Female urinary incontinence

Question 1

What does the urinary tract consist of?

Answer 1

2 mutually dependent components:

• Upper tract = kidneys and ureters
• Lower tract = bladder and urethra

Question 2

What is the role of the upper tract of the urinary system?

Answer 2

Low pressure distensible conduit with intrinsic peristalsis

Transports urine from nephrons via ureters to bladder

Question 3

What is the role of the lower tract of the urinary system?

Answer 3

Low-pressure storage of urine

Efficient expulsion of urine

Question 4

What rate does the bladder fill at?

Answer 4

0.5-5mls/min

Question 5

What is the vesico-ureteric mechanism?

Answer 5

Protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from bladder

Question 6

What nerves supply the bladder?

Answer 6

Hypogastric nerve (sympathetic T10-L2)
Pelvic nerve (parasympathetic S2-4)
Pudendal nerve (somatic S2-4)

Question 7

What does the hypogastric nerve (sympathetic T10-L2) supply and control?

Answer 7

Detrusor muscle

Storage - causes relaxation of the detrusor muscle, promoting urine retention

Question 8

What does the pelvic nerve (parasympathetic S2-4) supply and control?

Answer 8

Detrusor muscle

Voiding - contraction of the detrusor muscle, stimulating micturition

Question 9

What does the pudendal nerve (somatic S2-4) supply and control?

Answer 9

External urethral sphincter

Innervates the external urethral sphincter, providing voluntary control over micturition

Question 10

What does cortical activity control in regards to the bladder?

Answer 10

Increases sphincter contraction and activity
Activates sympathetic pathway & reciprocal inhibition of the parasympathetic pathway
Mediates contraction of bladder base and proximal urethra

Question 11

In simple terms, does sympathetic innervation aid voiding or storage?

Answer 11

Storage

Question 12

In simple terms, does parasympathetic innervation aid voiding or storage?

Answer 12

Voiding

Question 13

What physiologically happens during bladder emptying?

Answer 13

Detrusor contraction
Urethral relaxation
Sphincter co-ordination

Question 14

Where is the cortical activity in the brain helping with micturition?

Answer 14

Pontine micturition centre

Question 15

What does the pontine micturition centre control in terms of voiding?

Answer 15

Activation of parasympathetic pathway

Inhibition of sympathetic pathway

Question 16

What is mixed urinary incontinence (UUI)?

Answer 16

Involuntary leakage accompanied by or immediately preceded by urgency & on effort or exertion, sneezing or coughing

Question 17

How is the prevalence of UI affected with age?

Answer 17

Increases with age

Question 18

What impact does UI have on life?

Answer 18

Impair QoL
Reduce social relationships/activities
Impair emotional/psychological well being
Impair sexual relationships
Embarrassment/self-esteem

Question 19

What are risk factors for UI?

Answer 19

Age
Parity
Menopause
Smoking
Increased intraabdo pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery

Question 20

What is the main risk factor for stress incontinence?

Answer 20

Pregnancy & childbirth

Question 21

What might you ask in patient Hx of UI?

Answer 21

Age, parity, mode of deliveries, weight of heaviest baby, smoking, HRT
Medical conditions: DM, anti-HTN medications, glaucome, cognitive problems, anti-depressants/anti-psychotics
Previous PFMT, surgical treatment of SUI or POP

Question 22

What are irritation symptoms?

Answer 22

Urgency
Increased daytime frequency
Nocturia
Dysuria
Haematuria

Question 23

What are voiding symptoms?

Answer 23

Straining to void
Interrupted flow
Recurrent UTI

Question 24

What is OAB (overactive bladder) usually associated with?

Answer 24

Frequency
Nocturia
Urgency

Question 25

What are prolapse symptoms?

Answer 25

Vaginal lump | Dragging sensation in vagina

Question 26

What are bowel problems associated with UI?

Answer 26

Anal incontinence Constipation Faecal evacuation dysfunction IBS

Question 27

What can be assessed in patients with UI?

Answer 27

3 days urinary diary: fluid intake, urine output, daytime freq, nocturia, average voided volume Urine dipstick

Question 28

What should be examined in a woman with bladder/pelvic floor problems?

Answer 28

``` General Abdominal Neurological Gynaecological Pelvic floor assessment ```

Question 29

What is the scale for assessing pelvic floor?

Answer 29

Oxford Scale

Question 30

What are you looking for in an examintion in a woman with bladder/pelvic floor problems?

Answer 30

``` Prolapse SI Uro-genital atrophy changes Pelvic mass (space occupying lesion) Pelvic floor tone, strength, awareness ```

Question 31

What are investigations for urinary incontinence?

Answer 31

Urinalysis: Dipstix +/- MSSU Post voiding residual volume assessment Urodynamics

Question 32

When is urodynamic studies indicated?

Answer 32

If surgical treatment contemplated

Question 33

What is the management for UI?

Answer 33

Lifestyle changes Medical treatments Physio Surgery

Question 34

What lifestyle changes can be made for UI?

Answer 34

Stop smoking Lose weight Eat healthier to avoid constipation Stop alcohol and caffeine

Question 35

What does pelvic floor muscle training do?

Answer 35

Reinforcement of cortical awareness of muscle groups Hypertrophy of existing muscle fibres General increase in muscle tone and strength

Question 36

What drug for moderate to severe stress UI (SUI)?

Answer 36

Duloxetine

Question 37

What should Duloxetine be prescribed with?

Answer 37

Pelvic floor muscle training (PFMT)

Question 38

Who should receive Duloxetine?

Answer 38

PFMT failed or would be enhanced with Duloxetine | Or if no surgery in secondary care

Question 39

What is the theory related to SUI and the mechanism of continence at the time of increased intra-abdominal pressure?

Answer 39

Pressure-Transmission Theory

Question 40

Where is the anatomical defect in both SUI and UUI?

Answer 40

Anterior vaginal wall and pubo-urethral ligament (PUL)

Question 41

What anatomical feature might provoke a a premature micturition reflex and UI?

Answer 41

Suburethral hammock laxity resulting in stimulation of bladder neck stretch receptors

Question 42

What are surgical treatments for UI?

Answer 42

TVT - tension-free vaginal tape | Colposuspension

Question 43

What happens in surgery with tension-free vaginal tape (TVT)?

Answer 43

Minimally invasive procedure to reinforce the structures supporting the urethra

Question 44

What is the first choice treatment in the surgical treatment of SUI?

Answer 44

TVT

Question 45

What is overactive bladder syndrome?

Answer 45

Symptom related to urodynamically demonstrable detrusor overactivity (DO)

Question 46

What are the symptoms of overactive bladder?

Answer 46

Urgency (with/without UI) Frequency Nocturia

Question 47

What are risk factors for urge incontinence?

Answer 47

Advanced age Diabetes UTIs Smoking

Question 48

What type of condition is OAB?

Answer 48

Chronic - symptoms may wax and wain

Question 49

What is the management for OAB?

Answer 49

Treat symptoms No immediate cure MDT approach Lifestyle: normalise fluid intake, reduce caffeine, chocolate, stop smoking, weight loss Bladder training programs: timed voiding gradually increasing intervals

Question 50

What is the pharmacological treatment for OAB?

Answer 50

Antimuscarinics: solifenacin Tri-cyclic antidepressants: imipramine Botox Neuromodulation