Urinary Incontinence in Women

Question 1

What conditions can predispose to urinary incontence? Females?

Answer 1

Faecal impaction , decreased mobility, confusional states, drugs e.g. Diuretics & hypnotics.

Question 2

What are the commonets types of urinary incontinence in women?

Answer 2

Stress urinary inconinece- SUI-
Overactive bladder
Retention w/ overflow
Fistula

Question 3

Whats the commonets type of UI in women?

Answer 3

Stress UIs
60-70% of cases.
Can be a sign or symptom
Happens when there is a rise in intra- abdominal pressure without a detrussor contraction,
So notic leakege when coughing, sneezing, laughing
If severe: on walking or sitting up.

Question 4

What happens in an overavrive bladder? Whats its %0 along UIs?

Answer 4

Detrussor hyperreflexia
When a. Woman is incontinent due to an involuntary detrussor contraction.
30% of cases in adult women.
She experiences urgency, if too slow pee on herslef. :(
Same day & night- complain of nocturia, ore severely, enuresis (bed wetting).

Question 5

Whats commonest in eldelry patients?

Answer 5

Retention with overflow or thos with neurological problem.

Denervated bladder fills, until spills–> leakage.

Question 6

Causes of a fistula im women?

Answer 6

Abnormal connection in UK usually surgical complication.
Affluent countries- obstructed labour.
1 in 1000
Any abnormal connection between Lower urinary tapract (ureter, bladder, urethra) and genital system (vagina, uterus)–> continuous dribbling of incontinence.

Question 7

What should we consider!

Answer 7

That may have more than one type of ipcoexisting incontinence.
An over pactive bladder usualky coexists with both stress incontinence and voiding difficulty or tenetion.

Question 8

Mechanism of incontinence

Answer 8

Maintained at bladder neck
Proximal urethra maintains continence. There is no flow of urine( radio opaque medium, Xray, woman standing) .
No sphincter muscles exists.
There is a smooth muscle in proximal urethra but runs longitudinally and not in a circular direction.
So could not maintain continence.

Question 9

Whats the ‘proximal urethral sphincter mechanism’?

Answer 9

Water-tight seal which maintains the pressure in the urethra greater than that of the bladder.

Question 10

Whats the water-tight seal made out if?

Answer 10

Arteriovenous anastomoses with the wall of the proximal,urethra,
passinung entirely around the urethraforming a hermetic seal
by keeping the urethra occluded.

Question 11

Whats the distal urethral mechanism?

Answer 11

the greatest pressure however is in the mid-urethra.
Anatomical basis in muscle: The striated muscle innervated by spinal roots S2-4, is found within the wall of the mid-urethra.

Question 12

Define urinary incontinence

Answer 12

Condition in which there is involuntary loss of urine, social and hygienic problem.
Urine vol lost not feature of dx
But that the person CAN confirm that there is urine loss.

Causes sign distress
F- 10-20% of adult female pop incontenent 1> times a month.
Age> 75- 25-50% of women.

Question 13

Whats important about the intra-abdominal position of the urethra?

Answer 13

The supporting tissues– > if the proximal Urethravis intra-abdominal, then any pressure rise in the abdomen will be equally transmitted to the bladder & the prox urethra; the pressure difference will. Or change, and conintinence will be maintained.

Question 14

What are the supporting tissues around the urethra and what happens when they are damaged?

Answer 14

Weakness/damage may predispose to stress incontinence.

Pubourethral ligaments, derived from facial of pelvic floor & levator ani.

Question 15

What happens in vaginal delivery?

Answer 15

The pudental nerve might be compressed–> again, predisposing to stress UI.

Question 16

Whats a bladder? What happens to overactive bladders in women?

Answer 16

Detrussor muscle should only contract during micturition and relax when filled. The detrussor relaxes durinh filling, but then contracts involuntarily.

Question 17

How do the symptomes of overactive bladders come about?

Answer 17

If the contraction-modest, she will experience urinary urgency.
If severe- UI. Since the oressure in the bladder will be above the press of the urethra.

Question 18

Whats the aetiology of stress(SUI?)

Answer 18

Requires some degree of weakness in both proximal & distal urethral sphnicter mechanisms.
No cause, but predisposing factors:
Pregnancy
Prolapse( e.g. Anterior vjj wall)
Menopause
Collagen disorder (constitute the pubourethral ligaments)
Obesity

Question 19

How does pregnancy aid in SUI?

