Urinary incontinence Flashcards
When to screen for urinary incontinence?
females >65 yrs old
what to ask about in urinary incontinence?
duration, severity, triggering factors (cough, sneezing) associations (frequency, urgency, dysuria), obstetric or gyencological hx, Lifestyle (ETOH use) and medications.
Transient incontinence
reversible
cause of urge incontinence
detrusor muscle hyperactivity or overactive bladder
can see nocturia secondary to increased detrusor contractility during bladder filling and RF are older age, neurological injury and chronic bacteriuria.
see sudden overwhelming urge to urinate
see sudden overwhelming urge to urinate
urge incontinence
stress incontinence cause
decreased urethral sphincter tone and urethral hypermotility
leaking with coughing, laughing, sneezing, lifting
overflow incontinence cause
impaired detrusor contractility or bladder outlet obstruction
incomplete emptying or persistent involuntary dribbling
incomplete emptying or persistent involuntary dribbling
overflow incontinence
why is there detrusor hyperactivity
not always sure but sometimes can be due to neurological disorders or UTI’s
initial management of urge incontinence
behavioral modification - bladder training and fluid mangement strategies
if conservative measures don’t work for urge incontinence can try
alpha adrenergic antagonist (terazosin and tamulosin)
persistent symptoms can try antimuscarinic agents (tolterodine or oxybutynin)
0 low dose antimuscarinic drugs are safe and effective in men with underlying BPH
what should be measured prior to starting antimuscarinic agents for treatment of urge incontinence?
a post void residual. If there’s any volume PVR>200 ml there should be avoided as this can cause urinary retention
side effects of antimuscarinics in older men who have urge incontinence?
dizziness, dry mouth and constipation
when do we do urodynamic studies?
helps provide information on bladder sensation, capacity, detrusor activity, and outlet obstruction and urine flow
only used for people with unclear or multifactorial etiology
what is the long term surgical treatment for urinary urge incontinence?
sacral nerve stimulation via surgical lead placement - only used for people who have failed combined therapy.
non pharmacological tx for urinary incontinence:
weight loss (in over weight pts)
dietary changes (decreased alcohol, fluid and caffeine intake - all bladder irritants)
smoking cessation
stopping offending medications (diuretics)
behavioral therapy for urinary continence
bladder training (best for urge and mixed incontinence) timed voiding voiding diary relaxation techniques Pelvic floor (kegel exercises (for urge, stress, mixed incontinence)
how to treat urge incontinence if conservative therapy (behavioral and lifestyle changes) don’t help?
trial antimuscarinics: oxybutynin and tolterodine. or beta 3 agonists (mirabegron)
stress incontinence is from
increased intrabdominal pressure with Valsalva maneuver (coughing sneezing, laughing)
how to diagnose with stress incontinence
positive cough test.
if conservative measures don’t work with stress incontinence what is done?
a mid urethral sling placement is done to help with peeing.
TCA antidepressant like amitriptyline can cause urinary incontinence how?
it’s a antimuscarinic medication causing urinary retention and dry mouth and constipation and antihistamine (sedation) and alpha anti adrenergic - causing hypotension and tachycardia.
This can cause overflow incontinence with constant drippling
lower abdominal mass, continuous urinary leakage and will have elevated post void residual.
overflow incontinence from either detrusor underactivity (TCAs) or bladder outlet obstruction (prolapse)
treatment of overflow incontinence is based on:
addressing underlying cuase: medication change, lifestyle modifications, correction of prolapse and intermittent bladder catherization
what is interstitial cystitis?
increased bladder pain with filling and relief with voiding
see suprapubic tenderness (painful bladder) not enlarged bladder
no incontinence associated with thus
urethral diverticulum (literally an outpouching in urethra) is seen
as a dilated urethral sac that protrudes into the anterior vagina resulting in tender palpable vaginal mass that causes dysuria and dyspareunia
see post void dripping rather than continuous dripping seen with overflow incontinence
what causes a vesicovaginal fistula?
are are the physical exam findings for this ?
its’ a tract between bladder and vagina.
Occurs after pelvic surgery (hysterectomy) radiation or obstetrical complications.
See continuous urinary leakage as bladder continuously empties through vaginal vault.
will have normal post void residual volume
additionally would see urine pooling in vaginal vault.
Treatment of overflow incontinence
identification and correcitn of underlying cause
cholinergic agonists
intermittent self catherization
chronic urinary retention creases risk for UTI and renal damage and so need intermittent self catherization.
tolterodine is a
antimuscarinic that inhibits bladder contractions and used to treat urgency incontinence
in MEN who have urgency and urinary incontinence that is not controlled by behavioral therapy may benefit from
mirabegron or anticholingerics (darifenacin, fesoterodine, oxybutynin)
These meds reduce involuntary bladder contractions by blocking the muscarininc cholinergic receptors
ok for men and women but be cautious with men who have BPH
