Urinary incontinence Flashcards
What is urinary incontinence
Involuntary loss of urine
What are the types of urinary incontinence
MC: Stress, Urge, Mixed
Unaware
Nocturnal enuresis
Continuous
How can urinary incontinence be classified based on pathophys
intrinsic sphincter deficiency urethral hypermobility detrusor overactivity low bladder compliance urinary retention
Transient causes of urinary incontinence include
Delirium Infection Atrophic vaginitis Pharmaceuticals Psych Excess urine production Restricted mobility Stool impaction
When taking a urinary incontinence H&P, it is important to ask
Precipitating factors (cough, laugh, movement, caffeine, EtOH, constipation, immobility)
Amount in pads x day
Urinary Sx
GPA
Uro Hx (STI, UTI, strictures, surgeries)
Neuro conditions (CVA, parkinson/s, MS, spinal disc dz)
Fluid consumption (amt, type, time)
Meds (Furosemide?)
What should you do on PE for urinary incontinence complaint
Pelvic/Prostate exam
Perineal sensation
DRE (impaction. bulbocavernosal reflex)
Check for LE edema
What are the 3 components of a female pelvic exam
- Vaginal epithelium for atrophic vaginitis
- Cotton swab text for hypermobility (cotton swab in urethra; change 30+ degrees is abn)
- Cough test
What studies can you do when assessing urinary incontinence
UA, culture Voiding diary (for voids, consumption, bowel movements) Post void residual (for retention) Cytoscopy (for strictures or tumor) Urodynamic study
What imaging can you get for urinary incontinence
Voiding cystourethrogram
Pelvic MRI
Neuro imaging
How do you treat urinary incontinence based on cause
Delirium: underlying cause Infx: abx Atrophic vaginitis: topical estrogen periurethrally Pharm: eliminate or adjust Psych: refer to psych Excess UO: manage DM, CHF, etc. alter time of fluid intake Reduced mobility: bedpan, urinal Stool impaction: bowel management
Treatment to empty bladder includes
Avoid meds that cause retention
Catheterization
BPH meds, surgery
What do you do if you suspect continuous incontinence (or vesicovaginal fistula)
Pyridium test (drink pyridine, insert tampon, see if it fills orange) Surgery
Tx for female stress incontinence includes (general)
NON-invasive: Behavioral therapy, Meds, Continence devices
Min. invasive: Bulking agents
Surgical: anterior repairs, suspensions, AUS, sling
What is included in behavioral therapy
activity modification voiding diary timed voiding (empty bladder before leakage) pelvic floor muscle training fluid intake modification (not at night) diet modification (no caffeine, EtOH, spicy, acidic) weight loss (decrease intra-abd pressure) avoid constipation elevate edematous LE (mobilize fluid, void before sleeping- compression stockings)
What is pelvic floor muscle training
Good for SUI, UUI, and mixed UI
Contract muscles for 6-8 seconds 10 times, TID
What meds aid in treating SUI
Alpha Agonists (Pseudoephedrine, ephedrine, imipramine) Duloxetine (SNRI)
How do alpha agonists Tx SUI
Increase muscle tone of urinary sphincter (not FDA approved)
CI in cardiac dz, uncontrolled HTN, DM, MAOI, Sz risk, glaucoma (narrow angle), amd hyperthyroid
What are ADE of Duloxetine (SNRI)
Nausea
Suicide
What continence devices can be used to Tx SUI
Pessary Indwelling catheter (urethral or suprapubic)
What are bulking agents
Collagen, silicone, graphite, and calcium hydroxyapatite
Injected adjacent to proximal urethra (bladder nec)
Coapts urethral mucosa and increases bladder outlet resistance
Can be done transurethrally, but ned a few Tx
What should you be cautious with when giving bulking agents
Do skin test to check for allergic Rxn
Can migrate to into lymphatics- calcium visible on XRays
What is an anterior repair (Tx for SUI)
Pubocervical fascia is overlapped posteriorly to support bladder
What are the types of suspension surgery to Tx SUI
Marshall-Marchetti-Krantz (MMK)- periurethral
Burch- peruvesical
What is a sling (Tx for SUI)
a “hammock” under the urethra, autologous fascia sling
Can be allograft, Xenograft (bovine, porcine), or synthetic
What can happen if a sling is over corrected
Urinary retention! may need intermittent catheterization
Dangerous things to watch out for is patient has a bladder sling
Erosion into vagina;
Dyspareunia, vaginal pain/discharge/bleeding
Dysuria, hematuria, urgency, frequency, recurrent UTI
What are the 3 parts of an AUS
Cuff
Reservoir (posterior to abdominal wall)
Pump (in labia majora or scrotum)
Where is the cuff placed in men and women
M: perineal approach- encircles urethra
W: Transvaginal/abdominal approach- encircles bladder neck
What is important to remember about the pump of an AUS in men
it tends to move up, so they should pull it down once per day to prevent encapsulation
How do you place the cuff immediately after surgery
Leave it open (deflated, deactivated) for the first 6 weeks so it can heal w/o urethral pressure
After 6 weeks comeback and have it activated (inflated)
What MUST you remember about all AUS
DEACTIVATE and LOCK prior to CATHETERIZATION!
What are S/Sx of infection of AUS
MC in first 2 months- E. coli or Staph
pain, edema, erythema near pump or cuff
Leukocytosis, fever
Give abx!
What are S/Sx of erosion of AUS
2/2 harsh perineal pressure
Dysuria, hematuria, recurrent infections
Remove, re-implant >3 mo later
What is urge incontinence
Episodic involuntary loss of urine immediately preceded by urgency
Overactive bladder is urgency+frequency
What is Tx for UUI (general)
NON-invasive: behavioral therapy, estrogen, anticholinergic, B-adrenergic
Min. invasive: neuromodulatora, botox
Surgical: augmentation, auto augment, urinary diversion
Who can use estrogen as a UUI Tx, and how
Post-menopausal females
place peri-urethrally
CI if: PE, CVA, MI, cancer, DVT
How do anticholinergics work
Inhibit muscarinic 3 receptors= decreased detrusor muscle contractions
ADE of anticholinergics are
xerostomia, constipation, dizziness, drowsy, blurry vision, HA
CI: MG, intestinal obstruction, gastric or urinary retention, narrow angle glaucoma
What are the anticholinergics
Oxybutynin (IR, ER, patch, or gel)
Tolterodine (IR, ER)
Also Fesoterodine, Darifenazin, Solifenacin, Trospium
What is Mirabegron
Beta 3 agonist
Stimulates B3 in bladder= increased cAMP= decreased intracellular calcium= relax bladder and allow more filling
What must you monitor if taking Mirabegron
BP!
1x week for the first 4 weeks
How do you use botox as an UUI Tx
Inject cytoscopically into detrusoe
effects last 3-12 months
What is Interstim
Sacral neuromodulator
Electrically stim. S3 afferent nerve to modivy voiding reflex
2 week trial: Place electrode near S3 curve, connect to generator belt, activate
If that trial goes well, have an internal generator placed
What is Posterior tibialis nerve stimulation
In office procedure!
Electrode placed superior and posterior to medial malleolus of leg
Electrical stimulation x 30 min for 12 weeks
What is Augmentation enterocystoplasty
Bladder dome is opened and detubularized intestine is added to increase size of bladder
Decreased intravesical voiding pressure and incontinence
What is autoaugmentation
Detrusor of dome is incised, but urothelium kept intact (inner lining)
Bladder capacity expands and intravesical pressure lowers
Decreased incontinence
What is urinary diversion
Ileal conduit- urine bypasses bladder
