| How is etiology of stress urinary incontinence? | . |
| What is overflow incontinence? | Overflow urinary incontinence is the involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction. |
| What are the 3IQs of UUI? | . |
| What is urinary incontinence? | Urinary incontinence is the involuntary leakage of urine.
This medical condition is common in the elderly, especially in nursing homes, but it can affect younger adult males and females as well.
Urinary incontinence can impact both patient health and quality of life.
Several different types of urinary incontinence exist, including stress urinary incontinence, urge urinary incontinence, functional incontinence, mixed incontinence, and overflow incontinence. |
| How is etiology of stress urinary incontinence? | . |
| What is stress urinary incontinence? | The involuntary leakage of urine that occurs with increases in intraabdominal pressure (e.g., with exertion, effort, sneezing, or coughing) due to urethral sphincter and/or pelvic floor weakness.
Young women active in sports may experience this type of incontinence.
In addition, pregnant women and women who have experienced childbirth may be prone to stress urinary incontinence.
Loss of support from pelvic floor musculature and connective tissue
Neuromuscular damage from previous pelvic surgeries |
| How is epidemiology of stress urinary incontinence? | Stress urinary incontinence affects 15 % of adult women.
77 % of women report the symptoms to be bothersome.
30% report the symptoms to be moderate to severe.
Prevalence of stress urinary incontinence will increase with age particularly with menopause.
One study found that 41% of women older than 40 years old will have urinary incontinence. |
| How is hx and PE of stress urinary incontinence? | Detailed history, particularly the genitourinary review of systems (precipitating events, fluid intake, nocturia, protective devices used...)
Voiding diary
Physical examination with the demonstration of stress (full and empty bladder standing and supine to see degree of prolapse) incontinence and assessment of urethral hypermobility
Urinalysis with or without a urine culture
Measurement of postvoid residual urine volume (PVR)
Urodynamic testing is not initially indicated in uncomplicated stress urinary incontinence |
| What are indications of urodynamic testing? | Complicated SUI
Failed surgical treatment
Patients over 60 years old
Continuous/unpredictable leakage
History of radical pelvic surgery or pelvic irradiation |
| How is urodynamic testing? | . |
| What is tx of stress urinary incontinence? | Treatment of stress urinary incontinence subdivides into behavioral, pharmacological, and surgical management.
Bladder irritants to avoid include caffeinated beverages (coffee, tea, sodas) alcohol, citrus fruits, chocolate, tomato, spicy foods, and tobacco.
Behavioral therapy
Pharmacologic options (anticholinergics)
Surgery |
| What are behavioral therapies for stress urinary incontinence? | . |
| How is surgical therapy of stress urinary incontinence? | The goals of surgery for stress incontinence include reinforcing the pubourethral ligaments and the paraurethral connective tissue at the mid-urethral.
Surgical treatment generally divides into abdominal procedures (open or laparoscopic), vaginal procedures, and urethral bulking agents.
Abdominal (Burch Colposuspension, and Pubovaginal sling)
Vaginal (Mid-urethral sling [TVT- retropubic and TVT-O inside out placement of mesh from vagina through obturator out through groin skin]) |
| What is urge urinary incontinence? | Urge urinary incontinence is the involuntary leakage of urine that may be preceded or accompanied by a sense of urinary urgency (but can be asymptomatic as well) due to detrusor overactivity.
The contractions may be caused by bladder irritation or loss of neurologic control. |
| What are etiologies of UUI? | Detrusor overactivity is believed to be the uninhibited (involuntary) contractions of the smooth muscle during bladder filling.
Significant causes leading to this overactivity could be neurologic disorders (spinal cord injury), abnormalities in the urinary bladder, and an increase or alteration in the bladder microbiome.
This may also be completely idiopathic |
| Compare normal vs hyperactive bladder. | . |
| How is hx and PE in UUI? | Patient’s typical voiding pattern.
