

As women’s age increases / In menopausal women:
- Lack of estrogen causes vaginal dryness, bladder sensitivity and pelvic muscle weakening
- Shorter urethra -> increased risk of urinary incontinence

Question 10

History taking points for urinary incontinence

Answer 10

Type of incontinence
Screen RFs
Possible POP
Excessive fluid intake > 2L
Medications eg diuretics
Caffeine (diuretic) intake
Impact on QOL: how bothered are you by symptoms?

Question 11

Physical examination for urinary incontinence

Answer 11

General:
- BMI, Obesity

Abdominal PE:
- Previous scars
- Abdominal distension/ masses
- Tenderness

Pelvic PE:
- Bedside stress urinary incontinence (Ask patient to cough)
- Pelvic floor tone via digital assessment
+/- anal tone

IF there is POP -> do Pop-Q and look for:
- Vulva: Excoriations/ previous scars
- Atrophic vaginitis (pale, loss of ruggae)
- Ulcerations/ erosions
- Bleeding/ abnormal vaginal discharge

Question 12

Investigations of urinary incontinence

Answer 12

Urine tests
- UFEME, urine culture TRO UTI
- Check post void residual urine
(normal <100ml, for older patients <150ml)
- Urodynamics
- Bladder diary

Question 13

Diagnostic test for UI

Answer 13

Urodynamic studies: measures pressure within bladder and abdomen during bladder filling and emptying to determine likely cause of LUTS

Question 14

C/I of urodynamics studies

Answer 14

UTI - Do urine dipstick to TRO

Question 15

Treatment of stress incontinence

Answer 15

• Lifestyle modifications
• Pelvic floor exercises
• Bladder training
• Pessaries (incontinence ring or dish) IF there is an existing prolapse
• SURGERY

Question 16

Treatment of urge incontinence

Answer 16

1st line
- Lifestyle modifications
- Pelvic floor exercises (refer to PT)
- Bladder training (refer to PT)
2nd line
- MEDICATIONS
- Non-invasive procedures

Question 17

Lifestyle interventions

Answer 17

• Weight loss
• Avoid smoking
• Avoid constipation
• Avoid prolonged coughing/standing
• Avoid carrying heavy things
• Control medical conditions (COPD, Asthma, DM)
  &
• Less coffee, carbonated drinks, alcohol
• Frequent small fluid intake rather than large episodic intakes ~1.5L/day
• Regular timed voiding

Question 18

Bladder training

Answer 18

REFER TO PHYSIOTHERAPIST
Patients taught to void regularly by the hour -> trains the mind to not go so often:
If have to void <1h before next void:
- Sit and contract pelvic floor muscles for 1-2mins
- Keep pelvic floor contracted and walk slowly to toilet
- Gradually increase interval by 5-15mins until satisfied with voiding frequency

Question 19

Surgical options for SUI

Answer 19

Midurethral slings
- Compresses urethra to aid in urethral closure mechanism during increase in intra-abdominal pressure
- Pros: fast, good improvement rates, minimally invasive

“Synthetic tape inserted under vaginal skin to support the urethra”

Question 20

Types of midurethal slings

Answer 20

1. Retropubic tape
   - higher risk of bladder perf
   - high risk of retained urine
2. Transobturator tape
   - higher risk of neurological sx

Question 21

Medications for urge incontinence

Answer 21

*2nd line therapy after lifestyle intervention and pelvic floor exercises

ANTICHOLINERGICS
- blocks Ach from binding to muscarinic receptors in smooth muscle of bladder
- prevents muscle fibre contraction

or BETA BLOCKERS (mirabegron)

Question 22

Side effects of anticholinergics

Answer 22

Impaired cognition
Blurred vision
Dry mouth
Palpitations
Gastric reflux
Constipation
Urinary retention
*discontinuation common due to adverse S/E

Question 23

C/I of anticholinergics

Answer 23

Narrow angle glaucoma
Cardiac arrythmias

Question 24

Examples of anticholinergics

Answer 24

Oxybutynin, tolterodine, solifenacin (Vesicare), trospium, darifenacin, fesoterodine

Question 25

Risk factors of urge incontinence

Answer 25

Smoking
Caffeine
Dementia