Urinary Incontinence

• What are urodynamic tests?

  Test to assess presence & severity of urinary symptoms

  NOTE: Pts need to stop taking anticholinergic & bladder related meds around 5 days before tests
• What occurs in urodynamic tests?

  Thin catheter inserted into bladder & another into rectum

  Catheters measure pressures

  Bladder is filled with liquid & multiple measures are taken

  • cystometry -> measures detrusor muscle contraction & pressure
  • uroflowmetry -> flow rate
  • leak point pressure -> point where bladder pressure -> leakage of urine (pt asked to cough, move or jump to assess stress incontinence)
  • post-void residual bladder volume -> test for incomplete emptying
  • video urodynamic testing -> fill bladder w/contrast, take X-ray images as bladder is emptied
• What is urinary incontinence?

  Loss of control of urination
• What are the types of urinary incontinence?

  Urge incontinence

  Stress incontinence
• What is urge incontinence?

  Caused by overactivity of detrusor muscle of bladder

  Also known as overactive bladder
• What is the typical description of urge incontinence?

  Suddenly feel urge to pass urine, having to rush to bathroom & not arriving before urination occurs

  Significant impact on QoL
• What is stress incontinence?

  Due to weakness of pelvic floor & sphincter muscles -> allows urine to leak at times of increased pressure on the bladder
• What is the typical description of stress incontinence?

  Urinary leakage when laughing, coughing or surprised
• What is mixed incontinence?

  Combination of urge & stress incontinence

  Crucial to identify which is having the more significant impact & address this first
• What is overflow incontinence?

  Occurs when there is chronic urinary retention -> due to an obstruction to outflow of urine

  Can occur with...

  • anticholinergic meds
  • fibroids
  • pelvic tumours
  • neurological conditions (MS, diabetic neuropathy, spinal cord injuries)

  More common in men
• Urinary incontinence is more common in women.
• What are the RFs for urinary incontinence?

  Increasing age

  Postmenopausal status

  Increased BMI

  Previous pregnancies & vaginal deliveries

  Pelvic organ prolapse

  Pelvic floor surgery

  Neurological conditions (e.g. MS)

  Cognitive impairment & dementia
• What should be covered in a Hx & examination of urinary incontinence?

  Differentiate between stress & urge incontinence

  Assess modifiable lifestyle factors (caffeine, alcohol, meds, BMI)

  Assess severity (frequency of urination & incontinence, nighttime urination, use of pads/changes of clothing)

  Assess pelvic tone on examination

  Look for...

  • pelvic organ prolapse
  • atrophic vaginitis
  • urethral diverticulum
  • pelvic masses

  Ask pt to cough & watch for any leakage

  Bimanual examination of pelvic muscles (& grade)
• What are the Inx for urinary incontinence?

  Full Hx & examination

  Bladder diary

  Urine dip & MSU (assess signs of infection, haematuria & other pathology)

  Post-void residual bladder volume (using bladder scan)
• What are the DDx of urinary incontinence?

  Fistula

  Ectopic ureter

  UTI

  Pregnancy

  Neurogenic bladder
• What is the management of stress incontinence?

  Avoid caffeine, diuretics & overfilling of bladder

  Avoid exercise or restricted fluid intake

  Weight loss

  Supervised pelvic floor exercises (at least 3 months before considering surgery)

  Surgery (tension-free vaginal tape, autologous sling procedures, colposuspension, intramural urethral bulking)

  Duloxetine (SNRI) -> when surgery cannot be done
• What is the management of urge incontinence?

  Bladder retraining (gradually increasing time between voiding)

  Anticholinergic medications (oxybutynin, tolterodine, solifenacin)

  Mirabegron

  Invasive procedures

  • botox injection into bladder wall
  • percutaneous sacral nerve stimulation
  • augmentation cystoplasty (using bowel tissue to enlarge bladder)
  • urinary diversion
• What are the possible complications of urinary incontinence?

  UTI

  Surgical complications