Urinary Incontinence - Stress

Question 1

ESSENCE

Answer 1

Muscles of pelvic floor and sphincter muscles become weak, allowing urine to leak at times of increased pressure on the bladder such as laughing or coughing

Question 2

AETIOLOGY

Risk factors

Answer 2

• Increased age
• Postmenopausal
• Increase BMI
• Previous preganncy or vaginal delivery
• Pelvic organ prolapse
• Pelvic floor surgery
• Neurological conditions such as MS
• Cognitive impairment and dementia

Question 3

CLINICAL FEATURES

Presentation

Answer 3

• Urine leakage on effort, exertion, sneezing or coughing
• Frequency

Question 4

When assessing what should be checked

Answer 4

• Modifiable lifestyle factors
  
  • Caffeine
  • Alcohol
  • Medications
  • BMI
• Assess severity
  
  • Frequency of urination
  • Frequency of incontinence
  • Nighttime urination
  • Use of pads and changes of clothing
• Examination of pelvic tone
  
  • Pelvic organ prolapse
  • Atrophic vaginitis
  • Urethral diversiculum
  • Pelvic masses

Question 5

How can strength of pelvic floor muscles be assessed

Answer 5

Bimanual examination by asking woman to squeexe against examining fingers

Question 6

What can be used to grade strength of pelvic floor muscles after bimanual examination

Answer 6

• Modified Oxford grading system
  
  • 0 no contraction
  • 1 faint
  • 2 weak
  • 3 moderate with some resistance
  • 4 good with resistance
  • 5 strong, a firm squeeze and drawing inwards

Question 7

INVESTIGATIONS

First choice

Answer 7

• Bladder diary
• Urine dipstick - infection, haematuria, pathology
• Post-void residual bladder volume
• Urodynamic testing

Question 8

MANAGEMENT

General principles

Answer 8

• Address lifestyle factors
  
  • Caffeine, diuretics, fluid intake, weight
• Supervised pelvic floor exercises
• Surgery
• Duloxetine

Question 9

MANAGEMENT

Surgical options

Answer 9

• Tension-free vaginal tape (TVT)
• Autologous sling procedures
• Colposuspension
• Intramural urethral bulking

Question 10

What is tension free vaginal tape

Answer 10

Mesh sling looped under urethra and behind pubic symphysis to abdominal wall, supports urethra reducing stress incontinence

Question 11

What is autologous sling procedures

Answer 11

Similar to TVT, strip of fascia from patients abdominal wall is used rather than tape

Question 12

What is colposuspension

Answer 12

Stiches connecting anterior vaginal wall and pubic symphysis, around urethra pulling vaginal wall forwards and supporting urethra

Question 13

What is intramural urethral bulking

Answer 13

• Injections around urethra to reduce diameter and add support

Question 14

COMPLICATIONS

Answer 14

Surgery related haemorrhage, bowel injury, urinary retention, UTI