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female urinary incontinence Flashcards

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1
Q

what are the 2 components of the urinary tract (important!!)

A

upper - kidneys and ureters, low pressure distensible conduit w/ intrinsic peristalsis (verniculation), transports urine from nephrons via ureters to bladder

lower - bladder and urethra, low pressure storage of urine, efficient expulsion of urine at appropriate place and time

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2
Q

rate of bladder filling

A

0.5-5mls/min

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3
Q

rate of bladder filling

A

0.5-5mls/min

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4
Q

what is the vesico-ureteric mechanism

A

between UUT and LUT

one way valve

protects the nephrons from any damage 2y to retrograde transmission of back pressure/infection from the bladder

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5
Q

nerve supply to the bladder

A

s**torage - hypogastric nerve (**symp), T10-L2 - relaxation of bladder and contraction of ureteric sphincter

voiding - p**elvic nerve (**p**arasymp), S2-4 (**power), contraction of bladder and relaxation of sphincter

voluntary - pudendal nerve (somatic), S2-4

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6
Q

bladder filling

A

accomodate increasing volume at constantly low pressure

inhibition of contractions by giving rise to gradual awareness of filling

distensable bladder wall

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7
Q

cortical activity and bladder filling

A

activating a reciprocal guarding reflex by rhabdosphincter contraction, increase sphincter contraction and resistance

activates sympathetic pathway

reciprocal inhibition of the parasympathetic pathway

mediates contraction of bladder base and proximal urethra

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8
Q

bladder emptying

A

detrusor contraction

urethral relaxation

sphincter co-ordination

absence of obstruction (cystocele, diverticulum etc)

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9
Q

cortical influence on bladder emptying

A

pontine micturition centre

activation of parasympathetic pathway and inhibition of sympathetic pathway

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10
Q

what is urinary incontinence - UI

A

ANY involuntary leakage of urine

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11
Q

what is stress urinary incontinence -SUI

A

involuntary leakage on effort or exertion, on sneezing or coughing

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12
Q

what is urge urinary incontinence - UUI

A

involuntary leakage accompanied by or immediately preceded by urgency

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13
Q

what is mixed urinary continence - MUI

A

involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing

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14
Q

epidemiology of UI

A

10-25% of women aged 15-60

15-40% of women >60

>50% of women in nursing homes

WHO international health concern

prevalence increases w/ age

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15
Q

impact of UI

A

UI may significantly impact QOL

reduce social relationships and activities

impair emotional and psychological well being

impair sexual relationships

embarrassment and diminished self esteem

impact on QOL is why women seek help but often after yrs of suffering (~5yrs)

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16
Q

risk factors for UI

A

age

pregnancy

parity

menopause

smoking

medical problems

chronic increased intra-abdo pressure

pelvic floor trauma

denervation

connective tissue disease

surgery

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17
Q

what is the main risk factor for SUI

A

pregnancy and childbirth

large object passing through a constricted channel

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18
Q

patient assessment for UI

A

hx

examination

investigations

management

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19
Q

hx for UI

A

age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT

medical conditions: DM, anti-HT medications, glaucoma, heart/kidney/liver problems, cognitive problems, anti-depressants/psychotics

previous PFMT, surgical treatment of SUI/POP

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20
Q

irritation symptoms

A

urgency - sudden compelling desire to void that is difficult to defer

increased daytime frequency (>7)

nocturia (>1)

dysuria

haematuria (red flag; frank, not cystitis, >50, smoker)

