Urinary incontinence Flashcards
(47 cards)
Epidemiology of urinary incontinence (4)
+with age
+in women
+aged care facilities
+dementia/cognitive impairment
Impact on health (4)
Morbidity->perineal infections, falls
Sexual dysfunction
QOL->anxiety, embarrassment, depression, social, work
Increased caregiver burden
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
Types (3)
Stress
Urge
Overflow
Fistula
Definition and mechanism of stress incontinence
Def: involuntary leakage of urine on effort/exertion
M: Urethral hypermobility + intrinsic sphincteric deficiency
Definition of urge incontinence
Involuntary leakage of urine w/ immediate/preceeding urgency
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
How does prolonged defecatory effort predispose
Progressive neuropathy
How does stroke predispose
Interruption of CNS inhibitory pathways->associated with stress, urge and overflow incontinence
Impact of forceps delivery on continence
+bladder neck descent
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
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
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.
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.
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.
Brief difference in pathophysiology of urge incontinence and stress incontinence
Urge->defect on coordination of micturition->neurogenic, myogenic
Stress->anatomical defect
Definition of over-active bladder
Urgency w/ or w/o urge incontinence, usually w/ frequency and nocturia in absence of underlying metabolic/pathalogic condition
Reversible causes of urinary incontinence
DIAPPERS Delirium Infection Atrophic vaginitis Pharmacologic causes Psychiatric causes Excessive urine production Restricted mobility Stool impaction
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
Important medications to consider in incontinence
Benzos, diuretics, lithium, caffeine Alpha blockers, Anti-D, HRT Smoking
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
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
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
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
