Week 4- Urinary incontinence Flashcards
What urethral causes can cause urinary incontinence?
Detrusor overactivity
Urethral sphincter incompetence
Retention with overflow
Functional
What external causes to the urethra can cause urinary incontinence?
Congenital
Fistula
What are the types of urinary incontinence?
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
What are the risk factors for urinary incontinence?
Female sex- shorter urethra, pregnancy, childbirth and menopause are all RF’s.
Age- as you get older the muscles in your bladder and urethra lose some strength
Obesity- being overweight increases the pressure on your bladder
Smoking- risk of overactive bladder. Also chronic cough can cause episodes of incontinence.
Kidney disease or diabetes can increase risk of urinary incontinence.
What is meant by urgency?
The complaint of a sudden desire to pass urine which is difficult to defer.
What is meant by nocturia?
The complaint of having to wake up at night to void.
What is meant by frequency?
Patient voids too often per day.
What is urge urinary incontinence?
Involuntary urine leakage accompanied or preceded by the urge to urinate.
What is overactive bladder syndrome?
Urgency, with or without urge urinary incontinence, usually with frequency and nocturia in the absence of pathological or metabolic conditions that might explain these symptoms.
What is the difference between wet overactive bladder and dry overactive bladder?
Wet- is when there is urge urinary incontinence
Dry is when there isn’t.
What is mixed urinary incontinence?
Involuntary leakage associated with urge and also with sneezing, coughing and exertion (stress urinary incontinence)
What things in a history do you want to determine to get a good idea of what type of incontinence this is? Which tools can help with this?
Bladder diary for 3 days
Caffiene- important
Storage symptoms- frequency, nocturia, urgency, stress (e.g. cough, exertion).
Voiding symptoms- hesitancy, failure to void, poor flow
Postmicturition symptoms- incontinence, incomplete emptying.
Quantity of urine released.
On examination of urinary incontinence, what should you look for?
BMI
Abdominal exam- for pelvic masses
vaginal exam- prolapse, atrophy, SUI, fistula
PR- masses
How can urinary incontinence impact on quality of life?
Sexual- dont want to get into sexual interactions
Physicals- limit physical exercise
Psychological- guilt/depression. Loss of respect/dignity
Occupational- absence from work.
Domestic- requirements for specialised underwear/bedding.
Social- reduction in social interaction.
What occurs to the muscle in the bladder in overactive bladder?
It contracts frequently and involuntarily.
What occurs to the muscle in the bladder in stress incontinence?
Pressure on the muscle means the support muscles can’t remain closed, and therefore you get leakage of urine.
What tests on examination, and other investigations, can help diagnose a type of urinary incontinence?
Stress test- ask the patient to cough.
Post void residual- if more than 50mls is left- not good
Urinalysis- dipstick-
Bladder diary
Urodynamics- generally used in women who have had treatment but not got better.
Cystoscopy- maybe used in constant urine infections that aren’t treated.
Ultrasound- maybe for masses.
What is the normal voiding frequency and volume?
Normal is less than 8 times a day
Urine output of less than 2800.
How can you manage incontinence- go from least invasive to most invasive?
Lifestyle factors- weight loss, dietary advice, avoidance of caffeine Bladder drill Pelvic floor physiotherapy Drugs Botox Neuromodulation Reconstructive surgery.
What lifestyle measures can help with urinary incontinence?
Bladder retraining for a minimum of 6 weeks- aiming to increase bladder capacity and decrease frequency
Combination of bladder retraining and antimuscurinic if frequency is a problem
Sensible fluid intake
Caffeine reduction
Weight reduction
Which types of urinary incontinence do pelvic floor exercises benefit the patient?
Stress incontinence and mixed incontinence.
After lifestyle changes, what is the most common treatment for overactive bladder?
How do they work?
Anti-muscurinics.
They reduce intra-vesicle pressure, increase compliance, raise volume threshold for mictuiriton and reduce uninhibited contractions.
What side effects can you get from anti-muscarinics?
Dry mouth
Constipation
Blurred vision
Somnolence (strong desire to sleep)
If antimuscurinics fail, what other pharmacological treatment can be offered for overactive bladders?
beta 3 agonists- mirabegron
How do beta-3 agonists work?
Relaxes the bladders smooth muscle by activating the beta 3 adrenoceptor.
They increase the voiding interval and inhibit spontaneous bladder contractions during filling.
What are the conditions for using mirabegron?
Should only be used when anti-muscarinics are ineffective or contraindicated.
What other non-pharmacological (random) therapies can be used for overactive bladder?
