Urinary incontinence Flashcards Preview

Obstetrics and Gynaecology > Urinary incontinence > Flashcards

Flashcards in Urinary incontinence Deck (47):
1

Epidemiology of urinary incontinence (4)

+with age
+in women
+aged care facilities
+dementia/cognitive impairment

2

Impact on health (4)

Morbidity->perineal infections, falls
Sexual dysfunction
QOL->anxiety, embarrassment, depression, social, work
Increased caregiver burden

3

Risk factors

Strong:
+Age
+Parity, vaginal delivery, episiotomy
Obesity
LUTS
Care facility
Dementia
Constipation
Fecal incontinence
High impact physical activity
Pelvic organ prolapse
Stroke, parkinson's, MS
Diuretic use
Caffeine

4

Types (3)

Stress
Urge
Overflow
Fistula

5

Definition and mechanism of stress incontinence

Def: involuntary leakage of urine on effort/exertion
M: Urethral hypermobility + intrinsic sphincteric deficiency

6

Definition of urge incontinence

Involuntary leakage of urine w/ immediate/preceeding urgency

7

What are potential precursors to urinary incontinence

Burning with urination
Trouble starting urinary flow
Inability to stop urine flow
Needing to push and strain while urinating
Needing to urinate more than once to empty bladder
Nocturia are potential precursors of urinary incontinence

8

How does prolonged defecatory effort predispose

Progressive neuropathy

9

How does stroke predispose

Interruption of CNS inhibitory pathways->associated with stress, urge and overflow incontinence

10

Impact of forceps delivery on continence

+bladder neck descent

11

Explain the Delancey classification

Level 1: Upper Vertical, transverse cardinal, uterosacral supports->support of upper vagina, cervix, lower uterine segment posteriorly to sacrum
Level 2: Horizontal->ischial spine to post aspect of pubic bone. Lateral-> paravaginal fascia, The arcus tendineous fascia
pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina.
Level 3: Lower vertical support. The urogenital diaphragm and the perineal body provide support to the lower part of the vagina

12

Maintenance of continence (3)

Bladder factors:
Elastatic and inhibition of sacral plexus allows +bladder filling w/o +++pressure

Urethral factors:
Smooth/striated/elastic, blood vessel turgus (submucosal vascular plexus), mucosal folds, +resting tone of the urethra

Pressure transmission factors:
+intra-abdominal pressure= +pressure to bladder neck and proximal urethral->active contraction of urethral striated muscle and levator complex maintains continence

13

Micturition physiology of storage

Pontine micturition centre
Storage->contraction of sphincters, relaxation of bladder. Somatic to external, sympathetic to internal. Pudendal +external (supported by lateral vaginal wall by levator ani/fascia and ligaments). Involuntary/voluntary input +outflow resistance maintaining continence. SM vascular plexus +urethral turgor->sustaining closure of urethral sphincter.

14

Micturition physiology of voiding

Urethral sphincter relaxation and bladder contraction. PNS->S2-4 traveling through hypogastric nerves. ACh->Muscarinic receptors 2 and 3->detrusor muscle contraction= urinary flow through relaxed urethra.

15

Inhibition of voiding

Pontine storage centre. Afferents from distended bladder->T11 - L2 sympathetic->NE B receptor on bladder wall, alpha at bladder neck and urethra. Inhibits detrusor, and +sphincter. Inhibits.

16

Brief difference in pathophysiology of urge incontinence and stress incontinence

Urge->defect on coordination of micturition->neurogenic, myogenic
Stress->anatomical defect

17

Definition of over-active bladder

Urgency w/ or w/o urge incontinence, usually w/ frequency and nocturia in absence of underlying metabolic/pathalogic condition

18

Reversible causes of urinary incontinence

DIAPPERS
Delirium
Infection
Atrophic vaginitis
Pharmacologic causes
Psychiatric causes
Excessive urine production
Restricted mobility
Stool impaction

19

History

Obstetric and gynaecological history
Involuntary leakage on effort, exertion, sneezing etc
Incontinence accompanied by/immediately preceeded by urgency
Fluid/caffeine intake
Alcohol
Hx chronic constipation
Nocturia
Dysuria, hematuria, recurrent UTIs
Post void dribbling
Frequency
Fecal incontinece
FHx of incontinence
MSE
History of back injury/falls
Hormonal status
Age, weight
Long term residence in care
Lifestyle->high impact activity

Medical history- complete
Complete medication review
Evaluation of bladder diary

20

Important medications to consider in incontinence

Benzos, diuretics,
lithium, caffeine
Alpha blockers,
Anti-D, HRT
Smoking

21

Clinical examination

General->mobility, overall health
Abdomen and back->masses and tenderness.
Neurology S2-4
Rectal examination->perineal sensation, sphincter tone, fecal impaction, mass
Speculum->anterior wall/urethra->discharge, tender. Pooling of urine in vagina ?fistula
Signs of urogenital atrophy->mucosal pallor, erythema. Estrogen deficiency can cause urgency, frequency, incontinence
Look for vaginal bulge, prolapse
Bimanual->uterine size if ++may compress on bladder

