Urinary Incontinence Flashcards
What is urinary incontinence?
Complaint of any involuntary leakage of urine = common, distressing, embarrassing, socially stigmatising, often hidden
How common is urinary incontinence?
1 in 3 women
1 in 10 men
What are the types of urethral incontinence?
Urge incontinence, stress incontinence, mixed incontinence, overflow incontinence
How may urine leak by the extra-urethral route?
Ectopic ureter, vesico-vaginal fistula
What are the two phases of the micturition cycle?
Filling (storage) and voiding phases
What is compliance?
Ability of bladder to keep its pressure unchanged irrespective of bladder volume and afferent stimulation
What pressures contribute to the storage phase?
Intravesical, atmospheric, abdominal, urethral
What occurs in the voiding phase?
Detrusor pressure increases due to muscle contraction, urethral pressure is less than intravesical pressure so flow can occur, outflow mechanism relaxes
What gives the tracing in urodynamics?
Cystomethogram = catheter in the bladder and rectum (to give abdominal pressure)
What is the volume of a full bladder?
400ml
What are patients asked to do during a cystomethogram tracing?
Cough three times
How is the detrusor pressure calculated?
Abdominal pressure - intravesical pressure
What are the anatomical components of the micturition reflex?
Bladder and sphincters, spinal bladder centre, brain, S2-3
What nerves are involved in the micturition reflex arc?
Pelvic parasympathetic nerves, pudendal nerve
What controls the micturition reflex arc?
Descending control from the brain inhibits or enables the arc
What are some symptoms of outflow obstruction?
Bladder outflow is obstructed = huge palpable bladder, chronic retention, insensible incontinence, wet at night, renal impairment
What is urge incontinence a part of?
The urge syndrome
What are some features of urge incontinence?
Daytime frequency, small voided volumes, urgency provoked, enuresis (wet at night)
What are some triggers for urge incontinence?
Key in door, sound of running water, standing up, coughing, laughing
How are urge incontinence, urodynamic stress incontinence and detrusor overactivity diagnosed?
By urodynamics
What can detrusor overactivity cause?
Urge incontinence = mostly middle aged women, most common cause
What is detrusor overactivity?
Bladder dysfunction characterised by detrusor contractions occurring during inhibition of voiding
What are some causes of urge incontinence?
Cystitis, tumour, excess central facilitation (stress), loss of central inhibition (paraplegia), destruction of S2-3 centre, pelvic surgery/fracture (parasympathetic nerve damage)
What happens in urodynamic stress incontinence?
Urine leaks during increased intra-abdominal pressure = no detrusor contraction
What causes urodynamic stress incontinence?
Due to damage to pelvic floor or urethral function = childbirth, smoking, obesity, diabetes, chronic cough
When do people with urodynamic stress incontinence go to the toilet?
Early in the micturition cycle = frequent urination
What are some features of an overactive bladder?
Often mixed picture = SUI often overlaps
Split into wet (37%) and dry (63%)
What are some features of the examination?
Painless palpable mass arising from the pelvis = can’t get below it, dull to percuss
How is overflow incontinence treated?
Assess renal function and treat obstruction
Catheterise and bladder rehab
Teach intermittent self catheterisation
How is urge incontinence treated?
Avoid caffeine, biofeedback, bladder retraining, time bladder emptying, botox injection (unlicensed)
Neuromodulation (bladder pacemaker)
What are some medical interventions for urge incontinence?
Enterocystoplasty
Anti-muscarinics = oxybutynin, tolterodine
Beta 3 adrenergics = mirabegron
How is stress incontinence treated?
Weight loss and smoking cessation, pelvic floor physio
Medication (not much role) = duloxetine (5HT and NE uptake inhibitor)
Colpususpension open surgery largely replaced with minimally invasive tape procedures
How is mixed incontinence managed?
Combination of urge and stress therapies = must ask which is more dominant
What are some features of an ectopic ureter?
Rare = congenital, ureter joins on wrong side of sphincter mechanism, patient wet all the time
What are some features of a vesico-vaginal fistula?
Urine falls out of hole = constant wetness
Caused by prolonged labour in developing world and pelvic surgery in developed world
What is stress incontinence defined as?
Involuntary leakage on effort or exertion, or sneezing/coughing
What is urge incontinence defined as?
Involuntary leakage accompanied by or immediately preceded by urgency
What is urgency?
Complaint of sudden compelling desire to pass urine which is difficult to defer
What is overactive bladder/urge syndrome?
Urgency, with or without urge incontinence, usually with frequency and nocturia
What is detrusor overactivity incontinence defined as?
Incontinence due to an involuntary detrusor contraction
What is mixed urinary incontinence defined as?
Involuntary leakage associated with urgency as well as effort/sneezing/coughing
What are voiding symptoms?
Experienced during voiding phase = slow stream, spraying of stream, hesitancy, straining
What is a frequency volume chart (FVC)?
Records volumes voided as well as the time of each micturition = day and night for at least 24hrs
How long is a bladder diary recorded for?
3 days
