Urinary incontinence Flashcards
Epidemiology of urinary incontinence (4)
+with age
+in women
+aged care facilities
+dementia/cognitive impairment
Impact on health (4)
Morbidity->perineal infections, falls
Sexual dysfunction
QOL->anxiety, embarrassment, depression, social, work
Increased caregiver burden
Risk factors
Strong: \+Age \+Parity, vaginal delivery, episiotomy Obesity LUTS Care facility Dementia Constipation Fecal incontinence High impact physical activity Pelvic organ prolapse Stroke, parkinson's, MS Diuretic use Caffeine
Types (3)
Stress
Urge
Overflow
Fistula
Definition and mechanism of stress incontinence
Def: involuntary leakage of urine on effort/exertion
M: Urethral hypermobility + intrinsic sphincteric deficiency
Definition of urge incontinence
Involuntary leakage of urine w/ immediate/preceeding urgency
What are potential precursors to urinary incontinence
Burning with urination
Trouble starting urinary flow
Inability to stop urine flow
Needing to push and strain while urinating
Needing to urinate more than once to empty bladder
Nocturia are potential precursors of urinary incontinence
How does prolonged defecatory effort predispose
Progressive neuropathy
How does stroke predispose
Interruption of CNS inhibitory pathways->associated with stress, urge and overflow incontinence
Impact of forceps delivery on continence
+bladder neck descent
Explain the Delancey classification
Level 1: Upper Vertical, transverse cardinal, uterosacral supports->support of upper vagina, cervix, lower uterine segment posteriorly to sacrum
Level 2: Horizontal->ischial spine to post aspect of pubic bone. Lateral-> paravaginal fascia, The arcus tendineous fascia
pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina.
Level 3: Lower vertical support. The urogenital diaphragm and the perineal body provide support to the lower part of the vagina
Maintenance of continence (3)
Bladder factors:
Elastatic and inhibition of sacral plexus allows +bladder filling w/o +++pressure
Urethral factors:
Smooth/striated/elastic, blood vessel turgus (submucosal vascular plexus), mucosal folds, +resting tone of the urethra
Pressure transmission factors:
+intra-abdominal pressure= +pressure to bladder neck and proximal urethral->active contraction of urethral striated muscle and levator complex maintains continence
Micturition physiology of storage
Pontine micturition centre
Storage->contraction of sphincters, relaxation of bladder. Somatic to external, sympathetic to internal. Pudendal +external (supported by lateral vaginal wall by levator ani/fascia and ligaments). Involuntary/voluntary input +outflow resistance maintaining continence. SM vascular plexus +urethral turgor->sustaining closure of urethral sphincter.
Micturition physiology of voiding
Urethral sphincter relaxation and bladder contraction. PNS->S2-4 traveling through hypogastric nerves. ACh->Muscarinic receptors 2 and 3->detrusor muscle contraction= urinary flow through relaxed urethra.
Inhibition of voiding
Pontine storage centre. Afferents from distended bladder->T11 - L2 sympathetic->NE B receptor on bladder wall, alpha at bladder neck and urethra. Inhibits detrusor, and +sphincter. Inhibits.
Brief difference in pathophysiology of urge incontinence and stress incontinence
Urge->defect on coordination of micturition->neurogenic, myogenic
Stress->anatomical defect
Definition of over-active bladder
Urgency w/ or w/o urge incontinence, usually w/ frequency and nocturia in absence of underlying metabolic/pathalogic condition
Reversible causes of urinary incontinence
DIAPPERS Delirium Infection Atrophic vaginitis Pharmacologic causes Psychiatric causes Excessive urine production Restricted mobility Stool impaction
History
Obstetric and gynaecological history Involuntary leakage on effort, exertion, sneezing etc Incontinence accompanied by/immediately preceeded by urgency Fluid/caffeine intake Alcohol Hx chronic constipation Nocturia Dysuria, hematuria, recurrent UTIs Post void dribbling Frequency Fecal incontinece FHx of incontinence MSE History of back injury/falls Hormonal status Age, weight Long term residence in care Lifestyle->high impact activity
Medical history- complete
Complete medication review
Evaluation of bladder diary
Important medications to consider in incontinence
Benzos, diuretics, lithium, caffeine Alpha blockers, Anti-D, HRT Smoking
Clinical examination
General->mobility, overall health
Abdomen and back->masses and tenderness.
