Urinary incontinence (URO) Flashcards
What is urinary incontinence?
Common condition characterised by uncontrollable leakage of urine
Which group of people is urinary incontinence most common in?
Elderly females
What are the types of causes of urinary incontinence? (3)
- neurological causes
- genitourinary causes
- reversible causes
What are the neurological causes of urinary incontinence? (2)
- multiple sclerosis
- spinal injury
What are the genitourinary causes of urinary incontinence? (4)
- trauma to pelvic floor
- pelvic floor weakness
- sphincter deficiency
- bladder outlet obstruction
What are the reversible causes of urinary incontinence? (2)
- diuretics
- UTIs
What are the types of urinary incontinence? (4)
- stress incontinence
- urge incontinence
- mixed incontinence (stress + urge)
- overflow incontinence
What is stress incontinence?
- pelvic floor laxity –> urethra loses support –> increase in intra-abdominal pressure overwhelms sphincter muscles
- urination associated with sneezing, coughing, laughing, pregnancy
What is urge incontinence?
- over-active bladder –> involuntary urination preceded by feeling of not having to go
- overactivity of detrusor muscle –> strong sudden sense of urgency followed by involuntary leakage
- associated with nocturia and polyuria, and can be due to UTI, stroke, Parkinson’s, MS
What is mixed incontinence?
Combination of stress and urge incontinence
What is overflow incontinence?
Caused by urinary retention due to bladder outlet obstruction or ineffective detrusor muscle –> bladder pressure increases to exceed urethral resistance –> leakage
What is a symptom of overflow incontinence?
Weak/intermittent urinary stream or hesitancy
Frequent loss of small amounts of urine
What are some causes of overflow incontinence? (3)
- drug causes of urinary retention - TCA (amitriptyline) due to cholinergic effect, opioids
- blockage due to - BPH, prostate cancer, urethral strictures, severe constipation, prolapsed uterus
- ineffective detrusor - due to disorders affecting autonomic innervation of bladder e.g. DM, SC injury, CES, anticholinergics
What are some signs of urinary retention (overflow incontinence)? (3)
- palpable bladder
- suprapubic tenderness
- delirium in elderly patients
What might you find on examination in urinary incontinence? (3)
- vaginal bulge/pressure
- urogenital atrophy
- abnormal bulbocavernous and anal wink reflexes –> suggests disruption of sacral reflex
What are some risk factors for stress incontinence? (3)
- vaginal childbirth
- pregnancy
- hysterectomy
What are some risk factors for urge incontinence? (5)
- advancing age
- high BMI
- smoking
- caffeine
- UTI, stroke, Parkinson’s, MS
What are the first-line investigations for urinary incontinence? (5)
- cough stress test - urine leakage
- urinalysis - rule out UTI
- post-void residual measurement
- empty supine stress test
- urodynamic studies - differentiate types of incontinence
What does post-void residual measurement show in urinary incontinence?
- after a spontaneous void
- may confirm urinary retention if overflow incontinence suspected
- determined with US or sterile catheterisation
- elevated if >100mL or >50% voided volume
What does empty supine stress test show in urinary incontinence?
Valsalva manoeuvre in dorsal lithotomy position after spontaneously voiding –> urine leakage if positive
Why are bladder diaries completed in urinary incontinence?
To assess frequency and volume of micturition, completed for a minimum of 3 days
What examination excludes pelvic organ prolapse in urinary incontinence?
Vaginal exam - also assesses ability to initiate voluntary contraction of pelvic floor muscles
Why is urine dipstick and culture done for urinary incontinence?
To exclude UTI - can cause urgency, frequency and/or incontinence
What investigation is requested for suspected bladder outflow obstruction (–> overflow incontinence), and what does it show?
Urodynamic studies showing:
- increased detrusor pressure
- reduced urine flow rate
What is diagnostic for acute urinary retention?
- bladder US diagnostic for acute urinary retention
- post-void residual measurement (US or sterile catheterisation) can identify urinary retention
- chronic high pressure urinary retention - if renal function is impaired/hydronephrosis –> typically due to bladder outflow obstruction
- chronic low pressure urinary retention - normal renal function and no hydronephrosis
What is the difference between chronic high pressure vs chronic low pressure urinary retention?
- high pressure –> renal function impaired or hydronephrosis (typically due to bladder outflow obstruction)
- low pressure –> normal renal function and no hydronephrosis
What are some differential diagnoses for urinary incontinence? (5)
- urogenital fistula - continuous urine loss with no association to other Sx or timing
- ectopic ureter
- UTI
- atrophic urethritis/vaginitis - frequency and irritation with voiding
- pregnancy - frequency w/o irritation or incontinence, low perceived bladder volume
What lifestyle modifications can we prescribe for urinary incontinence? (3)
- weight loss
- diet changes (decrease alcohol and caffeine)
- smoking cessation
How do we manage stress incontinence?
- 1st line: pelvic floor exercises
- if urethral sphincter insufficiency - pseudoephedrine (alpha-blocker) or duloxetine (combined SNRI)
- if caused by menopause - oestrogen replacement therapy
- surgery (urethral hypermobility/displacement) - retropubic mid-urethral tape procedure, sling procedures (sling around NoB to support), retropubic suspension, retropubic colposuspension
- peri-urethral bulking injection (constrict urethra)
How do we manage urge incontinence?
- 1st line - bladder retraining –> lasts for minimum of 6 weeks with aim to increase intervals between voiding
- medications - oxybutynin (anticholinergic antimuscarinic = inhibits detrusor overactivity) or mirabegron (beta3 agonist)
- neuromodulation
- botulinum toxin type A
When is oxybutynin contraindicated (urge incontinence)?
First-line pharmacological therapy is oxybutynin (anticholinergic) but CI in glaucoma and best avoided in frail/elderly –> mirabegron (beta3 agonist) is the medication of choice
How do we manage overflow incontinence?
- medications:
- alpha blockers - prazosin, tamsulosin (relaxes smooth muscle in bladder neck)
- cholinergic agents - bethanchol (increases bladder muscle tone)
- surgery:
- anterior colporrhaphy (vaginal prolapse)
- colposuspension (stitches to support NoB)
- intermittent self-catheterisation
What are some complications of incontinence? (5)
- depression
- psychological stress
- dermatitis/skin infections (due to prolonged contact with urine)
- UTI
- surgery-related: urinary retention, bladder perforation, haemorrhage, bowel injury, voiding disorders, wound complications
What acute pathology can urinary retention lead to?
AKI
