Urodynamic stress incontinence and overactive bladder syndrome Flashcards
How are urinary symptoms divided?
Storage (FUND) and voiding (HIIPS) symptoms :
Storage:
- Frequency
- Urgency
- Nocturia
- Dribbling (incontinence)
Voiding:
- Hesitancy
- Intermittent flow
- Incomplete emptying
- Poor flow
- Straining
How common is urinary incontinence?
Affects 4-5% of the population
More common in elderly females
What are the RFs for stress UI?
- advancing age
- previous pregnancy and childbirth
- long labour
- perineal trauma
- forceps delivery
- multiparity (particularly vaginal births)
- high BMI/obesity
- FH e.g. connective tissue disease
- chronic cough
- doxazocin (alph-adrenergic agonist) for HTN causes relaxation of the urethral sphincter
What are the RFs for urge UI?
- childhood bedwetting
- obesity
- smoking
- previous hysterectomy
- previous continence surgery
What should you ask the patient about incontinence?
- No of episodes/day of frequency, urgency or leakage
- Need for pads? How many and what size?
- Ever need to change underclothes or outer clothes from leakage?
- Behavioural changes employed e.g. fluid intake reduced, social activities
- Associated symptoms - prolapse, faecal incontinence, sexual difficulties
- Full medical and surgical history
- Medication history
How should you examine a patient for inconinence?
General abdominal and pelvic examination -
- Look for surgical scars, obesity, pelvic masses e.g. large fibroid or ovarian cyst
- Lithotomy position using right-angles Sims speculum to assess each vaginal wall for prolapse
- Coughing/Valsalva maneouvre to assess for veasible leakage
- Assess for ability to contract and hold pelvic floor muscles
List the types of incontinence.
- overactive bladder (OAB)/urge incontinence
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence
- functional incontinence
Aetiology of continence, and stress and urge incontinence:
A) In normal women, the bladder neck is supported above the pelvic floor and so abdominal pressure increases are transmitted to the bladder neck
(B) Loss of bladder neck support results in descent of the bladder neck and loss of pressure transmission, resulting in leaking when coughing, straining, etc (stress incontinence).
(C) Detrusor overactivity causes increased sensation;
leakage only occurs if the contraction pressure exceeds the pelvic floor and sphincter pressure.
What is mixed incontinence?
Stress incontinence (leaking with cough, straining, exercise, etc) + frequency, urgency and urge incontinence.
Frequency, urgency +/- urge incontinence = OAB (overactive bladder)
What is detrusor overactivity the cause of?
Urge incontinence - involuntary contraction of the detrusor during filling phase of micturition
What is the aetiology and presentation of urge incontinence?
Caused by detrusor overactivity - cause of this is unknown but may be linked to decreased sensory and interstitial innervation to the bladder wall and changes in neurotransmitter levels
Urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
What is a common cause of urge incontinence?
Bladder outlet obstruction, e.g. due to prostate enlargement
What is functional incontinence and what are some causes?
Comorbid physical conditions impair the patient’s ability to get to a bathroom in time
Causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
What investigations should be done for UI?
- Bladder diaries - completed for a minimum of 3 days
- Vaginal examination - exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- Urine dipstick and culture
- Urodynamic studies
What is a ‘pad test’?
Patient is asked to wear a pre-weighed pad and asked to do various exercises e.g. climbing stairs, hand washing, coughing or other ADLs to assess objectively the level of incontinence.
Usually done over 24 hours at home
What is the management of stress incontinence?
- Pelvic floor muscle training - 8 contractions 3 times a day for 3 months
-
Surgery - u
- Retropubic mid-urethral tape procedure
- or Burch colposuspension
- or Periurethral injections of material to bulk up bladder neck
- Medication - if surgery declined i.e. duloxetine (SNRI)
What is the MOA of duloxetine in stress incontinence management?
Pudental nerve will have increased synaptic concentration of NA and 5HT
So urethral striated muscles within the sphincter undergo increased stimulation
This causes increased contraction
Ten teachers: duloxetine acts on the micturition centre in the sacral spinal cord to increase sympathetic nerve output to the urethral sphincter and increase sphincter tone. Causes improvement in 50% of patients with leakage symptoms.
