Subtypes of urinary incontinence
Pathophysiology of stress
Urine leakage occurring when intra-abdominal pressure exceeds the urethral pressure.
Exacerbated by coughing, straining, laughing or lifting.
It is mainly due to weakness of the pelvic floor muscle
Risk factors of stress UI
Post-partum due to damage of pelvic floor muscles and weakening of the urethral sphincter.
Pelvic surgery like TURP
Pathophysiology of Urge UI
Overactive bladder by detrusor hyperactivity.
This leads to uninhibited bladder contractions and a rise in intravesical pressure -> leakage of urine.
What might urge UI be due to.
Neurogenic causes like previous stroke, parkinsons or MS
Medication like cholinesterase inhibitors can also cause it.
Pathophysilogy of overflow UI
Normally a complicaiton of chronic urinary retention.
There is stretching of the bladder wall which leads to damage of the efferent fibres of the sacral reflex and a loss of baldder sensation.
When the bladder fills, it becomes grossly distended and then constant dribbling occurs.
Causes of overflow UI
Most common = Prostatic hyperplasia
Can also be due to spinal cord injury or congenital defects
What is continuous UI
Constant leakage of urine.
Usually an anatomical abnormality like ectopic ureter, bladder fistulae like vesicovaginal fistula.
Need to make sure to categorise it to the correct one.
There might be dysuria or haematuria
Ask about any precipitating factors, past medical and surgical history and drug history.
What should be done in order to keep record of urinary habits?
QoL questionnaires liike ICIQ, BFLUTS and I-QOL can quantify the severity of the condition.
Check for enlarged prostate
Midstream urine dipstick
Post-void bladder scans especially in overflow UI.
If unclear aetiology urodynamic assessment can be useful.
Intravesicular and intra-abdominal pressures are measured.
This allow for the detrusor muscle pressure to be calculated and any hyperactivity can then be seen.
Outflow urodynamics can also be done to measure detrusor muscel activity.
Cystoscopy, intravenous urogram, vaginal speculum examination or MRI imaging might also be done.
Reducing caffeine intake
Avoid drinking either excessive fluids or alcohol
Conservative management of stress UI or mixed UI
Pelvic floor muscle training ideally for at least 3 months
If no response to PFMT -> duloxetine (Serotonin-norepinephrine reuptake inhibitor) can be trialled to cause stronger urethral contractions.
Conservative managemnt of Urge UI
Anti-muscarininc durgs like oxybutynin or tolterodine acting to inhibit the detrusor contraction.
Bladder training should also be offered at least for 6 weeks
Indications for surgical management
Symptoms despite consertvatie management
Surgical interventions in urge UI
Botulinum toxin A injections
Percutaenous sacral nerve stimulation
Urinary diversion via ileal conduit
Surgical interventions for stress UI
Tension-free vaginal tape
Oen colposuspension elevating the bladder neck and urethra through a lower abdo incision
Intramural bulking agents
Artifical urinary sphincter