Urinary Incontinence Flashcards
What are the characteristics of the UUT
- Kidney & ureters
- A low-pressure distensible conduit with intrinsic peristalsis
- Transport urine from nephrons via ureters to the bladder
Characteristics of the LUT
- Bladder and urethra
- Low-pressure storage
- Efficient expulsion of urine at appropriate place & time
What is the vesico-ureteric mechanism
- Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
- Vesico-ureteric valve only allows flow 1 way
What is the length of the urethra (male and female)
- Women - 4cm
- Men - 25cm
What is the nerve supply of the bladder
- Storage - hypogastric nerve - T10-L2 (sympathetic) (s for storage)
- Voiding - pelvic nerve - S2-4 (parasympathetic)
- Voluntary - pudendal nerve - S2-4 (somatic)
Why are women more prone to bladder leakage
- The prostate aids voluntary control in men
What are the characteristics of bladder filling
- Accomodate increasing volume at constantly low pressure
- Inhibition of contractions by giving rise to gradual awareness of filling
What is the cortical activity of bladder filling
- Activating reciprocal guarding reflex by Rhabdosphincter contraction
- Increase sphincter contraction & resistance
- Activates sympathetic pathway
- Reciprocal inhibition of the parasympathetic pathway
- Mediates contraction of bladder base and proximal urethra
What is normal bladder capacity
- 400-600ml (1 pint)
- 125ml (1/4 pint) first sensation
- 250ml (1/2 pint) start to feel the need but not desperate
- 500ml (1 pint) need to go - max systemic capacity
How does bladder emptying occur
- Detrusor contraction
- Urethral relaxation
- Sphincter co-ordination
- Absence of obstruction or anatomical shunts (cystocele, diverticulum)
- Cortical influence (pontine micturatioon centre) –> activation of parasympathetic oathway & inhibition of sympathetic pathway
- E.g. convienient location
What is urinary incontinence
- Any involuntary leakage of urine
What is stress urinary incontinence
- Involuntary leakage on effort or exertion, on sneezing or coughing
What is urge incontinence
- Involuntary leakage accompanied by or immediately preceded by urgency
What is mixed urinary incontinence
- Involuntary leakage accompanied by or immediately preceded by urgency & on effort pr exertion, or on sneezing or coughing
What is the epidemiology of urinary incontinence
- 10-25% of women age 15-60
- 15-40% women >60
- >50% women in nursing homes
What is the impact of urinary incontinence
- Impairs QoL
- Reduces social relationships and activities
- Impairs emotional and psychological well-being
- Impairs sexual relationships
- Embarrassment and diminished self-esteem
- Average length of suffering - 5 years
Risk factors of urinary incontinence
- Age
- Parity - pregnancy main risk factor
- Menopause
- Smoking
- Medical problems
- Increased intraabdominal pressure
- Pelvic floor trauma
- Denervation
- Connective tissue disease
- Surgery
- Instrumental delivery
Theory of female urinary incontinence
- Both stress and urge incontinence arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament (PUL)
- Urethral/bladder neck closure dysfunction and USK
- Suburethral hammock laxity might result in stimulation of bladder neck stretch receptors, provoking a premature micturation rllfex and urgency incontinence
How are patients with urinary incontinence assessed
- History
- Examination
- Investigations
- Management
What is important in the history of UI
- Age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
- Medical problems
- DM (causes polyuria), anti-HTN medications dioxide relaxes urethra, reduce furosemide) glaucoma (cannot have urgency medication), heart/kidney/liver problems, cognitive problems antidepressants/anti-psychotics (anti-cholinergics)
- Previous PFMT, surgical treatment of SUI or POP
What is normal frequency
- Urge is normal, urgency is not
- Daytime frequency - 7
