urinary incontinence - anne Flashcards
what are the presentations of urinary incontinence
near constant dribbling or intermittent voiding
extreme urgency
occurs/worsens with intra-abdominal pressure
postvoid dribbling
family reports smell of urine
pt engages in “bathroom mapping”
what is urge incontinence
most common type in older people
uncontrolled urine leakage after urgent need to void
nocturia/nocturnal incontinence common
precipitated by use of diuretic
exacerbated by inability to quickly reach bathroom
atrophic vaginitis in women
what is stress incontinence
2nd most common in women
urine leakage due to increase intra-abdmonial pressure
leakage volume low to moderate
men: post surgical
more severe in obese pts
what is overflow incontinence
2nd most common type of incontinence in men
dribbling of urine from overly full bladder
volume usually small, but leaks may be constant
what is functional incontinence
urine loss due to cognitive or physical impairments or environmental barriers that interfere with control of voiding
what is mixed incontinence
any combination of other types of incontinence
what is the pathophysiology of urinary incontinence in post menopausal women
decreased estrogen leads to atrophic urethritis/vaginitis, decreased urethral resistance and closure pressure
what is the pathophysiology of urinary incontinence in men
prostate size increases, partially obstructing urethra leading to incomplete bladder emptying and strain on detrusor muscle; facilitate incontinence but do not cause it
what is the pathophysiology of urinary incontinence in younger patients
often begins suddenly, may cause little leakage and usually resolves quickly with little or no treatment
once cause in younger patients but several in older adults
What is transient incontinence
“diappers”
Delirium
Infection
Atrophic urethritis and vaginitis
pharmaceuticals
Psychiatric disorders
Excess urine output
Restricted mobility
Stool impaction
What is established incontinence
caused by persistent problem affecting nerves or muscles
what are the mechanisms of estbalished incontinence
bladder outlet incompetence or obstruction
detrusor overactivity or under-activity
detrusor-sphincter dyssynergia
combination
What is outlet incompetence
common cause of stress incontinence
in women, weakness of pelvic floor from multiple vaginal deliveries, pelvic surgery, age-related changes, or combo
what is outlet incompetence in men
common cause is damage to sphincter or to bladder neck and posterior urethra after radical prostatectomy
What is outlet obstruction
common cause in men
both sexes: fecal impaction
women: previous surgery for incontinence, prolapsed cystocele
what can obstruction lead to
chronically over distended bladder - loses ability to contract - does not empty completely resulting in overflow
detrusor overactivity and urge incontinence; detrusor muscle loses ability to contract
What is detrusor overactivity
common cause of urge incontinece in older and younger
idiopathic of dysfunction of frontal micturition inhibitory center or outlet obstruction
detrusor overactivity with impaired contractility
what is overactive bladder
described urinary urgency (with or without incontinence) often accompanied by urinary frequency and nocturia
what can cause detrusor underactivity
injury to spinal cord or nerve roots supplying bladder, periphaeral/autonomic neuropathies, other neurological disorders
what are the casues of detrusor underactivity in men
detrusor replaced by fibrosis and connective tissue with chronic outlet obstruction
what can cause detrusor under-activity in women
usually idiopathic
what is detrusor-sphincter dyssynegria
loss of coordination between the bladder contraction and external urinary sphincter relaxation; outlet obstruction with resultant overflow incontinence
what is dyssynegria
often due to spinal cord lesion that interrupts pathways to pontine micturation center
-causes severe trabeculation, diverticula, “christmas tree” deformation of bladder (cystogram)
what causes “christmas tree” deformation of the bladder
Dyssynergia
What needs to be excluded before treatment of urinary incontinence
urinary retention
what history is needed for the workup of incontinence
duration and patterns of voiding
bowel function
drug use
obstetric and pelvic surgical history
what needs to be assessed with physical exam for incontinence
neurological
pelvic
rectal exams are focus
what are tests used for urinary incontinence
urinalysis, urine culture
serum BUN, creatinine
post void residual volume
~urodynamic testing
what tests are required for urinary incontinence workup
UA, UCX, BUN and serum creatinine
what is normal post void residual volume
<50ml,
<100mg is usually acceptable for >65yo
what is a postvoid residual volume of >200ml suggestive of
detrusor underactivity or oulet obstruction
how can postvoid residual volume be measured
Catheterization or US
when is urodynamic testing indicated
when clinical eval and appropriate tests are not diagnostic or when abnormalities must be precisely characterized before surgery
What is urodynamics
term for all-encompassing series of tests and procedures regarding the lower urinary tract.
what is cystometrogram
testing bladder function, pressure and volume
what is electromyography
recording of electrical activity within muscle tissue
what is urethral pressure profile
measuring the balance of pressure along urethra
what your uroflowmetry
testing of volume of urine released from the body
what is pressure flow study
measuring the bladder pressure required to urinate and generated flow rate
what is peak urinary flow rate testing used for
flow meter used to confirm of exclude outlet obstruction in men
what is cystometry/cystometrography(CMG)
pressure-volume curves and bladder sensation recorded while bladder is filled with sterile water; provocation testing used to stimulate bladder contractions
what is electromyography of perineal muscles used for
assess sphincter innervation and function
what is pressure-flow video studies
usually done with voiding cystourethrography; correlates bladder contraction, bladder neck competency and detrusor-sphincter synergy; not widely available
what are general treatment of urge incontinence urinary incontinence
limit fluid intake at certain times
avoid fluids that irritate bladder (caffeine)
drink 48-64 oz of fluid a day
assistance for restricted mobility or cognitive impairments
what are bladder training treatments for urge incontinence urinary incontinence
times voiding (every 2-3 hours) while awake
prompted voiding for cognitively impaired
voiding diary helps establish how often and when voiding is indicated
what are the most common drugs used for urge incontinence urinary incontinence
oxybutynin and tolterodine
when is immediate-release oxybutynin used
prophylactic if incontinence occurs at predictable times
what is sacral nerve stimulation used for urinary incontience
sever urge incontinence refractory to other treatments
it is a implanted neurostimulator
what is posterior tibial nerve stimulation (PTNS)
application of low-voltage stimulation in 30 minute sessions Q weekly for 10-12 weeks
when is surgery indicated for urge incontinence urinary incontinence
last resort usually younger patients with severe urge incontinence refractory to other treatments
what is the most common surgical procedure for urge incontinence urinary incontinence
augmentation cystoplasty
what is the treatment for stress incontinence
behavioral
-bladder training, kegel exercises, avoid physical stress that provoke incontinence, losing weight, exercise using vaginal cones
what are drugs that are used for stress incontinence
psudophedrine: women with outlet incompetence
imipramine, duloxetine: mixed stress and urge incontinence or stres alone
what is the treatment for stress incontinence if use to atrophic urethritis
topical estrogen
what are surgery and devices used to treat stress incontinence urinary incontinence
non-invasive treatments ineffective
occlusive devices
what are treatment options for outlet obstruction
BPH or CA: drugs or surgery
urethral structure: dilation or stenting
cystoceles: surgery or reduced with pessary
alternatives: electrical stimulation, cholinergic agonist bethanechol
what are treatment options for overflow incontinence-detrusor under activity
bladder decompression or self cath, double voiding, valsalva maneuver, application of suprapubic pressure
complete acontractile detrusor: requires intermittent self-cath or use of indwelling catheter
what are the four types of urinary incontinence
urge, stress, overflow, functional