Onset, and duration of incontinence symptoms.
Whether or not the patient is bothered by symptoms and any associated factors that can affect incontinence.
Other factors requiring assessment should include urinary frequency (>7 micturition episodes in a day), urgency, pain with a full bladder, obstetric history (number and mode of deliveries), gynecological history (history of pelvic organ prolapse, anal incompetence, menopause, sexual dysfunction), any previous pelvic surgery |
| What are the 3IQs of UUI? | . |
| What are indications for urodynamic study in UUI? | Significant inconsistencies between symptom scale, history, and voiding diary
Planned or previous surgery
Hematuria
The presence of neurological diagnoses such as multiple sclerosis
Associated prolapse of pelvic organs
Previous history of correction surgery for incontinence
Elevated volume of post-void residual urine. |
| How is tx of UUI? | The first-line treatment includes teaching the patient some behavioral therapies such as bladder training and toileting habits, lifestyle modifications, voiding diary, dietary changes, and avoiding bladder irritants (such as caffeine, smoking), pelvic floor muscle training (PFMT), and biofeedback
Some antimuscarinic agents currently available for the treatment of urge incontinence include oxybutynin, tolterodine, fesoterodine, trospium, darifenacin, and solifenacin.
The beta-3 adrenoreceptor agonists cause direct relaxation of detrusor muscles |
| How are anti-muscarinic drugs in UUI? | Extended-release versions have been found to cause lesser side effects compared to immediate-release versions.
The common side effects related to these drugs are dry mouth, blurred vision, tachycardia, constipation, impaired cognition, and urinary retention. These side effect profiles have often culminated in high discontinuation rates and less than standard compliance rates.
Medicines like darifenacin and solifenacin (selective antimuscarinic agents) are sometimes preferred over non-selective agents to control cognitive side effects better |
| How are b3 agonists in UUI? | They achieve inhibition of spontaneous contractile activity in the bladder and reduction in bladder afferent activity.
Mirabegron is the first of its class and the only beta-3 adrenoceptor agonist that is used as a second-line treatment for those who either poorly tolerate antimuscarinic agents or cannot tolerate them at all.
Daily doses of mirabegron 25, 50, and 100 mg demonstrated significant efficacy in treating symptoms of urge incontinence in phase three clinical trials.
In some cases, combining an anticholinergic medication with mirabegron may result in increased efficacy and minimized side effect load.
This medication can theoretically lead to an increase in cardiovascular events, particularly hypertension and headache. |
| What are 3rd line tx of UUI? | If patients with urge incontinence meet the following criteria, they are eligible for third-line treatment (refractory cases): 1) They demonstrate a failure of response to behavioral therapy, and 2) They have either intolerance to or inadequate response to at least two second-line treatments.
Third-line treatment includes Percutaneous stimulation of tibial nerve (PTNS), temporary chemical denervation of the bladder detrusor muscle, and sacral neuromodulation.
Third-line treatment includes also Intravesical onabotulinum toxin A injection requires delivery via cystoscopy every six months if symptoms recur.
It results in flaccid paralysis of the detrusor muscle with consistent improvement in urge incontinence symptoms and quality of life |
| What is overflow incontinence? | Overflow urinary incontinence is the involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction. |
| What are etiologies of overflow incontinence? | Neurologic diseases such as spinal cord injuries, multiple sclerosis, and diabetes can impair detrusor function.
Bladder outlet obstruction can be caused by external compression by abdominal or pelvic masses and pelvic organ prolapse, among other causes.
A common cause in men is benign prostatic hyperplasia. |
| How is management of overflow incontinence? | Conservative management
clean intermittent catheterization, indwelling urethral catheter, relief of obstruction
Pharmacologic management - alpha-adrenergic antagonists (e.g. terazosin, tamsulosin)
Surgical management - suprapubic catheter, TURP |
| What are DD of urinary incontinence table? | . |
| Demonstration of different types of incontinence? | . |
