Urinary incontinence Flashcards by Nayla Mansoor

What is urinary incontinence

Involuntary loss of urine

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What are the types of urinary incontinence

MC: Stress, Urge, Mixed
Unaware
Nocturnal enuresis
Continuous

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How can urinary incontinence be classified based on pathophys

intrinsic sphincter deficiency 
urethral hypermobility 
detrusor overactivity 
low bladder compliance 
urinary retention

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Transient causes of urinary incontinence include

Delirium 
Infection 
Atrophic vaginitis 
Pharmaceuticals 
Psych 
Excess urine production 
Restricted mobility 
Stool impaction

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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?)

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What should you do on PE for urinary incontinence complaint

Pelvic/Prostate exam
Perineal sensation
DRE (impaction. bulbocavernosal reflex)
Check for LE edema

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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

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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

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What imaging can you get for urinary incontinence

Voiding cystourethrogram
Pelvic MRI
Neuro imaging

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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

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Treatment to empty bladder includes

Avoid meds that cause retention
Catheterization
BPH meds, surgery

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What do you do if you suspect continuous incontinence (or vesicovaginal fistula)

Pyridium test (drink pyridine, insert tampon, see if it fills orange) 
Surgery

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Tx for female stress incontinence includes (general)

NON-invasive: Behavioral therapy, Meds, Continence devices
Min. invasive: Bulking agents
Surgical: anterior repairs, suspensions, AUS, sling

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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)

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What is pelvic floor muscle training

Good for SUI, UUI, and mixed UI

Contract muscles for 6-8 seconds 10 times, TID

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What meds aid in treating SUI

Alpha Agonists (Pseudoephedrine, ephedrine, imipramine)
Duloxetine (SNRI)

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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

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What are ADE of Duloxetine (SNRI)

Nausea

Suicide

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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