Urinary incontinence

Question 1

Subtypes of UI

Answer 1

• Stress
• Urge
• Mixed
• Overflow
• Continious

Question 2

Stress UI

Answer 2

• Involuntary leakage of urine when intra-abdominal pressure exceeds urethral pressure
• eg coughing, straining, laughing, lifting

Question 3

When is stress UI often seen?

Answer 3

• Post-partum - damage to pelvic flor muscles weakens urinary sphincter
• Other RF - constipation, obesity, post-menopausal or pelvic surgery eg TURP causing external sphintcer damage

Question 4

Urge UI

Answer 4

• Overactive bladder
• Detrusor hyperactivity
• = uninhibited bladder contraction
• = rise in intravesicle pressure and leakage of urine

Question 5

Causes of urge UI

Answer 5

• Neurogenic - previous stroke
• Infection
• Malignancy
• Idiopathic
• Medications - cholinesterase inhibitors

Question 6

Overflow UI

Answer 6

• Complication of chronic urinary retention
• Progressive stretching of bladder wall = damage to efferent fibres of sacral reflex and loss of bladder sensation
• Bladder becomes distended, intravesicular pressure builds = dribble

Question 7

Common cause overflow UI

Answer 7

BPH
Others inc spinal cord injury

Question 8

Continious UI

Answer 8

• Constant leakage
• Typically due to anatomical abnormality eg ectopic ureter or bladder fistulae eg vesicovaginal fistula
• Could also be severe overflow incont

Question 9

Symptoms - what should patients be asked to do for UI?

Answer 9

• Bladder diary
• QoL questionaires eg ICIQ - international consultation incontinence questionaire

Question 10

Bedside tests for ?UI

Answer 10

• Midstream urine dipstick - infection/haematuria?
• Post void bladder scan - esp if suspect overflow UI

Question 11

Further investigations for ?UI - special tests if considering overactivity of detrusor or previous surgery for stress UI

Answer 11

• Urodynamic assessment - intravesicular and intra-abdominal pressures measured so detrusor pressure can be calculated
• Outflow urodynamics - measure detrusor muscle activity against urine flow rate
• Others: cystoscopy, IV urogram, vaginal speculum exam, MRI

Question 12

Lifestyle advice for UI

Answer 12

• Weight loss
• Reduce caffeine intake
• Avoid drinking excessive fluids each day
• Smoking cessation

Question 13

Conservative management for UI

Answer 13

Stress:
* Pelvic floor muscle training - 3 months at least
* Duloxetine can be tried if no response and unsuitable for surgery

Urge:
* Bladder training for minimum 6 weeks
* Antimuscarinic eg oxybutynin or tolterodine

Question 14

Surgical management urge UI

Answer 14

• Botulinum toxin A injections
• Sacral nerve stimulation
• Augmentation cystoplasty - detubularised segment of bowel inserted into bladder wall to increase capacity
• Urinary diversion via ileal conduit

Question 15

Stress UI surgical management

Answer 15

• Tension free vaginal tape - tape of mesh underneath the urethra. Tape acts like a hammock
• Open colposuspension - elevation of bladder neck and urethra through lower abdominal incision
• Intramural bulking
• Artificial urinary sphincter