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Urinary Incontinence-Women

Involuntary passage of urine

Stress UI- Decreased outlet resistance
( eg pelvic floor muscle weakness , bladder outlet or urethral sphincter weakness )
 Damage to the urethral sphincter from childbirth , pelvic surgery  Involuntary leakage on effort or exertion eg when sneezing , coughing or laughing

Urgency UI-Involuntary increase in bladder pressure due to detrusor over-activity – caused by a range of factors as
drugs
outflow obstruction
infection
CNS conditions
Local conditions as bladder stone , tumor Involuntary leakage accompanied , or immediately preceded by a strong urge to urinate

Mixed UI-Combination of urgency and stress – most common in older women and symptoms depend on which type predominates

Overactive Bladder Syndrome
( OAB ) Urinary urgency ( with or without urgency incontinence ) usually associated with increased frequency and nocturia

overflow incontinence- Complication of chronic urinary retention ( also known as Incontinence with high post-void residual )
Can lead to continuous or frequent loss of small quantities of urine
Causes

○ Outflow obstruction
○ Detrusor underactivity

Continous urinary incontinence-Constant leakage of urine- wet all the time- may be due to severity of the persons condition eg overflow incontinence or due to an underlying cause such as a fistula

Functional-Inability to reach the toilet in time – mobility , cognitive impairment , access

Disease burdrn-Under-diagnosed and underreported condition Extremely common in every part of world Older people more likely to delay seeking help Affects more than 5th of people aged 85 or over Causes significant distress and embarrassment
Physical social and emotional burden Estimates of prevalence vary widely- differing
○ study populations
○ definitions
○ methods of study Women suffer approximately twice more than men Significant costs to both individual and society–> Skin damage UTIs Increased risk falls Social isolation and alienation Increased risk of institutionalization Sexual problems Constipation 
( decreased fluid intake )Impaired quality of life

Causes of stress incontinence-Pregnancy ( ↑ intra-abdominal pressure ) Vaginal delivery ( pudendal N damage ) Obesity ( ↑ intra-abdominal pressure ) Constipation Deficiency of supporting tissues
○ prolapse
○ hysterectomy
○ collage disorders
○ oestrogen deficiency Family history Smoking Drugs

Urge incontinence causes- UTI Obstruction Impaired bladder contractility Bladder abnormalities- leading to inflammation Oestrogen deficiency Sphincter weakness Brain disorders
Stroke
Dementia
Parkinson’s
Multiple sclerosis Spinal cord
MS
Canal stenosis 
( cervical or lumbar )
Disc herniation
Injury CCF Venous insufficiency with oedema Diabetes Hypercalcaemia Excess coffee , alcohol , fluids Constipation Impaired dexterity Psychological conditions

history-Urinary symptoms
○ frequency
○ urgency
○ haematuria
○ UTIs
○ nocturia Duration and if symptoms worsening Pad usage Fluid intake Pelvic organ prolapse Obstetric history – difficult deliveries , grand multiparity , forceps use , lacerations and large babies Pelvic surgery , hysterectomy Lifestyle- eg smoking , alcohol or excess caffeine Medications

Examination-Focused physical examination Examine abdomen Pelvic examination – look for
○ leakage on coughing ( full bladder )
○ pelvic floor musculature ( squeeze the finger )
○ pelvic organ prolapse
○ urethral diverticulum
○ pelvic mass
○ atrophic vaginitis Lower extremity oedema Cognitive status Neurological exam Urine analysis ( all patients )
○ microalbumin , glucose , protein , leucocytes , nitrites ( MSU if indicated ) Renal function if AKI , obstruction suspected and other bloods if systemic cause suspected BMI

management stress UI- Manage any reversible cause or contributing factor Lifestyle advice
○ caffeine ( may improve urgency , frequency but not incontinence )
○ fluid intake ( 6-8 glasses of water / day is N )
○ weight loss
○ smoking –> cough ↑↑ SUI Supervised Pelvic floor training ( PFMT ) Anti-incontinence devices Pessaries
 Duloxetine is the only licensed medication in UK for SUI
○ offer only if women prefers drug to surgical Rx
○ not suitable for surgical Rx
○ may increase urethral sphincter contraction and closure pressure via effects in the sacral spinal cord–> reducing UI
 Surgery 
○ can effectively treat SUI
○ + 100 surgical procedures described – but common types are
♦ urethral bulking agents
♦ mid-urethral tape procedures
♦ colposuspension
♦ fascial slings


