urinary incontinence

Question 1

2 main types

Answer 1

stress and urge or mixed

Question 2

stressed

Answer 2

intra abdominal pressure exceeds urethral pressure, resulting in leakage

Question 3

Urge

Answer 3

can be caused by detrusor over activity or low compliance

Question 4

risk factors

Answer 4

age, parity, mode of deliveries, weight of heaviest baby, smoking

DM, anti HTN medications, glaucoma, heart/ kidney/ liver, anti depressants/ antipsychotics

** all due to to side effect of anticholinergics
increased intraocular pressure
increased risk of delirium
decreases effect of vagus on heart
prolapse related

Question 5

History

Answer 5

irritation:
urgency
increased daytime frequency
nocturia
dysuria
haematuria

incontinence symptoms
severity- how many pads/day
OAB

voiding symptoms
-straining to void
interrupted flow
recurrent UTI

fluid intake

Effect on QoL

Prolapse symptoms
-dragging sensation
Bowel Symptoms
-anal incontinence

Question 6

patient assessment

Answer 6

3 day urinary diary
urine dipstick
Examination
•	General
•	Abdominal
•	Neurological
•	Gynaecological
•	Pelvic floor assessment (Oxford Scale) 
•	Looking for: 
o	Prolapse
o	Stress incontinence
o	Uro-genital atrophy changes 
o	Pelvic mass (space occupying lesion)
Pelvic floor tone, strength, awareness

Question 7

investigations

Answer 7

urinalysis

urodynamics- only if surgery is contemplated

Question 8

urodynamics

Answer 8

o Uroflowmetry – Measures flow rate (Q) of urine in ml/s
o Flow rate is dependent on the urethral resistance, strength of detrusor contraction and abdominal straining
o Patients are asked to arrive with a full bladder and then void normally
Specialist investigation

Question 9

management

Answer 9

lifestyle changes
stop smoking
lose weight
stop drinking alcohol and caffeine
Physiotherapy- PFMTs
medical treatment:
Duloxetine
-licensed for moderate to severe SUI
given if PFMT failed
wish to have children

Question 10

surgery

Answer 10

colposuspension-open or lap
♣ The abdomen is opened and the bladder neck is lifted upwards by stitching the lower part of the front of the vagina to a ligament behind the pubic bone. This lift helps to prevent leakage by improving pressure transmission and compression of the neck of the bladder.

Question 11

integral theory of UI

Answer 11

♣ Both Stress and Urge incontinence arise from the same anatomical defect in the anterior vaginal wall & pubo-urethral ligament (PUL).

Sub-urethral Hammock laxity might result in stimulation of bladder neck stretch receptors, provoking a premature micturition reflex and Urgency Incontinence

Question 12

Mid urethral slings, retro pubic TVT (tension free vaginal tape)

Answer 12

♣ Polypropylene permanent Synthetic Tape inserted retro-pubically through abdomen
• Monofilament & Macro-porous
♣ Complications of TVT
• Bladder Perforation (1-21%)
• Vaginal & Urethral Erosions
• Vascular injuries, all attributed to blind penetration of retro-pubic space

first choice to colposuspension

Question 13

Overactive Bladder Syndrome

Answer 13

symptom complex
• urodynamically demonstrable detrusor overactivity (DO)
o DO is further qualified as neurogenic when there is a relevant neurologic condition or idiopathic when there is no defined cause.

defining symptoms:
urgency
frequency and nocturia 
\+/- urge incontinence
o	Frequency and urgency are considerably more common symptoms of OAB syndrome than urge incontinence, especially in persons between 35 and 55 years of age

management:
Treat symptoms
no immediate cure
multidisciplinary approach

conservative:
lifestyle interventions: 
normalise fluid intake
reduce caffeine, fizzy drinks
stop smoking
bladder training programme

pharmacological management:
Antimuscarinics
Tri-cyclic antidepressants
-imipramine

recent advances:
Botox
Neuromodulation