Urinary Incontinence in women

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Urinary Incontinence in women
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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

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Other urinary problems

• Overactive bladder urgency, frequency and
  nocturia
• Chronic urinary retention ( overflow) bladder
  cant empty completely and becomes over distended
• Detrusor over activity seen by urodynamic
  study's detrusor contractions during the
  filling phase (spontaneous or provoked)

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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

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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

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Overflow

• Outflow obstruction tumour, cystocele or
  constipation
• Detrusor under activity causing distension often
  from neurological cause (spinal cord injury,
  pelvic fractures, DM, MS, surgery)

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Other cause

• Fistula
• Urethral diverticula
• Intercurrent illness
• Congenital lesions
• Cognitive impairment
• Prolapse
• Drugs alcohol, diuretics, alpha adrenergic
  blockers or agonists, diuretics etc

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Risk factors

• Increasing age
• Vaginal delivery
• Increase parity
• High birth weight
• Obesity
• Family history

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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.

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Differential

• 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.

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Management

• History and exam ( check for prolapse, dryness,
  vaginal tone)
• Dipstick urine if positive M,CS.
• Bladder diaries
• Lifestyle advice
• Pelvic floor excercises

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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

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Urge Incontinence

• Bladder training
• Oxybutynin ( if not tolerated other
  anti-muscarinics 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