Pelvic floor disorders - incontinence

Question 1

What is the incidence of urinary incontinence

Answer 1

1 in 3 women ≥ 55 have urinary incontinence

Question 2

What are the risk factors for developing urinary incontinence ?

Answer 2

• Female
• Increasing age
• Obesity
• Smkoing - chronic cough, COPD can all cause episodes of incontinence or worsen it
• Other conditions - Kidney disease, Diabetes

Question 3

Describe the 4 classifications of urethral urinary incontinence and there cause

Answer 3

• Overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
• Stress incontinence: leaking small amounts when coughing or laughing
• Mixed incontinence: both urge and stress
• Overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Question 4

What are the 2 main causes of extraurethral urinary incontinence ?

Answer 4

Ectopic ureter draining straight into the urethra or a fistula

Question 5

Define what stress incontinence is

Answer 5

This is involuntary urine leakage on effort/extortion or on sneezing or coughing

Question 6

Define what overactive bladder (OAB) is

Answer 6

This is defined as urgency that occurs with or without urgency UI & usually with frequency & nocturia.

• OAB that occurs with urgency UI is known as ‘OAB wet’
• OAB that occurs without incontinence is known as ‘OAB dry’

Question 7

Define what urge UI is

Answer 7

• This is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)

==> think OAB as being the urge which can then occur with (OAB wet) urge UI or without (dry OAB)

Question 8

Define mixed UI

Answer 8

• This is involuntary urine leakage associated with both urgency & effort/exertion, sneezing or coughing

Question 9

Define what overflow incontinence is

Answer 9

• This is UI due to bladder outflow obstruction causing a build up resulting in chronic retention, then eventually the person is incontinent (usually due to prostate enlargement)

Question 10

What are the investigations done for someone presenting with UI ?

Answer 10

• History & physical exam - categorise the woman’s UI as SUI, mixed urinary incontinence or UUI/OAB. Start initial treatment on this basis.
• Bladder diaries should be completed for a minimum of 3 days
• Vaginal examination to exclude pelvic organ prolapse (prolapse associated with 50% of stress UI) and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
• Urine dipstick and culture - to exclude UTI or diabetes cause
• Measure post-void residual volume by bladder US in women with symptoms suggestive of voiding dysfunction or recurrent UTI
• Urodynamic studies may be done - to differentiate between OAB/urge & stress UI

Question 11

Describe the signs/symptoms of urge UI/OAB

Answer 11

• You have an urgent desire to pass urine and sometimes urine leaks before you have time to get to the toilet
• Sometimes provoked by things e.g. putting the key in the door, sound of running water etc

Question 12

What is urge UI/OAB often due to ?

Answer 12

Detrusor muscle overactivity - which is essentially due to overstimulation by nerves

Question 13

What are some of the causes of detrusor overactivity ?

Answer 13

• Tumours or bladder stones causing irritation in the bladder
• Pelvic surgery or fractures causing damage to the parasympathetic supplying the bladder
• Paraplegia - loss of central inhibition
• Destruction of S2,3 segment
• Infection

Question 14

How can urodynamics be used to differentiate between urge UI/OAB & stress UI?

Answer 14

• OAB/ UUI is due to bladder (detrusor) overactivity causing frequent involuntary contractions. On urodyanmics this is seen as an increase in detrusor pressure causing a rise in intravesicular pressure with no increase in abdominal pressure
• In SUI urodynamics will show increased abdominal pressure corresponding to increased filling without increased detrusor pressure

Note - don’t do before primary surgery if SUI or stress-predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary incontinence at examination.

Question 15

What are the signs/symptoms of stress incontinence ?

Answer 15

• Urine leaks during increased intra abdominal pressure, without a detrusor contraction
• e.g. when coughing can get leaks, can be due to weak pelvic floor muscle due to pregnancy

Question 16

What is the most common type of urinary incontinence ?

Answer 16

SUI

Question 17

Describe the symptoms/signs of overflow incontinence

Answer 17

• It is due to bladder flow obstruction causing urine to build up resulting in chronic retention then eventually the person is incontinent
• Large palpable bladder
• Usually don’t feel that they are incontinent
• Often wet at night

Question 18

Who is usually affected by overflow incontience ?

Answer 18

Men - as can be caused commonly by enlargement of the prostate

Question 19

Describe the 2 phases which make up the micturation cycle/ micturation reflex

Answer 19

1. Filling phase - bladder pressure (intravesicular) has a slight rise as it fills. The internal urethral sphincter remains tense & detrusor muscle relaxed by sympathetics
2. Voiding phase - Adequate filling of bladder occurs, which is sensed by stretch receptors (which send signals to S2,3 & the brain), these receptors have increased firing now to the point where thy stimulate pelvic parasympathetic nerves to cause detrusor muscle contraction & internal urethral sphincter relaxation

Voluntary control via the peudendal nerve (conscious thought) can stimulate perineal muscles & external urethral sphincter to contract to prevent voiding

Question 20

On urodyanmics what does a very high detrusor muscle pressure in the context of UI indicate ?

Answer 20

Obstruction (overflow) e.g. prostate enlargement

Question 21

What is the treatment of UUI/ OAB wet

Answer 21

• 1st line = dietary (avoid caffeine, sensible fluid intake & decrease weight) + bladder training (min 6weeks) + pelvic floor strengthening by physio
• 2nd line = Antimuscarinics - (e.g. oxybutynin, tolterodine, darifenicin)
• 3rd line = Beta 3 adrenergics (mirabegron)

Question 22

Why do you need to review someone 4 weeks after putting them on an anti-muscarinic ?

Answer 22

Due to potential unacceptable side effects:

• Dry mouth
• Constipation
• Blurred vision
• Somnolence

Question 23

What is the treatment of stress UI?

Answer 23

• 1st line = lifestyle (weight loss, stop smoking) and physio (pelvic floor exercises) - physio for min of 3 months
• 2nd line = Surgical correction is the mainstay - either colposusspension or tape procedures (preferred as less invasive)

Question 24

What is the treatment of mixed UI ?

Answer 24

Management depends on whether urge or stress UI is the predominant picture. Focus on treating the predominant problem

Question 25

What is the treatment of overflow incontinence/voiding symptoms?

Answer 25

Conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products * 1st line = alpha-blocker (**tamulosin**, doxazosin) * 2nd line = 5-alpha reductase inhibitor (**finasteride**, dutasteride) If storage symptoms which arent responding to tamulosin then can add in a antimuscarinic (anticholinergic)

Question 26

What should you stop/ avoid in overflow UI?

Answer 26

Anticholinergics - as there is obstruction so you don't want to promote detrusor muscle contraction

Question 27

What are the common side effects of finasteride ?

Answer 27

Sexual dysfunction & gynaecomastia

Question 28

What are the indications of multi-channel urodyanmics (cystomethogram)

Answer 28

1. Uncertain diagnosis 2. Failure to respond to treatment 3. Prior to surgery for UI & prolapse

Question 29

When should mirabegron be avoided ?

Answer 29

If someone has sustained uncontrolled hypertension