Urinary incontinence Flashcards
what in urinary incontinence
involuntary leakage of urine
what is stress urinary incontinence
leakage on effort or exertion, sneezing or coughing
urine leaks whenever urethral resistance is exceeded by increased abdominal pressure
what causes stress urinary incontinence
bladder neck/ urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
what muscles aids the action of the external urethral sphincter in women
levator ani
what is urge urinary incontinence
leakage accompanied by or immediately preceded by urgency
what causes urge urinary incontinence
bladder overactivity (detrusor instability) less commonly pathology that irritates the bladder (infection, tumour, stone)
what is mixed urinary incontinence
a combination of stress UI and urge UI
what does bed wetting in elderly men indicate
high pressure chronic retention
what is post micturition dribbling and what causes it
dribbling immediatley after leaving the toilet
due to urine pooling in the bulbar urethra
what does a constant leak of urine suggest
fistulas communications between the bladder and vagina (due to surgical injury at the time of hysterectomy or caesarian section)
can also be an ectopic ureter draining into the vagina
what should you suspect in a young girl with a constant leak of urine
ectopic ureter (draining into the vagina)
what nerve conditions can cause urinary incontinence
cerebral cortex:
- stroke
- MS
- brain injury
- parkinsons
- cerebral palsy
spinal cord:
- lesions
- trauma
- spina bifida
- MS
peripheral nerve damage
-diabetes
where is the sacral mictrurition centre
S2-4
what are the risk factors for urinary incontinence
female
caucasian
genetic predisposition
neurological conditions
anatomical disorders
child birth (SVD, increasing parity, pregnancy (stress UI)
pelvic, perineal and prostate surgery (radical hysterectomy, prostatectomy, TURP
(causing pelvic muscle and nerve injury or damage to external urethral sphincter)
radical pelvic radiotherapy
diabetes
what anatomical disorders can cause UI
vesicovaginal fistula, ectopic ureter (girls), urethral diverticulum, urethral fistual, bladder extrophy,
epispadias
what factors can promote UI
smoking (chronic cough) obesity infection (UTI) increased fluid intake poor nutrition ageing cognitive defect poor mobility oestrogen deficiency
what should you ask in a history of UI
type triggering factors frequency +degree of bother RFs previous surgery bowel symptoms symptoms of sexual dysfunction/ pelvic organ prolapse on women
what are the red flags in UI
pain haematuria recurrent UTI significant voiding/obstructive symptoms history of pelvic surgery/ radiotherapy
what should you include in a female exam for UI
chaperoned pelvic exam
ask patient to cough or strain and look for anterior and posterior vaginal wall prolapse, uterine or vaginal vault descent and urinary leakage
internal pelvic exam to assess voluntary pelvic floor muscle strength and bladder neck mobility
inspect the vulva for oestrogen deficiency (vaginal atrophy)
what should you do in both sexes for an exam for UI
abdo- palpable bladder (urinary retention)
neurological exam to asses gait, anal reflex, perineal sensation and lower limb function
DRE to exclude constipation, rectal mass and to asses anal tone
what are the exam red flags in UI
new neurological deficit
haematuria
urethral, pelvic or bladder mass and suspected fistula
what investigations into UI
bladder diary (frequency volume chart) urinalysis +/- culture flow rate post void residue (USS) pad testing
blood tests, imaging, cytoscopy (if suspecting anatomical abnormality or fistula)
what will flow rate charts look lik
low long curve= BOO
lots of ups and downs= straining, intermittent flow
women flow will be higher than mens due to shorter urethra
what is urodynamics
2 way catheters that senses both the bladder and abdominal pressure in order to isolate the bladder pressure
(cystometry)
what is the conservative treatment for UI
pelvic floor exercises (improvement in 30% of women- 8 contraction 3x daily)
weight loss, smoking cessation, avoid constipation, modify fluid intake
biofeedback- ability and strength of pelvic floor contraction is fed back to patients as a visual/ auditory signal
electrical stimulation of the pelvic floor (no proven)
medication
what medication for stress UI
duloxetine- inhibits re-uptake of both serotonin and noradrenalin (increases sphincteric muscle activity during bladder filling)
what is injection therapy for UI
injection therapy
-bulking materials (silicone, teflon) injected into bladder neck and periuretheral muscles to increase outlet resistance
(mainly for female SUI secondary to demonstrable intrinsic sphincter deficiency w/ normal bladder muscle function)
aim to achieve urethral mucosal apposition and closure of the lumen
50-80% success but deteriorates with time, repeated treatments often needed
what are the indications of injection therapy for UI
UTI, untreated bladder overactivity, bladder neck stenosis
what are the complications of injection therapy for UTI
temporary urinary retention, de novo urge incontinence, UTI, haematuria
what is retropubic suspension
to treat stress incontinence caused by urethral hypermobility
elevate and fix the bladder neck and proximal urethera in a retropubic position in order to support the bladder neck and regain continence
what is the surgical treatment for UI
injection therapy retropubic suspension burch colposuspension (elevation of vaginal wall to lateral pelvic wall) urethral stapes and slings artificial urinary sphincter
how do urethral tapes and slings work
lift up urethra and hold in place to prevent urethral movement
what are the complications of urethral slings
– voiding dysfunction (retention or de novo bladder overactivity
- vaginal, urethral and bladder perforation/erosion
- pain
- damage to bowel or blood vessels
how does a artificial urinary sphincter work
provides a constant circumferential pressure to compress the urethra. To void, the pump is squeezed, which transfers fluid to the reservoir balloon, thereby deflating the cuff. The cuff then automatically re-fills within 3 minutes
used for mod/ severe SUI/ uretheral sphincter deficiency
good long term success
what are the complications of an artificial uretheral sphincter
urethral atrophy, mechanical failure, urethral erosion, bladder overactivity or reduced compliance, infection
what is bladder over activity
detrusor overacitivity causes -urgency (+/- urge incontinence) -frequency -nocturia
what is the conservative treatment for an overactive bladder
pelvic floor exercises biofeedback acupuncture electrical stimulation behaviour modification: fluid intake, stimulants (caffeine, alcohol), bladder training
what medication for an overactive bladdr
anticholinergics (antimuscarinics) which inhibit contractions
-oxybutynin, solifenacin, tolterodine…
beta adrenoreceptor agonists; β3 sub-typE induce detrusor relaxation. β3-AR agonists increase bladder capacity with no change in micturition pressure and the residual volume
-Mirabegron
what causes bladder overacticity
acetylcholine acts on muscarinic receptors on the bladder smooth muscle to cause involuntary contractions and provoke symptoms of bladder overactivity
what are the contraindications for anticholinergics for bladder overactivity
uncontrolled open angle glaucoma, myasthenia gravis, BOO, bowel disorders (UC, bowel obstruction)
what are the side effects of anticholinergics
dry mouth, constipation, blurred vision, urinary retention, cognitive impairment
what are the contraindications to beta agonists
uncontrolled hypertension
what are the treatments for refractory cases of overactivity of the bladder
intravesical botulinum toxic (sparing the trione, temporarily paralyses detrusor)
neuromodulation (sacral nerve stimulation (S3) to inhibit detrusor activity)
clam ileocystoplasty (attaching segment of ileum to increase bladder volume)
ileal conduit urinary diversion with stoma (intractable cases only)
