Urinary incontinence Flashcards
Types of unrinary incontincence
Stress urinary incontinence
Urge incontinence
others : high pressure chornic retention, post-micturition dribble, contant leaking
Stress urinary incontinence
- as a result of hypermobility, and neuromuscular problems that causes weak internal sphincter, wehn abdominal pressure increases anf the stability of the urethra decreased
Urge incontinence
leakade accompanied or immediately preceded by urgency
overactive bladder /detrussre instability or due to a pathology
High pressure chronic retention
on sleeping the pressure in the baldder overtakes the sphincter continence and bed wetting
Post-micturition dribble
prostate enlarges, sits in the bulbar urethra and comes out
Constant leak of urine
Fistula - in women with pelvic surgery/ bladder damage during hysterectomy
Little girl always dribbling the whole time
ectopic ureter –> opens into the proximal urethra or vagina –> needs surgery to re-implant it
Micturition cycle problems from the brain
Thalamus, scaral micturition centre, diabetic damage to periphersl nerves, cerebral lesions, micturition centre in the forntal lobe,
bladder - hypotonic (high pressure bladder developed and the bladder contracts repeatedly and empties constantly)
Who is it more common in?
Women –> Causcasian > Afro-carribeans
Bladder extrophy
front of the pelvis doesnt close properly and the bladder is open on the surface
Risk factors
fistula, ectopic ureter in girls, urehtral diverticulum, urethral fistula, surgeries, child birth
Risk factors
smokin - causing cough obesity infection - UTO poor nutrition ageing cognitive defect poor mobility oestrogen deficiency
History in urinary incontincence
Type Triggering factors frequency defree of bother risk factors sense of something coming down (prolapse) Red flags: painful micturition, haematuria, recurrent UTI, significant vioding
Physical exam women
Chaperone
lie down
as them to cough, look for bladder dripping, examine abdomen for palpable bladder, pelvic exam to asses floor muscle strength, bladder neck mobility, vulva for oestrogen deficiency in older women
Physical exam both sexes
abdomen fro palpable bladder
Basic investigation
Bladder diary - frequency, timing and how much they drink
urinalysis - +/_ culture
flow rate and post-void residue
pad testing
normal void - men 25/30 mls per sec
(bell shaped curved)
women - faster as the urethra is shorter
Renal function
Blood tests
imaging
cystoscopy
Cystometry
overactive bladder or for surgeries
2-way catheter - one for water and the other for pressure (detrssur pressure)
rectum - to remove the artefact (subtracts abdominal pressure)
ask them when they feel the urge to void and stuff
Cystometry actiity
no detrusser activity on filling
overactive bladder- reaches 200 mls and they can’t hold on and have to pee
What is the conservative treatment?
pelvic floor exercises - pelvic floor exercises, needs to be practiced all the time to maintain the benefit
lifestyle modification- weight loss, stop smoking, modify fluid intake
biofeedback - instrument that gives you a visual/ auditory feedback as to which mucle you should strengthen and train
muscle - duloxetine - increase sphincter activiyt, but doesnt work that much
Electrical stimulation of the pelvic flood - not that helpful
Surgical treatment
inject bulking materials submucosally - > to increase resistnace, in women esp in stress incontinence, silicon or teflon pastes
contraindications for surgery
UTI, untreater bladder overactivitiy (dont want to increase their outflow resistance), bladder neck stenosis
What is retropubic suspension?
to treat -female stress oncontinence, hypermobile urethra
lift and fix to-a retro0urethral position
Bursch col- suture vagina on either side of the urethra and attach it to the lateral pelvic wall - suspend the bladder neck and urethra
succes rate - 70%
Suburethral tapes and slings
recent
pelvic pain associated
complications
insicionin the vagine, anterior under the urethra to push up either end of the bladder and attach it to the lower end of the abdominal wall and tight it
support the urethra for those with intrisic sphincter deficiency
pubovaginal sling
wih rectal fascia
Artificial urinary sphincter
implant
more in men
balloon, pump and cuff
ballon in the iliac fossa, cuff around urethra, pump in scrotum, when full man pumps, moves the the fluid to balloon and deflateds the cuff. the cuff automatically refills in 3min
can get urethral atrophy and stuff
Overactive ballder
urgency and mostly with urge incontinence usually with frequency and nocturia
management for overactive bladder
Pelvic floor exercises
behaviour modification –> cut out caffeine and alcohol
modify fluid intake - try to hold on or 5 min, then 10 min –> densensitise bladder over the course of the time
acupuncture and electrical stimulation
anticholinergic medication (antimuscarinin)
helps to contol the derusser
side effects - dry mouth, GORD, constipation, cognitive impairement, anti-cholinergic burden in the elderly
immediate release oxybutynin - not that good so try to reduce the frequency of using it
Contra-indication for anti-cholinergics
anrrow angles galucoma, myasthenia gravis, UC
B-aginists
helps increase bladder capacity without changing bthe pressure or volume
contraindication - uncontrolled hypertension
Intravesical botulinium toxin
botox paralyses the detrusser muscle and stops the over activity
but they might not be able to void for 2-3 weeks so they need to be ready to self-catheterise, and do this 2-3 times per year
neuromodulation
sacral nerve stimulation involved electrical stimulation of the baldder’s nerve supply to suppress reflexes responsible for involuntary detrusser contraction
external device that can stimulate the S3 afferent nerve at the level of the sacral spinal cord
Clam ileocystoplasty
intractable incontinence, and have tried everything else, change in bowel habit, urge and UUI in patients
patient has an operation to bivalve the bladde to make it into 2 flaps, thus it destroys the bladders ability to contract and squeeze down with as much pressure as before
take the mesentery of SI, flap of mesentery with blood supply and suture it on the bladder
complications - mucus in bladder
Ileal conduit urinary diversion
last resort, those who have hadradiotherapy to the pelvic
instead of indwelling catheter
ureter disconnected, ureter then sutured to the ileum and then to a stoma and outside
