Urinary Incontinence Flashcards
Stress as a form of urinary incontinence
Urine leaks out during any form of exertion (e.g.,exercise,coughing, sneezing, laughing) as a result of pressure on the bladder.
Urge as a form of urinary incontinence. associated with? present in which population?
A sudden and unstoppable urge to urinate. Associated with neuropathy and often present in those with diabetes, strokes, dementia, Parkinson disease or multiple sclerosis (although people without comorbidities can be affected).
Mixed
Combination of urge and stress
functional
There is no abnormality in the bladder, but the patient may be cognitively, socially or physically impaired thus hindering accessto a toilet (e.g.,patients in wheelchairs).
Urinary urgency
a sudden feeling of needing to urinate. This is the primary symptom of OAB; it can occur with or without incontinence and is usually accompanied by urinary frequency and nocturia.
Urinary frequency
voiding >= 8 times during waking hours.
Nocturia
> = 2 awakenings in the night to urinate
Urinary Incontinence
involuntary leakage of urine (see table for different forms).
OAB wet
about 1/3 patients with OAB have incontinent episodes
OAB dry
abour 2/3 patients with OAB do not have incontinence episode
What are the comorbidities that exist in patients with OAB
falls and fractures, skin breakdown and skin infections, UTis, depression and sexual dysfunction.
Social implications of OAB
Due to the embarrassment of the condition, there are many social implications of OAB, including low self-esteem, lack of sexual intimacy, social and physical isolation, sleep disturbances, limits on travel and dependence on caregivers. These can lead to a reduced quality of life. Many patients become dehydrated because they limit fluid intake. The cost of pads and adult diapers can cause a financial burden.
The detrusor muscle is innervated by:
the parasympathetic nervous system: ACH acting on Muscarinic receptor
the bladder neck is innervated by the
Sympathetic Nervous System
Internal and External sphincter innervated by:
Internal: sympathetic
External: Somatic
both voluntary and involuntary contractions of the detrusor muscle are mediated by:
Ach activation of muscarinic receptors
What happens in OAB
there is an inappropriate stimulation of the muscarinic receptors on the detrusor muscle causing involuntary contractions and the feeling of urinary urgency –> this is a contraction of the bladder even when its not full
Human bladder muscarinic receptor subtypes:
M2 and M3 in a 3:1 ratio
M3 receptor is responsible of:
emptying contractions and involuntary bladder contractions
What are the risk factors for an OAB?
1- Age >40
2- Diabetes
3- Prior vaginal delivery
4- Obesity
5- Neurologic conditions (parkinson, stroke, dementia)
6- drugs that increase incontinence (alcohol- cholinesterase inhibitors- diuretics- sedatives)
7- restricted mobility
8- hysterectomy
9- pelvic injury
What are non-drug treatments of AOB?
Behavioral therapies are considered first-line to improve OAB symptoms. These include:
- bladder training
- delayed or scheduled voiding
- pelvic floor muscle exercises (Kegel exercises)
- urge control techniques (distraction, self- assertions)
- fluid management
- dietary changes (avoiding bladder irritants)
- weight loss and other lifestyle measures (e.g., stopping medications that can worsen OAB; or with diuretics, changing the time of administration to avoid nocturia).
Can behavioral be combined with other treatment modalities? (medications or surgical interventions)
yes: medications
Surgical interventions should be reserved for the rare non-neurogenic patient who has failed all other therapeutic options and whose symptoms are intolerable.
What is technique of Kegel exercices
Instruct the patient to imagine that they are trying to stop urination midstream. Squeeze the muscles they would use. If they sense a “pulling” feeling, those are the correct muscles for pelvic exercise. Pull in the pelvic muscles and hold for a count of three, then relax for a count of three. Patients should work up to three sets of 10 exercises per day to reduce wetting episodes.
Drug treatment
A step-wise approach is recommended that begins conservatively with behavioral therapy (see previous section). Treatment depends on the degree of severity felt by the patient; with severe symptoms, treatment can begin at a higher level (see algorithm). Drugs are added to the behavioral recommendations (e.g., Kegel exercises, bladder training, weight loss), when needed.
Urge incontinence/ Mixed incontinence drug treatment:
Mixed incontinence has an urge incontinence component and is treated in a similar manner.
First-line drugs include:
–> anticholinergics (e.g., oxybutynin) or a beta-3 receptor agonist (e.g., mirabegron). OnabotulinumtoxinA (Botox) has higher efficacy but is NOT first-line due to cost and the route of administration through the urethra and into the detrusor muscle.
Nerve stimulation or surgical intervention in urge incontinence/mixed?
Used last
Women with postmenopausal symptoms of vulvar and vaginal atrophy
can use vaginal estrogen in a cream or a ring, which may provide modest relief of symptoms. Estrogen is not FDA-approved for this purpose.