Neurology S2-4
Rectal examination->perineal sensation, sphincter tone, fecal impaction, mass
Speculum->anterior wall/urethra->discharge, tender. Pooling of urine in vagina ?fistula
Signs of urogenital atrophy->mucosal pallor, erythema. Estrogen deficiency can cause urgency, frequency, incontinence
Look for vaginal bulge, prolapse
Bimanual->uterine size if ++may compress on bladder
Investigations
Empty supine stress test (leakage with cough/valsalva)
Post void residual
Urinalysis-> UTI, glycosuria
If conservative doesn’t work->refer
Urodynamics
Q-tip test, pad test
Cystourethroscope
Management of stress incontinence
Lifestyle: Adjust medications if needed Weight loss Caffeine reduction Fluid managament Reduction of physical exertion which strains pelvic floor Smoking cessation Resolution of chronic constipation Pelvic floor exercises Biofeedback->bladder retraining Referral to continence advisor/specialist physio for 3 month
W/ Urethral sphincter insufficiency, consider adding–>
Pseudoephedrine, tds
Estrogen for post menopausal
SLing procedure or peri-urethral bulking injection
W/urethral hypermotility or displacement-->Surgery Retropubic suspension Bladder neck suspension Anterior vaginal repair Consider sling procedure Tranurethral radiofrequency
Management of urge incontinence
Behavioural:
Bladder retraining
Prompted voiding
Pelvic floor
Lifestyle: Adjust medications if needed Weight loss Caffeine reduction Fluid managament Reduction of physical exertion which strains pelvic floor Smoking cessation Resolution of chronic constipation
Second line->anticholinergic
Oxybutynin, tolterodine
Third-> neuromodulation, botulinum A toxin
What does bladder retraining involve
Techniques to distend the bladder or delay voiding
Bladder retraining–>use diary to modify
voiding habits
Times between voids increased, intake monitored and
“just in case voiding” avoided
Mental distraction/attempts to suppress urgency
What is prompted voiding
Teaches patients to initiate micturition themselves
+use in dementia/those in a nursing home
Pathogenesis of retention with overflow incontinence
Over-distended bladder followng surgery Osbstruction from pass, fecal impaction etc Drugs/neurogenic
Symptoms of overflow incontinence
Dribbling incontinence
Symptoms of overactive bladder
Voiding difficulty
Pathogenesis of detrusor overactivity
Xcortical inhibition of sacral reflex Idiopathy--> anxiety, caffein, cold weather Neurogenic-->UMN (MS, spinal trauma, CVA) Urethral obstruction?
Symptoms of detrusor overactivity
Urgency Frequency >7 voids in a day Urge incontinence Nocturia Nocturnal enuresis (ask about bed wetting in childhood)
Why is a history of bedwetting in childhood important
May indicate detrusor overactivity
Role of anticholinergics
To reduce the likelihood of unstable contraction and +bladder volume
Pathogenesis of fistulas in developed country vs non developed
Undeveloped->prolonged obstructive labour, pressure necrosis of bladder base and vagina
More developed countries->pelvic surgery complication, radiation, surgery
What is the arcus tendineus fascia pelvis
Second third of vagina attached to pelvic sidewall condensation of CT ->from inner surface of pelvic rami to ischial spine where fuses with arcus tendineus levator ani
What is the arcus tendineus levator ani
Attachment stretches vagina laterally, preventing bladder anterior and rectum posterior to protrude
Attachments of vagina
Anteriorly, the vagina fuses with the urethra, posteriorly with the perineal body, and laterally with the levator ani muscles
Relationship between bladderneck prolapse, intra-abdominal pressure and proximal urethra
Bladder neck open, not supported
Transmitted intra-abdominal pressure cannot close off proximal urethra
What is the typical form of levator trauma related to childbirth
Unilateral avulsion of pubococcygeus muscle off pelvic sidewall
Palpable as asymmetrical loss of substance in inferomedial portion of muscle
Important risk for levator avulsion
Age
What does levator avulsion +risk of
Significant cystocele and uterine prolapse
Numbers needed to harm for C-section and SVB/OVB and prolapse
Relative to cesarean deliveries, 8.9 spontaneous vaginal births would lead to one additional case of prolapse
Relative to cesarean deliveries, 6.8 operative births would lead to one additional case of prolapse
Urgent referral
Microscopic hematuria >50 yo
Visible hematuria
Recurrent/persisting UTI w/ hematuria >40yo
Suspected malignant mass
Indications for referral
Symptomatic prolapse visible at or below the vaginal introitus
Palpable bladder on bimanual/abdominal examination after voiding
Consideration for referral
Persisting bladder or urethral pain Clinically benign pelvic mass Associated fecal incontinence Suspected neurological disease Symptoms of voiding difficulty Suspected urogenital fistula Previous continence surgery Previous pelvic cancer surgery Previous pelvic radiation
Surgical options for stress incontinence
Tension free vaginal tape
Burch colposuspension
Anterior colporrhaphy, anterior repair
Bladder neck injections
Surgical options for overactive bladder
Bladder distension, urethral dilitation
Botox injections to bladder wall
Detrusor myomectomy, clam enterocystoplasty
Explanation for tension free vaginal tape
Relatively simple
Insertion under local anaesthetic
Day case
Quick return to work in 2 weeks
Good initial success
Long term success->up to 11 years