Urge UI-Address treatable cause if possible Fluid intake and lifestyle measures , self help Supervised bladder retraining AUA/SUFU guideline recommends pelvic floor muscle training as a 1st line Rx for overactive bladder syndrome Anticholinergics Beta3-Adrenoceptor Agonists- Mirabegron® Mirabegron works on beta3 adrenoceptors- decreased traditional adverse effects compared to anticholinergics Medications target the parasympathetic acetylcholine pathway to reduce intensity of detrusor contraction –> reduce feeling of urgency and improve bladder capacity Advice that it may take upto 4 weeks to work and can be continued long term if effective and advice about adverse effects + behavioral therapy Referral Alternative antimuscarinic for 4 weeks Mirabegron for 4 weeks Review at 12 weeks and annually after that

Pelvic floor muscle 
training -offer 1st line 
for Urinary Incontinence 
 with 8 contractions
 3 times
 a day for 3 months
(Cochrane database syst review 2010 )

Referral-Macroscopic ( visible ) haematuria without UTI Age 60 and over and have unexplained non-visible haematuria and either dysuria or a raised WCC count on a blood test-
( NICE 2015 ) A suspected malignant mass arising from the urinary tract or pelvis Visible haematuria that persists or recurs after successful treatment of UTI 
( NICE 2015 ) Symptomatic pelvic organ prolapse Persistent bladder or urethral pain ( USC if cancer suspected) Benign pelvic mass -eg uterine fibroids Associated faecal incontinence Suspected or known neurological disease Previous h/o
○ prolapse surgery
○ incontinence surgery
○ pelvic cancer surgery
○ previous radiation therapy Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent UTI ( NICE 2015 )

PATIENT INFORMATION

Information about incontinence and bladder problems from Royal College of Obstetricians and Gynaecologists https://www.rcog.org.uk/en/patients/menopause/incontinence-and-bladder-problems/

Age UK on incontinence https://www.ageuk.org.uk/information-advice/health-wellbeing/conditions-illnesses/incontinence/

Bladder Health UK on overactive bladder https://bladderhealthuk.org/bladder-conditions/overactive-bladder

Bladder diary from BAUS https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Input%20output%20chart.pdf

Bladder and Bowel Org bladder diary https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC005_Bladder-Diary-2015.pdf

Bladder retraining from Oxford University Hospitals https://www.ouh.nhs.uk/patient-guide/leaflets/files/14187Poveractivebladder.pdf

Pelvic Floor Exercises

From International urogynaecological association https://thepelvicfloorsociety.co.uk/images/uploads/eng_pfe.pdf

Penine Acute Hopistals NHS Trust https://www.pelvicfloorexercises.info/shop/pelvictoner-8wc-offer.htm?gclid=EAIaIQobChMIvZyD7PmL6QIVIlgVCB3z9wTAEAEYASAAEgIHRPD_BwE

Continence Foundation of Australia – with a 2-minute video https://www.continence.org.au/pages/pelvic-floor-women.html 

 

 

 

 

 

 

References

  1. Guideline Summary: Urinary incontinence: the management of urinary incontinence in women . [ National Collaborating Centre for Women’s and Children’s Health ] National Guideline Clearinghouse 2014
  2. Urinary incontinence in women : management: guidance ( CG 171 ) NICE September 2013 https://www.nice.org.uk/guidance/cg171
  3. Seshan, V., AlKhasawneh, E. and Al Hashmi, I.H. (2016), Risk factors of urinary incontinence in women: a literature review. Int J Urol Nurs, 10: 118-126. doi:10.1111/ijun.12107RN , RM, BSN , MSN et al International Journal of Nursing January 2016 ( Abstract )
  4. Smith A, Bevan D, Douglas HR, James D. Management of urinary incontinence in women: summary of updated NICE guidance [published correction appears in BMJ. 2013;347:f6392]. BMJ. 2013;347:f5170. Published 2013 Sep 10. doi:10.1136/bmj.f5170
  5. 10-minute consultation Female stress urinary incontinence BMJ 2010 ;340: b5533
  6. Clinical Management of Urinary Incontinence in Women Am Fam Physician 2013 May 1;87 (9) : 634-640
  7. Urinary Incontinence Medscape Nov 2016
  8. Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014;349:g4531. Published 2014 Sep 15. doi:10.1136/bmj.g4531
  9. Evaluating and managing urinary incontinence – Alosa Health April 2015
  10. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. JAMA. 2017;318(16):1592–1604. doi:10.1001/jama.2017.12137
  11. Female urinary incontinence – primary care management Anita Sharma BJMP 2010;3(3):a329

  12. Stress urinary incontinence: management in primary care Dr Helen Wood January 2019 https://www.gmjournal.co.uk/stress-urinary-incontinence-management-in-primary-care

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