- Nocturia - 1
- Number increase by 1 each decade after 60
What irritation symptoms for patients complain of
- Urgency; sudden compelling desire to void that is difficult to defer
- Increased daytime frequency (>7)
- Nocturia (>1)
- Dysuria
- Haematuria
What incontinence symptoms do patients complain of
- Stress UI
- Urhency UI
- Coital incontinence
- Severity - pads/day
What voiding symptoms do patients complain of
- Straining to void
- Interrupted flow
- Recurrent UTI
What other symptoms need to be asked about in the history of UI
- Fluid intake: quantity and quality
- Effect on QoL - scale 1-10
- Prolapse symptoms
- Vaginal lump/dragging sensation in vagina
- Bowel symptoms
- Anal incontinence, constipation, faecal evacuation dysfunction, IBS
What should be done before the clinic of UI
- £ day urinary diary
- Fluid intake: quantity and quality
- Urine out-put (exclude nocturnal polyuria)
- Day-time frequency
- Nocturia
- Average voided volume
- Can show if SUI or UUI
- Urine dipstick
What examination should be done in UI
- General
- Abdominal Neurological
- Gynaecological
- Pelvic floor assessment (Oxford scale)
What should be looked at those with UI and bladder/pelvic floor problems
- Prolapse
- Stress incontinence
- Uro-genital atrophy changes
- Pelvic mass (space-occupying lesion)
- Pelvic floor tone, strength, awareness
What investigations in UI
- Urinalysis
- Multistix +/- MSSU
- Post voiding residual volume assessment
- Usually bladder scanning
- Only symptoms of voiding difficulties
- Urodynamic - only indicated if surgical treatment contemplated
- Uroflowmetry
- Multi-channel cytometry
What is the general management of UI
- Lifestyle changes - e.g. reduce intake, lose weight (>30), reduce caffeine, avoid chocolate, avoid fizzy drinks, avoid sugar/sweeteners
- Medica treatments
- Physio
- Surgery
What is the management of stress urinary incontinence
- Urethral closure pressure increased by
- Pelvic floor muscle training
- Surgery
- Pharmacological agents
Lifestyle changes for treatment of UI
- Stop smoking
- Lose weight
- Eat more healthily to avoid constipation
- Stop drinking alcohol and caffeine
What is the conservative treatment of UI
- Should be used on everyone (unless previously failed)
- Pelvic floor muscle training
- Reinforcement of cortical awareness of muscle groups
- Hypertrophy of existing muscle fibres
- General increase in muscle tone and strength
Pharmacological treatment of UI
- Yentreve (duloxetine)
- Moderate to severe stress UI
- Adjuvant to exercises
- Can cause nausea
Surgical management of UI
- Colosuspension
- Lifting the urethra back up
- Mid-urethral slings retro-pubic TVT
- Tension-free vaginal tape (TVT) was introduced as minimally invasive procedure to reinforce structures
- 80% cure at 11-years follow up
- Problem with foreign body
What is overactive bladder syndrome
- Symptoms complex usually related to urodynamically demonstrable detrusor overactivity
- Symptoms syndrome - not easy to diagnose
Symptoms of overactive bladder syndrome
- Urgency (with/without incontinence)
- Usually with frequency and nocturia
What are the risk factors for overactive bladder syndrome
- Advanced age
- Diabetes
- UTIs
- Smoking
Treatment of overactive bladder syndrome
- Treat symptoms
- No immediate cure
- MD approach
- Lifestyle
- Bladder training
- Pharmacological
Lifestyle changes as management of overactive bladder syndrome
- Normalise fluid intake
- Reduce caffeine, fizzy drinks, chocolate
- Stop smoking
- Weight loss
What is the bladder training programme in overactive bladder syndrome management
- Timed voiding with gradually increasing intervals - continence nurse
Pharmacological treatments of overactive bladder syndrome
- Antimuscarinic
- Oral
- Solifenacin
- Fesoteridine
- Trospium chloride
- Darifenacin
- Lyrical XL
- Oxybutynin
- Transdermal
- Kentera patches
- Oral
- Tricyclics
- Botox
- Neuromodulation
