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what is the definition of urinary incontinence?
- involuntary loss of urine
- that becomes a social problem
- irrespective of amount
which part of ANS helps voiding and which prevents?
- parasympathetic aids voiding
- sympathetic inhibits
what does continence depend on in terms of pressure?
pressure in urethra > pressure in bladder
as the bladder fills with urine, what happens to the pressure inside it?
no change as destrusor muscle is expandable
why does coughing not usually cause incontinence?
cough = increase IAP - transmitted equally to the bladder and upper urethra because both lie within the abdomen
what are the 2 main types of incontinence?
- stress incontinence
- urge incontinence (destrusor overactivity)
what is urge incontinence?
- get an urgent desire to pass urine and sometimes urine leaks before you have time to get to toilet
- due to overactive bladder
- uncontrolled increases in detrusor pressure
- so bladder pressure > normal urethra pressure
what is the mechanism of stress incontinence?
- upper urethra neck has slipped down from the abdomen
- so when there is an incerase in IAP eg cough, the pressure is transmitted ot he bladder but not urethra
- so bladder pressure > urethral pressure when coughing
what are 2 other rarer causes of incontinence?
- 1. FISTULA formation eg during labour so urine bypasses the sphincter through a fistula
- 2. pressure in bladder overwhelming the sphincter due to OVERFILLING the bladder due to neurogenic causes (MS) or outlet obstruction
why would you want to do urine dipstick?
- UTI - leucocytes, nitrites
- diabetes - glycosuria, protein
- bladder cancer - haematuria, protein
- stones - haematuria protein
what can you ask the patient to do?
- keep urinary diary
- record for a week of the time and volume of fluid intake and micturition
how can you exclude chronic retention of urine?
- do post-micturition US or catheterisation
- to check if retaining
which is the single most important urodynamic study?
cystometry (measure pressure in bladder)
which 2 pressures are measured in cystometry and how?
- bladder pressure: catheter into bladder and measure pressure when filling and see what happens when provoked with cough
- intra abdo pressure: pressure transducer in rectum
what is detrusor pressure and how is detrusor pressure calculated?
- true detrusor pressure = pressure generated by true contraction of detrusor muscle
- automatically calculated by: bladder pressure - IAP
when would an IVP intravenous pyelogram be useful?
assess and located fistulae and filling defects
when would contrast CT be useful?
- examine integrity and route of ureter
- stones, strictures
what is methylene dye test?
- blue dye instilled into bladder
- dye leakage from places other than urethra = fistula
in a normal bladder, what happens to detrusor muscle when you cough?
in stress incontinence, what happens to detrusor muscle when you cough?
in detrusor overactivity, what happens to detrusor muscle when you cough?
detrusor contraction after a cough
in a normal bladder, what happens to urine flow with a cough?
no urine flow
in SUI, what happens to urine flow when cough?
urine flow with cough
in DO, what happens to urine flow when cough?
urine flow happens with detrusor contraction IF the increase in bladder pressure is SUFFICIENT to overcome urethral pressure
what can cystoscopy diagnose?
- inspect anatomy of bladder and urethra
- exclude mechanical causes of incontinence eg stones or cancer
- but not assess bladder function
what is stress incontinence?
- involuntary loss of urine
- bladder pressure > urethral pressure
- in absence of detrusor contraction
what are causes/RF for stress incontinence?
- vaginal delivery
- prolonged labour
- forceps delivery
what commonly co-exists with stress incontinence?
what is the mechanism of incontinence in stress incontinence?
- as bladder neck has SLIPPED BELOW PELVIC FLOOR (because its supports are weak)
- then there is increased IAP, the bladder neck is not compressed together with the bladder
- so only bladder is compressed and its neck is open - so urine will come out
if stress incontinence is due to childbirth injury, what else may exist?
why do you have to palpate abdomen if thinking SI?
exclude distended bladder
what may you see on sims speculum in SI?
cystocele or urethrocele
what lifestyle changes can be made to help with SI?
- lose weight if obese
- stop smoking - cause chronic cough
- reduce xs fluid intake
what is the conservative Rx of Stress incontinence? and this is first line Rx
- pelvic floor muscle training for 3 months taught by physiotherapist
- 8 contractions, tds
- vaginal cones are inserted into vagina and held in position by voluntary muscle contraction
what are 2 drug Rx for stress incontinence?
- 1. duloxetine (SNRI) can enhance pudendal nerve stimulation of pelvic floor
- give after PFMT failed. it can increase tone of urethral sphincter
- SE: headache and gastric problems
- 2. oestrogen HRT
which Rx can cure the majority of women with SUI?
what needs to be done before any surgery for SUI? why?
- exclude overactive bladder
what is the main aim of surgery for Rx of SUI?
allow transmission of raised IAP to bladder neck as well as the bladder
what is the traditional gold standard surgical Rx of SUI called?
- Burch colposuspension
- bladder neck is lifted using sutures placed via abdominal incision
what is the new, surgical procedure of choice for SUI which is 1st line?
- TVT = Tension free Vaginal Tape
- inserted through a small vaginal incision over the mid urethra
- TVT compresses the urethra when you cough to stop leakage
what are 3 advantages of TVT > colposuspension
- 1. less invasive
- 2. can do under spinal or local anaesthetic
- 3. shorter hospital stay
what are risks of all the operations for SUI?
- voiding difficulty & retention
- de novo overactive bladder!
- bladder perforation
what is overactive bladder?
- with or without urge incontinence
- usually with frequency, nocturne
- in absence of proven infection
how can destrusor overactivity be diagnosed in urodynamics?
- by involuntary detrusor contractions during the filling phase
- which may be spontaneous or provoked by eg coughing
- (get increase in detrusor pressure which you dont with SUI)
what is cause of overactive bladder?
- after operation for SI
- neuropathy eg MS causing detrusor overactivity
- spinal cord injury
why may you think its stress incontinence when its actually overactive bladder?
- as coughing can lead to provocation of destrusor contraction
- which is overactive bladder
what is different about the symptoms in OAB compared to SUI?
- get urgency, urge incontinence
- hx of childhood enuresis is common
what do you see on examination of OAB?
what may urinary diary show in OAB?
- passage of small vol of urine
- esp at night
- and when take caffeine
what would cystometry show in detrusor overactivity?
detrusor contractions on filling or provocation
what is Rx of OAB?
- 1. caffeine and fluid reduction if xs
- 2. bladder training: void by the clock at increasing intervals
- 3. antimuscarinic eg tolterodine or oxybutynin, solifenacin - relax smooth muscle in bladder
how may you treat OAB in post menopausal women?
- if also have vaginal atrophy then give
- intravaginal oestrogens
if medical/conservative Rx failed for OAB, what is next step - 2 options?
- botulinum toxin A (botox)
- sacral nerve stimulation
where is botox given? and MOA?
- into detrusor muscle with a needle cystoscopically
- MOA: blocks NMJ so relax detrusor contraction
what is risk of botox?
- risk of total bladder paralysis
- so need self catheterisation
how long can botox Rx last for?
how does sacral nerve stimulation work?
- like a pacemaker - causes contraction of external sphincter and pelvic floor muscle
- causes inhibition of bladder contractions
if there is very severe OAB, what is surgical option?
clam augmentation ileo cystoplasty
what is frequency?
>7/8 times a day
what is nocturne?