Urinary Incontinence Flashcards
what is stress urinary incontinence?
leakage on effort or exertion, sneezing or coughing
occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
urine leaks whenever urethral resistance is exceeded by increased abdominal pressure
what is urge incontinence?
incontinence accompanied by or immediately preceded by urgency
may be due to bladder over activity (detrusor instability)
other types of urinary incontinence?
bedwetting in elderly men (high pressure chronic retention)
post micturition dribble (poor urine pooling in bulbar urethra)
constant leak of urine (fistulous communication between the bladder and vagina
can be due to surgical injury at time of hysterectomy or caesarean section
can be due to presence of an ectopic ureter draining into the vagina instead of the bladder (common in young girls)
risk factors for urinary incontinence?
female Caucasian genetic neurological disorders anatomical (vesicovaginal fistula, ectopic ureter, urethral diverticulum, urethral fistula, bladder extrophy, epispadias) childbirth pelvic, perineal and prostate surgery (hysterectomy, prostectomy, TURP biopsy) radical pelvic radiotherapy diabetes
promoting factors in urinary incontinence?
smoking (causes cough) obesity infection increased fluid intake poor nutrition ageing cognitive problems poor mobility oestrogen deficiency
red flags?
pain haematuria recurrent UTI significant voiding/obstructive symptoms history of pelvic surgery/radiotherapy
female examination?
ask patient to cough or strain and look for prolapse and urinary leakage
internal pelvic examination can be performed to assess voluntary pelvic floor muscle strength and bladder neck mobility
inspect vulva for oestrogen deficiency
both sexes examination?
examine abdomen for palpable bladder
basic investigation?
bladder diary (frequency/volume) urinalysis +/- culture flow rate and post void residue pas testing can do bloods, imaging, cystoscopy for complex cases
when and how is cystometry used?
overactive bladder
thinking about treatment
thin catheter with 2 lumina (one fills bladder, one goes in rectum?)
measures abdominal pressure and bladder pressure and compares the two
how is a true detrusor muscle reading found?
measure abdominal pressure (via rectum) and bladder pressure
subtract abdominal from bladder to give detrusor muscle reading
conservative treatment for urinary incontinence?
pelvic floor exercises (8 contractions, 3 times per day for 3 months)
lifestyle
biofeedback (technique where ability and strength of pelvic floor contraction is fed back to patient as visual/auditory signal)
medication - duloxetine which inhibits reuptake of both serotonin and noradrenaline which acts to increase sphincteric tone
surgical treatment?
injection therapy (bulks up urethra which increases outlet resistance, used for stress incontinence) injected submucosally into urethral mucosa
contraindications for injection therapy?
UTI
untreated overactive bladder
bladder neck stenosis
what is used if conservative and injection therapy fails?
retropubic suspension
treats female stress incontinence mainly causes by urethral hypermobility
elevates and fixes bladder neck and proximal urethra in retropubic position in order to support bladder neck and regain continence
how are suburethral tapes and slings used?
The tape is inserted under the waterpipe /urethra and brought out through two small incisions above the pubic bone or the groin
complications of tapes and slings?
voiding dysfunction
perforation/erosion
pain
damage to bowel or blood vessels
pubovaginal slings?
uses segment of rectal fascia 10-20cm long which is placed under the neck of the bladder or under medial urethra and acts as a support to prevent downward slippage of the bladder neck and urethra during physical activity
when are artificial urinary sphincters used?
males with incontinence after radical prostatectomy
moderate to severe stress incontinence
how does AUS work?
inflateable cuff placed around bulbar urethra or bladder neck
pressure regulating balloon placed extraperitoneally ……….
what is overactive bladder?
causes urge incontinence
urgency with/without urge incontinence, usually with frequency and nocturia
usually causes by bladder (detrusor overactivity)
conservative management fo overactive bladder?
pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy may provide some benefit
behavioural modification - modify fluid intake, bladder retraining
medcation?
anticholinergic (antimuscarinincs) drugs which inhibit contractions and increase bladder capacity
- oxybutynin
- solifenacin
beta-adrenoreceptor agonists (relax detrusor and increase bladder capacity)
side effects and contraindications of antimuscarinics?
dry mouth, constipation, blurred vision, photophobia, glaucoma, difficulty urinating contraindications - glaucoma - obstruction - peptic ulcer
whenis intravesical botox used?
injected at multiple (20) sites under the bladder mucosa or into detrusor sparing the trigone
flooding incontinence, resistant to other treatments
if intravesical botox doesn’t work?
artificial electrical stimulator
sacral nerve stimulation of bladder’s nerve to supply (suppresses reflexes responsible for involuntary detrusor contraction
stimulates S3 afferent nerve
what is clam ileocystoplasty?
if botox doesn’t work
operation to bi-valve the bladder into 2 flaps which destroys ability to contract in a normal way
then take a length of small bowel which has be de-tubularised and anastamosed with bladder dome creating a larger bladder volume
ileal conduit urinary diversion?
last resort treatment, only for intractable cases
both ureters are anastamosed and connected to a short length of ileum which is brought out cutaneously as a stoma
urine collects in a bag
