Lesson 6: Stress Urinary Incontinence Flashcards
Pathology
- Sphincter dysfunction
- Inadequate urethral resistance permits leakage during periods of increased intraabdominal pressure
— Ie. coughing, sneezing, laughing, lifting - Leakage occurs when bladder pressure exceeds urethral pressures
Etiology
Pelvic floor relaxation
- Primarily for women
- Weak muscles permit urethral hypermobility
- Urethra drop out of position → compromised sphincter function
Sphincter damage/denervation
- Leakage occurs with minimal increase in bladder pressure
- Pelvic trauma
- Radical prostatectomy
- Spinal cord injury
- Myelomeningocele
- Long-term urethral instrumentation
Urethral damage/denervated
Risk Factors
- Aging
- Traumatic vaginal deliveries
- Hysterectomy
- Chronic constipation
- Repeated urethral instrumentation
- Pelvic trauma
Presentation
- leakage with activity
— coughing, laughing sneezing - no associated urgency to void
Diagnostics - History
- Leakage with activity with no urge to void
- Leakage is low volume
Male
- Radical prostatectomy
Female
- Multiple/difficult vaginal deliveries
Diagnostics - Physical
- Weak pelvic floor muscles
- Immediate leakage with cough
- Possible atrophic urethral and vaginal tissue
Management - Pelvic Muscle Exercises
For mild-moderate incontinence
Criteria
- Intact innervation
- Ability to voluntarily contract pelvic floor muscles
- Cognitively intact + motivated
Mechanism
- Repetitive contraction of striated muscles increased muscles tone + contractility
- Pelvic muscle contraction inhibits bladder contractions
Guidelines
- Help patient identify muscles to be contracted
- “Tighten + left”
- Provide feedback/coaching
- Goal: 10-20 reps, 3-4 times/day
- Both quick flicks and long holds
- Can use biofeedback device
Management - Pharmacologic
Estrogen
- For pts with atrophic urethritis/vaginitis
- Improved urethral coaptation
- Reduces urethral + bladder irritability
- Reduces incidence of UTIs
SNSRI
- Sympathomimetic drugs
- Duloxetine + pseudoephedrine
— Duloxetine = nausea, dizziness, fatigue, bowel dysfunction
— Pseudoephedrine = tachycardia, elevated BP
- Activates sympathetic receptors in proximal urethral
- Causes increases resistance
Management - Vaginal Pessaries
Manages pelvic organ prolapse
- Support proximal urethra + bladder neck
- Provides limited urethral compression
Indications
- Effective bladder emptying
- Well-estrogenized tissue
- Patient able to remove, clean, and reinsert pessary
Management - Penile Clamps
Used to prevent stress incontinence by mechanically compressing urethra
Indications
- Intact sensation
- No issues with bladder overactivity or urge UI
- Inappropriate use = tissue damage
Management - Urethral Inserts
- Small caliber silicone urethral catheter
- Occludes bladder neck + urethra
- Provides temporary protection against leakage
- One time and PRN only
Management - Retropubic Suspension
- Sutures used to stabilize urethral in anatomically correct position
- Good outcomes only if issue is urethral hypermobility
- Requires open surgical procedure
Management - Minimally-invasive mid-urethral tension-free sling procedures
- Include TVT, TOT, PBS
- Placement of synthetic mesh/strip of fascia in suburethral tissue
- Collagen deposited along length of mesh/fascia
Management - Compressive Urethral Sling
- Strip of fascia, rectum muscle, or synthetic material under urethra
- End of sling attached to symphysis pubis with enough tension to partially collapse urethra
- Goals = create enough tension to prevent leakage but avoid outlet obstruction
Management - Artificial Urinary Sphincter
Soft, inflatable cuff placed around bladder neck or urethra
Reservoir placed into abdo cavity with control pump