22

Investigations

Empty supine stress test (leakage with cough/valsalva)
Post void residual
Urinalysis-> UTI, glycosuria

If conservative doesn't work->refer
Urodynamics
Q-tip test, pad test
Cystourethroscope

23

Management of stress incontinence

Lifestyle:
Adjust medications if needed
Weight loss
Caffeine reduction
Fluid managament
Reduction of physical exertion which strains pelvic floor
Smoking cessation
Resolution of chronic constipation
Pelvic floor exercises
Biofeedback->bladder retraining
Referral to continence advisor/specialist physio for 3 month

W/ Urethral sphincter insufficiency, consider adding-->
Pseudoephedrine, tds
Estrogen for post menopausal
SLing procedure or peri-urethral bulking injection

W/urethral hypermotility or displacement-->Surgery
Retropubic suspension
Bladder neck suspension
Anterior vaginal repair
Consider sling procedure
Tranurethral radiofrequency

24

Management of urge incontinence

Behavioural:
Bladder retraining
Prompted voiding
Pelvic floor

Lifestyle:
Adjust medications if needed
Weight loss
Caffeine reduction
Fluid managament
Reduction of physical exertion which strains pelvic floor
Smoking cessation
Resolution of chronic constipation

Second line->anticholinergic
Oxybutynin, tolterodine

Third-> neuromodulation, botulinum A toxin

25

What does bladder retraining involve

Techniques to distend the bladder or delay voiding
Bladder retraining-->use diary to modify
voiding habits
Times between voids increased, intake monitored and
"just in case voiding" avoided
Mental distraction/attempts to suppress urgency

26

What is prompted voiding

Teaches patients to initiate micturition themselves
+use in dementia/those in a nursing home

27

Pathogenesis of retention with overflow incontinence

Over-distended bladder
followng surgery
Osbstruction from pass, fecal
impaction etc
Drugs/neurogenic

28

Symptoms of overflow incontinence

Dribbling incontinence
Symptoms of overactive bladder
Voiding difficulty

29

Pathogenesis of detrusor overactivity

Xcortical inhibition of
sacral reflex
Idiopathy-->
anxiety, caffein, cold weather
Neurogenic-->UMN (MS,
spinal trauma, CVA)
Urethral obstruction?

30

Symptoms of detrusor overactivity

Urgency
Frequency >7 voids in a day
Urge incontinence
Nocturia
Nocturnal enuresis (ask about bed wetting in childhood)

31

Why is a history of bedwetting in childhood important

May indicate detrusor overactivity

32

Role of anticholinergics

To reduce the likelihood of unstable contraction and +bladder volume

33

Pathogenesis of fistulas in developed country vs non developed

Undeveloped->prolonged obstructive labour, pressure necrosis of bladder base and vagina

More developed countries->pelvic surgery complication, radiation, surgery

34

What is the arcus tendineus fascia pelvis

Second third of vagina attached to pelvic sidewall condensation of CT ->from inner surface of pelvic rami to ischial spine where fuses with arcus tendineus levator ani

35

What is the arcus tendineus levator ani

Attachment stretches vagina laterally, preventing bladder anterior and rectum posterior to protrude

36

Attachments of vagina

Anteriorly, the
vagina fuses with the urethra,
posteriorly with the perineal body, and
laterally with the levator ani
muscles

37

Relationship between bladderneck prolapse, intra-abdominal pressure and proximal urethra

Bladder neck open, not supported
Transmitted intra-abdominal pressure cannot close off proximal urethra

38

What is the typical form of levator trauma related to childbirth

Unilateral avulsion of pubococcygeus muscle off pelvic sidewall
Palpable as asymmetrical loss of substance in inferomedial portion of muscle

39

Important risk for levator avulsion

Age

40

What does levator avulsion +risk of

Significant cystocele and uterine prolapse

41

Numbers needed to harm for C-section and SVB/OVB and prolapse

Relative to cesarean deliveries, 8.9 spontaneous vaginal births would lead to one additional case of prolapse
Relative to cesarean deliveries, 6.8 operative births would lead to one additional case of prolapse

42

Urgent referral

Microscopic hematuria >50 yo
Visible hematuria
Recurrent/persisting UTI w/ hematuria >40yo
Suspected malignant mass

43

Indications for referral

Symptomatic prolapse visible at or below the vaginal introitus
Palpable bladder on bimanual/abdominal examination after voiding

44

Consideration for referral

Persisting bladder or urethral pain
Clinically benign pelvic mass
Associated fecal incontinence
Suspected neurological disease
Symptoms of voiding difficulty
Suspected urogenital fistula
Previous continence surgery
Previous pelvic cancer surgery
Previous pelvic radiation

45

Surgical options for stress incontinence

Tension free vaginal tape
Burch colposuspension
Anterior colporrhaphy, anterior repair
Bladder neck injections

46

Surgical options for overactive bladder

Bladder distension, urethral dilitation
Botox injections to bladder wall
Detrusor myomectomy, clam enterocystoplasty

47

Explanation for tension free vaginal tape

Relatively simple
Insertion under local anaesthetic
Day case
Quick return to work in 2 weeks

Good initial success
Long term success->up to 11 years