Answer 19

(denervation of pudental nerve–> damage to the supporting tissues round urethra)
The 1st vjj delivery more common to cause it.
Caesarean section can prevent it.
⬆️ intra abdo pressure, + smooth muscle- relaxant effect of progesterone.

Question 20

Why does menopause cause SUI? What does that mean?

Answer 20

Oestrgen abscence reduces the maximal urethral closure pressure; hence urethral pressure not as great as it used to be :( oh noo.
A small rise in intra abdo pressure, will reult is SUI.

Question 21

Whats the pathophysiology of an overactive bladder?

Answer 21

Idiopathic
Neurogenic
Psychogenic

Poss agentsinvolved:
Nerve growth Factor, glutamate, nitric oxide, ATP

Question 22

Voiding difficulty

Answer 22

Opposite as that of men!
Women: due to underactive detrussor (hypotonia) 90% and 10% shows anatomical obstruction.
Usually simple ageing, natural reduction of muscle fibres and strength–> enough to present clinically.
Neuronprobs- inapropriate contraction of urethral sphincter.

Question 23

Clinical presentations of UI in women-

Answer 23

Stand alone- uncommon.
Urge incontinence- overactive bladder.
Ask about voiding difficulties
Sx are same as men: prostatic enlargement:
Hesitancy, poor stream, intermettent stream, streining to void, feeling of incomplete emptying and post- micturition dribbling.
Haematuria❌ – upper & lower urinary tracts ecpxamined.

Question 24

What else can coexist with UI?

Answer 24

Anal. Incontinence
Full DHx +medical Hx
Essential: what impact on her lifestyle
Can prevent socialising 
Severe: personality changes + womans sex life.

Question 25

What effects can Nocturia have?

Answer 25

Lack of sleep
Diff concentration -& working
In elderly- common cause of Falls and esp NOF!
In elderly- 2nd most common cause that elderly cant go back to individual living.

Question 26

Whats the diagnostic evaluation of UI in women?

Answer 26

All should undergo pelvic and abdo exam, after she has emptied her bladder.
Palpable bladder- urinary retention or unsuspected pelvic mass……
Pelvic exam may reveal pelvic organ prolapse or vaginal atrophy.
Coexisting symptomatic prolapse- surgical solution for incontinence while vaginal oestrogens for atrophy.
SUI- asked to give a sharp cough- check S2-4 dermatomes and check anal incontinence if prsent- digital rectal examination.

Question 27

What further assesments could be done?

Answer 27

Urinalysis! Every woman presenting w/ lower urinary tract infxs
Leukocytes & nitrites: UTIs- may be worsening symptoms.
Broad spec antibiotics!
Haematuria- cystoscopy (or recurrent UTIs and not for overactive bladders) & USS of upper renal tracts.
Glycosuria- DM- can predispose for UTIs & Ufrequency.
Frequency vol chart can be completed
&quality of life questionnaire before and after treatment

Urodynamic studies
Dymanic!
Invasive, embarassing , expensive & time comsuming.
Less emphasis.

More emphasis on her perspective of the symptms.

Question 28

What are the Treatment options of UI?

Answer 28

Conservative: lifestyle interventions lose weight, and bladder retraining,
Physiotherapy
Drug therapy
Surgery

Question 29

What are the lifestyle intervantions that can be taken?

Answer 29

Normalise fluid intake
If drink too much⬆️ frequency & incontinence
1.5 L per day aim
Cut down alcohol & restrict caffeine.
BMI >30
Stop smoking
Avoid carbonated drinks

Question 30

Types of bladder restraining

Answer 30

Physical therapy
Distraction techniques or doing something that requires concentrationsitting in hard seat or across a tightly rolled towel
Pelvic floor squeezes

Question 31

What happens w/ Physiotherapy?

Answer 31

1st line treatment for incontinence
Muscle training of pelvic flood muscles
Teach voluntarily contractions- regularly contractions & relaxations of pelvic flood muscles

Question 32

What could be a potential surgery SIU?

Answer 32

Tension free vaginal tapes.

Question 33

Surgery for Overactive Bladder

Answer 33

Sacral nerve root stimulation
Botulinum toxin A injections
Detrussor myectomy

Question 34

Tx for voiding disorders and fistula

Answer 34

Indwelling Catheter- check risk of infection

fistula: if that fails, surgical correction.

Question 35

Key points

Answer 35

UIs QOL issue
10-20% of adult women
Many will also suffer from anal incontinence but this will not usually be voiced
Lifestyle advise essential
Tape surgery is succesful in up to 90% of stress UIs