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21
Q

incontinence symptoms

A

SUI

UUI

coital incontinence

severity - how many pads/day

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22
Q

patient assessment - complaint

A

irritation symptoms

incontinence symptoms

voiding symptoms

OAB (overactive bladder) - usually associated w/ frequency, nocturia and urgency

fluid intake - quantity and content

effect on QOL

prolapse symptoms

bowel symptoms

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23
Q

voiding symptoms

A

straining to void

interrupted flow

recurrent UTI - red flag

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24
Q

prolapse symptoms

A

vaginal lump

dragging sensation in vagina

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25
bowel symptoms
anal incontinence constipation fecal evacuation dysfunction IBS
26
patient assessment following hx taking
2-3 days urinary diary urine dipstick
27
urinary diary
fluid intake - quantity and content urine ouput - excluding nocturnal polyuria daytime frequency nocturia avg voided volume
28
examination of a women w/ bladder/pelvic floor problems
general/abdo neuro - if indicated by hx gynae - prolapse; stress incontinence; uro-genital atrophy changes; pelvic mass; pelvic floor tone, strength, awareness
29
investigations for urinary incontinence
urinalysis - multistix +/- MSSU post-voiding residual volume assessment - bladder scanning urodynamics
30
what is urodynamics
study of bladder/urethral physiology to detect underlying pathology that may explain symptoms invasive set of tests that are only indicated if surgical treatment is contemplated women w/ SUI symptoms may not need urodynamics prior to surgery unless symptoms of voiding difficulties/concomitant prolapse or prev failed continence surgery
31
indications for urodynamics
confirm diagnosis differentiate SUI vs detrusor overactivity vs MUI investigate voiding symptoms
32
NICE guidelines for urodynamics
* do not perform prior to conservative UI management * perform in women w/ refractory OAB * women w/ predominant SUI symptoms and demonstratable SUI on examination, perform prior to 1y surgical treatment for SUI if associated prolapse or VD symptoms
33
DO management following urodynamics for refractory OAB
if DO confirmed → offer botox, SNM if no DO confirmed → consider botox/SNM
34
management of UI
lifestyle changes medical physiotherapy surgical
35
conservative management for UI
**MUST** be offered to **ALL** women w/ UI * 60-70% of women will not come back for further surgery should be completed prior to contemplating surgical treatment where not possible (rare) - documentation and MDT discussion
36
lifestyle changes for UI
normalise fluid intake (1.5-2L/day) reduce caffeine, fizzy drinks, chocolate stop smoking weight loss avoid constipation and chronic cough
37
what is offered to every woman w/ UI
physiotherapist for pelvic floor muscle training (unless score of 3 or 4) (+/- electrical stimulation, vaginal cones)
38
pharmacological treatment for UI
SUI - duloxetine OAB - anticholinergics - Mirabegron and vaginal oestrogen
39
PFMT
1. reinforcement of cortical awareness of muscle groups 2. hypertrophy of existing muscle fibres 1. general increase in muscle tone and strength
40
evidence for PFMT
more effective than no treatment more effective than electrical stimulation more effective than vaginal cones 60-70% cure/significant improvement - experienced physio w/ special interest and well motivated patient
41
what is PFMT
pelvic floor muscle training
42
Duloxetine for SUI
aka Yentreve selective noradrenaline reuptake inhibitor * 1st and currently only drug licensed for treatment of moderate - severe SUI * should be part of overall management strategy including PFMT
43
continence theory and surgical management - NICE guidelines
synthetic MUS (mesh) autologus (rectus) fascial slings colposuspension urethral bulking
44
surgical management of UI - synthetic MUS
- RP-TVT (retro-pubic approach, tension-free vaginal tape) = all mesh based procedures continue to be suspended in UK for concerns on safety native tissue surgery is now the most common
45
surgical management of UI - autologous (recuts) fascial slings
modified aldrige vs sling on string
46
how can colposuspension be carried out
open laparoscopic
47
what is colposuspension and what does it depend on
uses stitches to support the neck of the bladder so that it can't move about and cause stress incontinence pressure - transmission theory lifts lateral vaginal wall up at the level of the neck of the bladder stitch it to the iliopectineal ligament creates a hammock around the bladder neck
48
what is the integral theory of female UI
SUI and UUI arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament (PUL) → urethral/bladder neck closure dysfunction and SUI suburethral hammock laxity might result in stimulation of bladder neck stretch receptors, provoking premature micturation reflex and UUI
49
synthetic (mesh) mid-urethral slings - retropubic TVT * what is it * what does it rely on * effectiveness
tension free vaginal tape - introduced as a minimally invasive procedure to reinforce the structures supporting the urethra depends on the hammock theory for continence 80% cure at 11yrs polypropylene permanent synthetic tape
50
autologous (rectal) fascial sling
abdominal incision create sling from abdominal rectus sheath insert vaginally as with TVT creates hammock around mid-urethral level
51
peri-urethral bulking * who is it for * success rate
* not medically fit for surgery or not completed family * success rate 70% at 1yr, 45% at 2yrs * ? long term success and adverse effects
52
SUI surgery rates
2007-2016 48% reduction in MUS in 2016 vs 2008
53
defining symptoms of OAB
urgency (w/ or w/o urgency incontinence) usually associated w/ frequency and nocturia usually (but not always) related to urodynamically demonstratable detrusor overactivity
54
define urgency
sudden, compelling desire to pass urine that is difficult to defer
55
define urge incontinence
involuntary leakage of urine accompanied or immediately preceded by urgency
56
define frequency
usually accompanies urgency w/ or w/o urge incontinence pt considers that they void too often during the day
57
define nocturia
usually accompanies urgency w/ or w/o UI and is the complaint that the individual has to wake at night ≥1 time to void
58
risk factors for OAB and UI
advanced age DM UTI smoking OAB is a chronic condition therefore symptoms may come and go
59
OAB management
treat symptoms no immediate care MDT approach
60
OAB conservative management
lifestyle interventions - normalise fluid intake; reduce caffeine, fizzy drinks and chocolate; stop smoking; weight loss bladder training programme - time voiding w/ gradually increasing intervals w/ continence nurse
61
OAB pharmacological treament
anti-muscarinic mirabegron - beta 3 agonist andispasmodic tri-cyclic antidepressant - imipramine
62
antimuscarinics for OAB
**_oral_** * solifenacin (vesicare 5-10mg) * fesoteridine (toviaz 4-8mg) * trospium chloride (60mg XL) * darifencain (emselex 7.5-15mg) * lyrinel XL (10-20mg) * oxybutinin (5-10mg/tds) **_transdermal_** * kentera patches don't need to know all individual names, just that there is oral or transdermal
63
botox for OAB
botulinum toxin Neurogenic DO/Idiopathic DO 200-300 unit (12U/kg) - for NDO, 1001-50U for IDO cytoscopy/GA 75% cure and sig improvement effects last 6-9mths CISC - 10% pts
64
neuromodulation for OAB
needle stimulation - S2-S4 reflex inhibition to detrusor muscle cheap minimally invasive 70% improvement in refractory OAB
65
what are the management options for OAB if medication fails
botox sacral neuromodulation

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