Urinary incontinence Flashcards
Upper urinary tract consists of what?
Upper tract (Kidneys & Ureters): > A low pressure distensible conduit with intrinsic peristalsis > Transport urine from nephrons via ureters to the bladder.
Lower urinary tract consists of what?
Lower tract (Bladder & Urethra):
> The bladder fills at rate of 0.5-5 mls/min
> A low-pressure storage of urine
> Efficient expulsion of urine at appropriate place & time
What is the vesico-uteric mechanism?
Vesico-ureteric mechanism: Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
Hypogastric nerves?
Hypogastric nerves (sympathetic) T10-L2
Allows storage in the bladder
Pelvic nerves?
Pelvic nerves (Parasympathetic) S2-4
Controls voiding
Pudendal nerves?
Pudendal nerves (Somatic) S2-4
Voluntary
What happens during bladder filling?
1) Accommodate increasing volume at constantly low pressure.
2) Inhibition of contractions by giving rise to gradual awareness of filling.
Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
What happens to cortical activity during bladder filling?
Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
1) Activates Sympathetic pathway &
2) Reciprocal inhibition of the Parasympathetic pathway
3) Mediates contraction of bladder base and proximal urethra.
What happens during bladder emptying?
1) Detrusor contraction.
2) Urethral Relaxation.
3) Sphincter co-ordination.
4) Absence of Obstruction or anatomical shunts (Cystocele, Diverticulum)
What happens to cortical activity during bladder emptying?
Cortical Influence (Pontine micturition centre) 1) Activation of parasympathetic pathway &
2) Inhibition of Sympathetic pathway
What is urinary incontinence (UI)?
Any involuntary leakage of urine
What is stress of urinary incontinence (SUI)?
Involuntary leakage on effort or exertion, on sneezing or coughing
What is urge urinary incontinence (UUI)?
Involuntary leakage accompanied by or immediately preceded by urgency
What is mixed urinary incontinence (MUI)
Involuntary leakage accompanied by or immediately preceded by urgency & on effort or exertion, or on sneezing or coughing
What percentage of women aged 15-60 have urinary incontinence?
15-25%
What percentage of women aged >60 have urinary incontinence?
15-40%
What percentage of women in nursing homes have urinary incontinence?
More than 50%
Impact of urinary incontinence?
1) UI may significantly impair the QoL.
2) Reduce social relationships and activities.
3) Impair emotional and psychological well- being.
4) Impair sexual relationships.
5) Embarrassment and diminished self- esteem.
Risk factors of urinary incontinence?
> Age > Parity > Menopause > Smoking > Medical problems > Intra abdo pressure > Pelvic floor trauma > Denervation > Connective tissue disease > Surgery
Childbirth = Main risk factor
What is the main risk factor of urinary incontinence?
Pregnancy and childbirth
Patient assessment in urinary incontinence - History?
> Age, parity, mode of deliveries, weight of heaviest baby, Smoking, HRT,
> Medical Conditions: DM, anti-HTN medications, Glaucoma, Heart/Kidney/Liver problems, Cognitive problems, Anti-depressants/ anti-psychotics.
> Previous PFMT, Surgical treatment of SUI or POP
Patient assessment in urinary incontinence - irritation symptoms?
Irritation Symptoms:
> Urgency ; Sudden compelling desire to void that is difficult to defer.
> Increased daytime frequency (>7)
> Nocturia (>1)
> Dysuria
> Haematuria ☻
> Fluid intake increased
Patient assessment in urinary incontinence - incontinence symptoms?
> Stress UI
> Urgency UI
> Coital Incontinence
> Severity: How many pads/ day?
Patient assessment in urinary incontinence - voiding symptoms?
Voiding Symptoms:
> Straining to void
> Interrupted flow
> Recurrent UTI ☻
Patient assessment in urinary incontinence - prolapse symptoms?