How does it work?
Posterior tibial nerve stimulation.
Unknown mechanism of action but effective in the short and medium term.
What are the first line choices for women with overactive bladder or mixed urinary incontinence?
Oxybutylin (immediate release)
or - tolterodine (immediate release)
or propiverine (immediate release)
What are the second line choices for women with overactive bladder or mixed urinary incontinence?
Tropsium (immediate release) or
Oxybutylin (extended release)
Darifenacin
What is uroflowmetry?
Measurement of volume of urine expelled from the bladder each second.
When is uroflowmetry indicated?
Hesitancy Voiding difficulty Neuropathy History of urine retention Post op follow up
When is multichannel urodynamics indicated?
Uncertain diagnosis
Failure to respond to treatment
Prior surgery
What is cystometry?
A measure by which the pressure/volume relationship of the bladder is measured during filling, provocation and during voiding.
When is post-residual volume considered abnormal?
greater than 100-150
What is overflow incontinence?
When there is obstruction of the urethra.
Poor contractile bladder muscle.
What must you stop in overflow incontinence?
Must stop anticholinergics.
How do you treat stress urinary incontinence conservatively?
Lifestyle- lose weight, less caffeine, stop smoking, avoid excessive fluid intake.
Physiotherapy- pelvic floor muscle retraining, biofeedback, electrical stimulation
Drugs- duloxetine
Others- incontinence pads, vaginal pessaries
How does duloxetine work?
Its a combined serotonin and noradrenaline reuptake inhibitor (increased intraurethral closure pressure)
What surgical methods can treat stress incontinence?
Low tension vaginal tape
Intraurethral injection
Artificial sphincters
Colposuspension
What surgical methods can treat overactive bladder?
Augmentation cystoplasty Sacral nerve modulation Tibial nerve stimulation Bladder overdistension Botox injections
What are the three compartments of prolapse?
Anterior
Middle or apical
Posterior
How is uterovaginal prolapse classified?
1st degree- into the vagina
2nd degree- at interiotus
3rd degree- outside vagina
Procidentia- entirely outside the vagina
What compartment does a cystocele occur in?
Anterior
What is a cystocele?
Occurs when the wall between the vagina and bladder are weakened and allows the bladder to droop into the vagina.
What are the symptoms of a cystocele?
Bulging pressure Mass felt Difficulty voiding Incomplete voiding Difficulty inserting tampon Pain with intercourse.
What compartment does an enterocele occur in?
Middle/apical compartment.
What is an enterocele?
The peritoneal sac containing bowel droops posterior to the vagina into the rectovaginal space between the posterior surface of the vagina and anterior surface of the rectum.
What are the symptoms of an enterocele?
Same symptoms as cystocele: Bulging pressure Mass felt Difficulty voiding Incomplete voiding Difficulty inserting tampon Pain with intercourse.
What compartment does a rectocele occur in?
Posterior
What is a rectocele?
Herniation of the anterior wall of the rectum into the vagina.
What are the symptoms of a rectocele?
Bulging pressure Mass felt Incomplete defecation Difficulty inserting tampon Pain with intercourse.
In taking a history of someone with prolapse, what headings do you need to cover?
Urinary symptoms
Bowel symptoms
Sexual history/dysfunction
How is prolapse diagnosed?
Which tests may benefit?
Clinical diagnosis Could perform: USS MRI Anorectal manometry Endoanal USS
What is complete eversion?
All compartments-
Uterine providentia (completely outside the body)
Complete uterine prolapse
What is the pelvic organ prolapse quantifications system (POP QS)
Patient is straining while 6 specific sites are evaluated.
Measure each site to the hymenal ring- which is fixed.
If the site is above the hymen- negative number
If below- positive number.
What are the risk factors for vaginal prolapse?
Ageing Pelvic surgery Menopause Loss of muscle tone Multiple vaginal births Obesity Chronic constipation, coughing or heavy lifting Uterine fibroids Family history Connective tissue disorders e.g. marfans.
How do you manage uterovaginal prolapse?
Reassure
Avoid heavy lifting, lose weight, stop smoking
Vaginal oestrogens- if atrophic vaginitis.
What are the treatment options for prolapse?
Expectant Management Physiotherapy Pessary Surgery (Many!!) -Abdominal -Vaginal -Laparoscopic -Robotic assisted Laparoscopy -Mesh kits
Who is suitable for a pessary?
Women unfit for surgery Relief symptoms whilst awaiting surgery Further pregnancies planned or pregnant As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI Patient request
