Urinary incontinence Flashcards
What is urinary incontinence?
Involuntary leakage of urine
What is bladder compliance?
The bladder’s ability to accommodate an increase in volume with a negligible increase in pressure.
What are some risk factors for urinary incontinence?
Female
Caucasian
Genetic predisposition
Neurological disorders
Anatomical disorders
Childbirth
Pelvic, perineal or prostate surgery
Radical pelvic radiotherapy
Diabetes
What are some anatomical disorders that can cause urinary incontinence?
vesicovaginal fistula, ectopic ureter in girls, urethral diverticulum, urethral fistula, bladder extrophy, epispadias
What are some factors that promote urinary incontinence?
- Smoking - causing cough
- Obesity
- Infection - UTI
- Increased fluid intake
- Poor nutrition
- Ageing
- Congnitive deficit
- Poor mobility
- Oestrogen deficiency
What are some types of urinary incontinence?
- Stress urinary incontinence (SUI)
- Urge urinary incontinence (UUI)
- Mixed urinary incontinence (MUI)
- Overflow incontinence
- Others
What are some other types of urinary incontinence?
Enuresis (Bedwetting)
Post-micturition dribble
Fistula
What is meant by stress urinary inconinence?
Leakage on effort or exertion, sneezing or coughing
-Urine leaks whenever urethral resistance is exceeded by increased abdominal pressure
What causes stress urinary incontinence?
- Occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
What is urge urinary incontinence?
Leakage accompanied or immediately preceded by urgency
What causes urge urinary incontinence?
May be due to bladder overactivity (detrusor instability) or less commonly due to pathology that irritates the bladder (infection, tumour, stone)
What is mixed urinary incontinence?
Combination of SUI and urge urinary incontinence
What is overflow incontinence?
- This occurs when the bladder becomes over-full due to bladder outflow obstruction
- This will cause a huge palpable bladder and a large pressure on the bladder
- This causes insensible incontinence, often at night
What is indicated by enuresis in elderly men?
high-pressure chronic retention
What causes post-micturition dribble?
happens in men immediately after leaving the toilet and is due to urine pooling in bulbar urethra
What are some possible causes of bladder-vaginal fistula formation?
surgical injury at the time of hysterectomy or Caesarian section
Describe the pathway of micturition
Stretch receptors in the bladder wall send signals up the spinal cord, entering at the sacral micturition centre (S2-S4)
It passes up the spinal cord to the pontine micturition centre, then to the thalamus and then to the micturition centre in the frontal lobe
This can either allow urination, or override the reflex and stop it
When allowing micturition, efferent neurones carry the signal down the spinal cord to the detrusor muscle and to the internal and external urethral sphincter
What are some pathologies affecting the micturition centre and thalamus?
- Stroke
- MS
- Acquired brain injury
- Parkinson’s disease
- Cerebral palsy
What are some spinal cord pathologies which can affect micturition
- Trauma
- Spina bifida
- MS
What is a condition that can affect the peripheral nerves of micturition
Diabetes
What are some red flags of urinary incontinence?
- Pain
- Haematuria
- Recurrent UTI
- Significant voiding/obstructive symptoms
- History of pelvic surgery/radiotherapy
What are some signs of urinary incontinence specific to women?
- Ask patient to cough or strain and look for:
- Vaginal wall prolapse
- Uterine or vaginal vault descent
- Urinary leakage
What examinations are required in women in urinary incontinence
- Ask to cough and inspect for leakage or prolapse
- Internal pelvic exam to asses pelvic floor strength
- Inspect vulva for oestrogen deficiency causing vaginal atrophy
What examinations are required in both sexes for urinary incontinence?
Examine palpable bladder
Neurological examination
Rectal exam for anal tone, constipation and masses
What are some investigations required in urinary incontinence?
Bladder diary
Urinalysis ± Culture
Flow rate and post-void residue testing
Pad testing
Cystometry
Cystoscopy
What is involved in cystometry
What are some conservative management options in urinary incontinence?
Pelvic floor exercises
Lifestyle modification
Biofeedback
Medication
How are pelvic floor exercises performed?
At leats 8 contractions, 3x per day for a minimum of 8 months
What are some lifestyle modifications required in urinary incontinence?
weight loss, stop smoking, avoid constipation, modify fluid intake
What is biofeedback in urinary incontinence management?
a technique where ability and strength of pelvic floor contraction is fed back to patient as a visual and auditory signal
What are some medications used in urinary incontinence?
- Anticholinergic medication e.g. tolterodine (inhibit contraction)
- β-adrenoceptor agonists (induce detrusor relaxation)
What are some surgical management options in urinary incontinence?
Injection therapy
Retropubic suspension
Artificial urinary sphincter
What is involved in injection therapy?
Injection of bulking materials into the bladder neck and periurethral muscles to increase outlet resistance; main indication is for female stress incontinence secondary to intrinsic sphincter deficiency with normal bladder function
Usually microplastique (Silicone) or Teflon
Contraindications for injection therapy
UTI, untreated bladder overactivity, bladder neck stenosis
Complications of injection therapy
Temporary urinary retention, de novo urge incontinence, UTI, haematuria
What is involved in retropubic suspension?
- Used to treat female stress incontinence predominantly caused by urethral hyper-mobility
- Aims to elevate and fix the bladder neck and proximal urethra in a retropubic position to support the bladder neck and regain continence
When is artificial urinary sphincter used?
Used for moderate to severe SUI secondary to urethral sphincter deficiency in patients with normal bladder capacity and complicance, more common in men
What is involved in artificial urinary sphincter?
- An inflatable cuff is placed around the bulbar urethra or bladder neck
- A pressure-regulating balloon is placed extraperitoneally in the abdomen
- An activating pump is then placed in the scrotum or labia majora
What are some possible complications of artificial urinary sphincter?
Urethral atrophy, mechanical failure, urethral erosion, bladder overactivity or reduced compliance, infection