Prolapse Symptoms:
> Vaginal Lump
> Dragging sensation in vagina
Patient assessment in urinary incontinence - bowel symptoms?
Bowel symptoms: > Anal Incontinence > Constipation > Faecal evacuation dysfunction > IBS
Patient assessment in urinary incontinence - measuring impact on quality of life?
How much does Urinary leakage interfere with your day to day activities?
Ranked 1-10 with 1 being not at all and 10 being a great deal
Patient assessment in urinary incontinence - Patient assessment?
1) 3 day urinary diary: > Fluid intake: Quantity & Quality > Urine Out-Put (exclude Nocturnal Polyuria) > Daytime Frequency, > Nocturia > Average voided volume.
2) Investigations:
- Urinanalysis
- Post voicing residual volume assessment
- Urodynamics
3) Quality of life
4) Examination
Patient assessment in urinary incontinence - Investigations?
1) Urinalysis: Multistix +/- MSSU
2) Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties.
3) Urodynamics: ONLY indicated if surgical treatment is contemplated.
Patient assessment in urinary incontinence - Urodynamics Investigations?
Uroflowmetry:
> Measures flow rate (Q) of urine in ml/s
> Flow rate is dependent on the urethral resistance, strength of detrusor contraction and abdominal straining
Patient assessment in urinary incontinence - Cystometry Investigations?
Uses water to measure:
1) Pves vesicle pressure is the pressure of the bladder and the abdomen
2) Pabd is the abdominal pressure
3) Pdet is the detrussor pressure which is calculated by subtracting pabd from pves
Patient assessment in urinary incontinence - Cystometry Investigations, Pves?
Pves vesicle pressure is the pressure of the bladder and the abdomen
Patient assessment in urinary incontinence - Cystometry Investigations, Pabd?
Pabd is the abdominal pressure
Patient assessment in urinary incontinence - Cystometry Investigations, Pdet?
Pdet is the detrussor pressure which is calculated by subtracting pabd from pves
If a woman was to cough within cystometry what would you see?
The woman is asked to cough every minute to make sure the machine is working.
A rise in pressure should appear on both pves and pabd but no change on pdet (detrussor).
How is urinary incontinence managed?
> Lifestyle changes
Medical treatments
Physiotherapy
Surgery
What causes stress incontinence?
Stress incontinence occurs when intra-abdominal pressure exceeds urethral pressure, resulting in leakage
What increases urethral closure pressure, a management for stress incontinence?
> Pelvic floor muscle training
> Surgery
> Pharmacological agents
Lifestyle changes to aid stress incontinence?
> Stop smoking
Lose weight
Eat more healthily to avoid constipation
Stop drinking alcohol and caffeine
How is urinary incontinence treated?
1) Everyone should receive conservative treatment to start:
- Stop smoking
- Lose weight
- Eat more healthily
- No alcohol
- No caffeine
2) Pelvic floor exercises:
- Reinforcement of cortical awareness of muscle groups.
- Hypertrophy of existing muscle fibres.
- General increase in muscle tone and strength.
3) Pharmacological agents
- Yentreve (Duloxetine)
4) Surgery:
- Colpsuspension
- Transobturator tape
- Tension-free vaginal tape
Who should receive Duloxetine?
1) Primary care = If pelvic floor muscle training has failed or would be enhanced by the prescribing of Duloxetine
2) Secondary care:
- Does not wish surgery
- Not fit surgery
- After failed surgery
- When the patients family is not complete
Types of surgery for urinary incontinence?
1) Colposuspension (Pressure-theory)
2) Mid-urethral slings (Transobturator tape), retro-pubic tension-free vaginal tape (hammock theory)
Is TVT (tension-free vaginal tape) better than Colposuspension?
TVT is as effective as Colposuspension for the treatment of primary USI up to 2 years.
Less Operative & Postoperative Morbidity
As a result, TVT has now replaced Colpususpension as the 1st choice treatment go stress urinary incontinence
What are the theories for stress urinary incontinence?
