Urinary Incontinence Flashcards
Define urinary incontinence?
Complaint of any involuntary leakage of urine
It is common and socially stigmatising
Types of urinary incontinence?
Urethal:
• Urge incontinence - involuntary leakage accompanied, or immediately preceded, by urgency
• Stress incontinence - involuntary leakage on effort/exertion, sneezing or coughing
• Mixed incontinence - involuntary leakage assoc. with urgency and also with exertion (effort, sneezing, coughing)
• Overflow incontinence
Urine leaking via an extra-urethral route:
• Ectopic ureter
• Fistula
Phases of micturition cycle?
Filling (storage) phase
Voiding phase
Describe how the filling phase proceeds
Increased intravesical pressure (due to increased volume of urine)
Abdominal pressure remains the same
Urethral pressure increases as the urethral sphincter must remain closed; in order to hold the urine, the detrusor muscle expands (compliant)
Define compliance?
Ability of the bladder to keep its pressure unchanged irrespective of bladder volume and afferent stimulation
Describe how the voiding phase proceeds
Detrusor muscle contract to void and the urethral sphincter relaxes; as voiding occurs, the intravesical pressure decreases
Abdominal pressure should remain the same (straining or pressing on the abdomen is not normal)
Ix for urinary incontinence?
Cystomethogram - urodynamics
Can be used to determine the type of incontinence and, if mixed, which type is most predominant
What will the urodynamics Ix show if there is obstruction?
The detrusor pressure will be very high as there is an attempt to compensate
Components of micturition reflex (filling phase)?
Filling (storage) phase - sympathetic nervous system is engaged
Allows bladder relaxation and external sphincter to contract (prevents incontinence)
Occurs via the hypogastric nerve (T10-L2)
Components of the micturition reflex (voiding phase)?
Voiding phase - parasympathetic nervous system is engaged
Allows bladder contraction and relaxation of the external sphincter (allows micturition)
Occurs via the pudendal nerve (S2, 3, 4)
Causes of overflow incontinence?
Usually bladder outflow obstruction, e.g: enlarged prostate
With chronic retention, the bladder fills with more urine and the detrusor stretches so much that it does not work; this increases the intravesiclar pressure as the detrusor has lost its compliance pressure increases at the renal pelvis and this leads to renal dysfunction
Symptoms and signs of overflow incontinence?
Huge palpable bladder
Chronic retention
Insensible incontinence
Often they are wet at night (nocturia and enuresis)
Renal impairment
Describe urge incontinence
Is part of the urge syndrome, i.e:
Daytime frequency with only small voided volumes
Urgency:
• Provocation - key in the door, sound of running water, standing up, coughing/laughing
Enuresis
Urge urinary incontinence
Potential cause of urge incontinence?
May be due to detrusor overactivity incontinence
Bladder dysfunction characterised by involuntary contractions occurring during inhibition of voiding
Ix of detrusor overactivity?
Urodynamics - the detrusor contracts when it should not; the rise in detrusor P causing an increase in intravesical P but abdominal pressure remains the same
How does afferent over-stimulation occur?
Source of irritation in the bladder, e.g: bladder stone
Paraplegia (loss of central inhibition)
Destruction of S2-3 centre - bladder becomes an inert bag
Pelvic surgery or fracture - parasympathetic nerves damaged
Idiopathic detrusor overactivity
Describe (urodynamic) stress incontinence
Urine leaks during increased intra-abdominal pressure, without a detrusor contraction
Due to damage to the pelvic floor or urethral function, e.g: childbirth
They require catheterisation
Ix for stress incontinence?
Urodynamics - detrusor pressure is normal;
Describe spectrum of overactive bladder
Mixed, OAB wet, OAB dry
Symptoms and signs of urinary incontinence?
Painless, palpable mass arising from the pelvis
Cannot “get below it”
Dull to percussion
This is the “full” bladder
Treatment of overflow urinary incontinence?
Assess renal function
Catheterise
Treat the obstruction and rehabilitate the bladder
If necessary, teach intermittent self-catheterisation OR insert long-term catheter
Treatment of urge urinary incontinence?
Dietary discretion (avoid caffeine)
Biofeedback
Bladder retraining, time bladder emptying
Pharmacotherapy:
• Anti-muscarinics, e.g: oxybutynin, tolterodine
• β3-adrenergics (mirabegron)
Botulinum toxin injection (botox for the bladder)
Neuromodulation (pacemaker for the bladder)
Enterocystoplasty surgery - increases the volume of the bladder
Treatment of stress incontinence?
Weight loss and smoking cessation
Pelvic floor exercises (physiotherapy)
Pharmacotherapy (role is not big):
• Duloxetine (serotonin 5-HT) and norepinephrine (NE) reuptake inhibitor
Surgical correction:
• Open procedures - colposuspension
• Tape procedures (minimally invasive)
Treatment of mixed incontinence?
Must confirm which type of incontinence is the most dominant
Combination of urge and stress incontinence therapies are used
Causes of urinary incontinence in the elderly?
Multifactorial: • Immobility • Dementia • Drugs, e.g: diuretics and sedatives • Obstruction and overflow • Neuropathy • Pelvic flood weakness
Describe ectopic ureter
Rare congenital cause of urinary incontinence
Describe vesico-vaginal fistula
Can be caused by prolonged obstructed labour, which is common in developing countries
Define urgency?
Complaint of a sudden compelling desire to pass urine, which is difficult to defer
Urgency, with/without urge incontinence and usually with frequency and nocturia, can be described as overactive bladder syndrome (AKA urge syndrome, urgency-frequency syndrome)
What are voiding symptoms?
Experienced during the voiding phase and inc: • Slow stream • Splitting • Spraying of the urinary stream • Hesitancy • Straining
What is a frequency volume chart (FVC)?
Records the volumes voided as well as the time of each micturition, day and night, for at least 24 hours, e.g: a bladder diary for 3 days
