Download Urinary Incontinence in women

Urinary Incontinence in women
Urinary incontinence
• Stress – involuntary leakage of urine on effort,
sneezing or coughing
• Urgency – involuntary leakage accompanied
or immediately preceded by a sudden desire
to pass urine which is difficult to defer.
• Mixed – Combination of above
Other urinary problems
• Overactive bladder – urgency, frequency and
nocturia
• Chronic urinary retention ( overflow) –
bladder can’t empty completely and becomes
over distended
• Detrusor over activity – seen by urodynamic
study's – detrusor contractions during the
filling phase (spontaneous or provoked)
SUI
• Bladder pressure exceeds the urethral pressure
Associated with• loss of pelvic floor or damage to urethral
sphincter (pudendal nerve often damaged during
NVD)
• Increase in intra-abdominal pressure eg if
pregnant or obese
• Deficiency in supporting tissues – prolapse
• Lack of oestrogen – may decrease urethral
closure pressure
OAB
Multiple causes including
•Lower urinary tract conditons – eg UTI,
obsturction, oestrogen deficiency
•Neurological conditions – brain stem, spinal
cord or peripheral nerves
•Systemic conditions – eg HF or DM
•Functional and behavioral disorder – excess
caffeine of constipation
Overflow
• Outflow obstruction – tumour, cystocele or
constipation
• Detrusor under activity causing distension
often from neurological cause (spinal cord
injury, pelvic fractures, DM, MS, surgery)
Other cause
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Fistula
Urethral diverticula
Intercurrent illness
Congenital lesions
Cognitive impairment
Prolapse
Drugs – alcohol, diuretics, alpha adrenergic
blockers or agonists, diuretics etc
Risk factors
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Increasing age
Vaginal delivery
Increase parity
High birth weight
Obesity
Family history
Consequences
• Psychological problems: depression, feelings of shame, loss
of self confidence, poor self-rated health, low self esteem,
guilt, social isolation.
• Sexual problems: incontinence during sex may cause
embarrassment
• Loss of sleep: nocturia and fear of leakage.
• Constipation: due to limiting fluid intake.
• Falls and fractures: particularly in older people who have to
rush to the toilet.
• Impairment in quality of life.
• Financial problems: cost of pads, protective bedding, and
laundry.
Differential
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Vaginal discharge
Sweat
Amniotic fluid (if pregnant)
Psychological
Normal - The normal volume of urine passed
per void is between 200 mL and 400 mL,
average voiding frequency is 4-8 times daily,
including one void per night.
Management
• History and exam ( check for prolapse,
dryness, vaginal tone)
• Dipstick urine – if positive M,C&S.
• Bladder diaries
• Lifestyle advice
• Pelvic floor excercises
SUI management
• At least 12 weeks pelvic floor exercises
• Surgery - Retropubic mid-urethral tape (open
colposuspension and autologous rectal fascial
sling are recommended alternatives)
• Duloxetine 2nd line if not for surgery
• Continence advisor
Urge Incontinence
• Bladder training
• Oxybutynin ( if not tolerated other antimuscarinics eg tolteridine, solifenacin) –
review after 6 weeks and discuss s/e
• Consider vaginal oestrogen
• Desmopressin for nocturia (unlicensed)
• If all fail consider referral for sacral nerve
stimulation, botox or surgery