1) Pressure-transmission theory
2) Integral theory:
Suburethral Hammock laxity might result in stimulation of bladder neck stretch receptors, provoking a premature micturition reflex and Urgency Incontinence
What concerns are there over the safety of the TVT?
1) Common Surgical Complications: Bladder Perforation (1-21%).
2) Vaginal & Urethral Erosions.
3) Several vascular injuries, all attributed to Blind penetration of retro-pubic space:
- A case of right external iliac artery injury.
- 2 deaths.
TVT versus TOT - Lower preoperative morbidity?
> Bladder Injury: 1%Vs. 9%
> No need for Cystoscopy , hence Cheaper.
> No cases of Bowel or Major Blood Vessels injury .
> Trend towards lower potoperative Voiding dysfunction
> Higher Vaginal perforation & Erosion Rates
> Higher rates of disabling Thigh pain in TOT
What is overactive bladder syndrome?
Overactive bladder syndrome is a complex of symptoms suggestive of detrusor overactivity (DO), but that may also be due to other urethrovesical dysfunction
What is detrusor overactivity?
DO is a urodynamic parameter characterized by involuntary detrusor contractions during filling that are either spontaneous or provoked. DO is further qualified as neurogenic when there is a relevant neurologic condition or idiopathic when there is no defined cause
What are the defining symptoms of overactive bladder syndrome?
Defining symptoms:
> Urgency (with/without urgency incontinence)
> Frequency
> Nocturia
Who is most commonly affected by overactive bladder syndrome?
OAB syndrome occurs in both sexes and at all ages (including children)
Prevalence of OAB increases with age, and is slightly higher in women
What is urgency?
Urgency: The complaint of a sudden, compelling desire to pass urine that is difficult to defer
What is urge incontinence?
Urge incontinence: The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency
What is frequency?
Frequency: Usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids too often by day
What is nocturia?
Nocturia: Usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void
What are the risk factor of urge incontinence?
> Advanced age
Diabetes
Urinary tract infections
Smoking
OAB is a chronic condition therefore Symptoms may wax and wane
From which age is overactive bladder syndrome more common in men than women?
In those 60 years old, it is higher in men than in women; this effect of sex is more pronounced in individuals 75 years old
Management of overactive bladder syndrome?
1) Life style interventions:
- Normalise fluid intake
- Reduce caffeine
- Reduce Fizzy drinks
- Reduce Chocolate
- Stop Smoking
- Weight loss
2) Bladder training programme
3) Pharmacological treatment:
- Anti-muscarinic
- Tri-cyclic antidepressants
- Botox
4) Neuromodulation
5) Multidisciplinary approach
Management of overactive bladder syndrome - Bladder training programme?
1) Principle:
- The re-establishment of cortical control over detrusor function and voiding
2) Achieved by:
- Timed bladder emptying programme
- In-patient/ Outpatient
Management of overactive bladder syndrome - anti-muscarinic?
Antimuscarinic Oral: > Solifenacin (Vesicare 5-10mg ) > Fesoteridine (Toviaz 4-8 mg) > Trospium Chloride (60mg XL) > Darifencain (Emselex 7.5-15 mg ) – Constipation; FI > Lyrinel XL (10-20 mg ) > Oxybutinin (5-10 mg/ tds)
Transdermal: Kentera Patches
Management of overactive bladder syndrome - Tri-cyclic anti-depressants?
Imipramine
Management of overactive bladder syndrome - Botox?
> Botulinum Toxin (A&B)
> NDO/ IDO
> 200-300 Unit (12U/Kg)
> Cystoscopy/ GA
> 75% Cure & Significant Improvement
> Effects last for 6-9 months
> CISC
Management of overactive bladder syndrome - Neuromodulation?
> Needle stimulation (S2-4)
> Reflex Inhibition to the Detrusor muscle
> Cheap
> Minimally invasive
> 70% improvement in Refractory OAB$
