Urinary Incontinence Flashcards
How could a lower motor neurone lesion lead to urinary incontinence?
E.g. cauda equine syndrome
Low detrusor pressure Large residual urine S2, 3, 4 Reduced perianal sensation Lax anal tone
+/- overflow incontinence
How could an upper motor neurone lesion lead to urinary incontinence?
High pressure detrusor contractions
Poor coordination with sphincters
Dilated ureters
Detrusor sphincter dyssynergia
Lower urinary tract symptoms (LuTs)
Storage: increased frequency, urgency, nocturia, incontinence
Voiding: slow stream, splitting or spraying, intermittency, hesitancy, straining, terminal dribble
Post- micturition: PM dribble, feeling of incomplete emptying
Definition of urinary incontinence
The complaint of any involuntary leakage of urine
Types of incontinence and prevalence
Stress urinary 47% incontinence - leakage on effort/ exertion/ sneezing/ coughing
Urgency UI 21% - leakage accompanied by/ proceeded by urgency
Mixed UI 28% - leakage associated with urgency & exertion/ effort
Overflow I - bladder becomes overly full (caused by blockage/ weak detrusor)
What is an overactive bladder?
Group of urinary symptoms including sudden urge to urinate ( + increased frequency + nocturia) may less often lead to urgency urinary incontinence if leakage occurs (wet OAB as opposed to dry OAB)
Risk factors for urinary incontinence
Pregnancy
Childbirth
Pelvic surgery/ DXT
Pelvic prolapse
Race
FH
Anatomical abnormalities
Neurological abnormalities
Co- morbidities Obesity Older Increased intra-abdo pressure Cognitive impairment UTI Drugs Menopause (reduced tone)
What will you need to examine for if present with incontinence?
BMI
Abdo exam (check exclude palpable balder)
Digital rectal exam (prostate)
Neurological exam
External genitalia FM (stress test, vaginal exam)
What investigations would you do if someone presents with incontinence?
Mandatory:
Urine dipstick - UTI, haematuria, proteinuria, glucosuria
Basic non-invasive urodynamics:
Frequency- volume chart, bladder diary _>3 days, post- micturition residual volume
Optional: invasive urodynamics (pressure-flow studies) e.g. video pressure- flow study total pressure - abdo p= detrusor p, pad tests, cystoscopy
General urinary incontinence management
Conservative: modify fluid intake, weight loss, stop smoking, decreased caffeine (UUI), avoid constipation, timed voiding (fixed schedule)
If unsuitable for surgery by failed conservative/ medical management = contained: indwelling catheter urethral/ suprapubic, sheath device (adhesive condom attached catheter tubing and bag), incontinence pads
Specific management of stress urinary incontinence
Initial: pelvic floor muscle training - 8 contractions X3/ day at least over 3 months
Pharmacological:
Duloxetine - combined noradrenaline & serotonin uptake inhibitor, increased activity in striated sphincter during filling phase (may be offered as alternative to surgery)
Surgery:
females - permanent intention (open retropubic suspension procedures correct anatomical position proximal urethra, classical autologous sling procedures supports urethra & augments bladder outflow resistance, low tension vaginal tapes supports mid urethra by polypropylene mesh). Temporary intention e.g. if further pregnancies planned (intramural bulking agents improve ability urethra resist abdo pressure improving urethral coaptation), injections (fat, silicone, collagen).
Males - artificial urinary sphincter, Male sling procedure
Specific management of urgency urinary incontinence
Initial:
Bladder training - schedule of voiding e.g. every hr not between wait or leak, intervals increased 15-30mins/ week until intervals 2-3hrs, at least over 6 weeks.
Pharmacological:
anticholinergics - acts muscarinic receptors (M2, M3) stops detrusor contracting
(side effects M1 CNS/ salivary, M2 SM heart, M3 SM ocular intestinal/ salivary, M4 CNS, M5 CNS/ eyes)
E.g. oxybuynin, solifenancin.
B3- adrenoceptor agonist- e.g. mirabegron, increases bladders capacity to store urine (stops detrusor contraction)
Intravesical injection of botulinum toxin- neurotoxin, inhibitis release Ach at pre-synaptic junction causing targeted flaccid paralysis 3-6 months
If that fails ->
Surgery: sacral nerve neuromodulation, autoaugmentaion, augmentation cystoplasty (makes bladder larger), urinary diversion
What is bedwetting and enuresis? Difference between primary and secondary?
Involuntary wetting during sleep at least 2X/ week in children aged >5yrs with no CNS defects
Enuresis - involuntary urination (often used synonymously to bedwetting)
Primary - never achieved sustained continence at night
Secondary - restarted having been dry at night for 6+ months
How to manage enuresis
Primary without daytime symptoms: reassurance, alarms with positive reward system, maybe desmopressin
Primary with daytime symptoms - usually disorders of lower urinary tract e.g. anatomical, OAB refer secondary Care
Secondary- treat underlying cause e.g. UTIs, constipation, diabetes, psychological, neurological, physical primary or secondary care
