Urinary Incontinence in women

1. Urinary Incontinence in women

2. 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

3. Other urinary problems • Overactive bladder – urgency, frequency and nocturia • Chronic urinary retention ( overflow) – bladder can’t empty completely and becomes over distended • Detrusor over activity – seen by urodynamic study's – detrusor contractions during the filling phase (spontaneous or provoked)

4. 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

5. 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

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

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

8. Risk factors • Increasing age • Vaginal delivery • Increase parity • High birth weight • Obesity • Family history

9. 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.

10. 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.

11. Management • History and exam ( check for prolapse, dryness, vaginal tone) • Dipstick urine – if positive M,C&S. • Bladder diaries • Lifestyle advice • Pelvic floor excercises

12. 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

13. 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