01 Aug Female Urinary Incontinence

• Urinary incontinence: Involuntary loss of urine: common problem among older women.
• Two main types of incontinence: possible to have both types at the same time:
  • Stress incontinence: Loss of urine during jogging, laughing, coughing, or sneezing.
    • Increase the intraabdominal and intra-pelvic pressure.
    • Most common problem in women of childbearing age.
    • Risk factors:
      • Previous pregnancies.
      • Weak perineum
      • Movement of the bladder from its ordinary position and increase the angle of the bladder and the urethra.
    • Signs, Symptoms and Clinical Presentation:
      • Leakage of small to medium amounts of urine only when they increase their intra-pelvic pressure.
      • Do not wet the bed.
      • Normal bladder studies.
      • Normal bladder musculature.
      • Normal urinary bladder dynamic studies.
    • Urge incontinence: Strong urge to urinate secondary to various stimuli resulting in the loss of urine before reaching the bathroom.
      • Risk factors:
        • advanced age.
        • Pelvic surgery.
        • Neurologic
        • Frequent urinary tract infections,
        • Bladder cancer
      • Signs, Symptoms and Clinical Presentation:
        • Overactivity of the bladder musculature: Autonomic nervous system control
        • Not related to a filled bladder.
        • Can happen even with small amounts of urine in the bladder.
        • Can happen just thinking of voiding or hears sound of running water.
        • Secondary to an overactive bladder.
        • Overactive bladder: Increase in the muscle tension in the bladder muscles.
        • May wet the bed.
        • Release large amounts of urine.
        • Cannot get to the bathroom on time to void.
        • Urinary bladder muscle trabeculation
        • Increase in urine bladder muscle tension on urodynamic studies.
        • Emotional stress can precipitate it.
        • Irritation of the bladder muscle can cause it.
        • Increase in urge incontinence among patients with stroke or Parkinson’s disease.
      • Management of Urinary incontinence:
        • Behavioural:
          • Bladder training: Attempting to hold the urine for up to ten minutes at a time when there is an urge to urinate.
          • Double voiding: Voids first until the bladder feels empty and then voids a few minutes later to completely empty the bladder.
          • Kegel exercises: good for stress incontinence: strengthen the perineal muscles: stop the flow of urine, holding the muscles tight for several seconds: repeated several times per day to strengthen the muscles that hold back urine during increased intra-pelvic pressure.
          • Electrical stimulation: imitate exercises using electrode applied to the perineal muscles to strengthen the pelvic floor muscles: works for both urge and stress incontinence.
        • Medical: Address the hyperactivity of the bladder muscles:
          • Anticholinergic therapy: drugs that decrease the overactivity of the bladder: darifenacin, tolterodine, and oxybutynin.
          • Medication to relax the bladder muscle and increases bladder capacity: mirabegron (Myrbetriq).
          • Topical estrogen therapy rejuvenates the perineal and bladder muscles to hold back urine easier.
          • Oral estrogen therapy: not recommended: problem worse.
          • Devices:
            • A urethral insert: Small device inserted into the urethra holds back the flow of urine
            • Pessary: Ring inserted into the vagina holds the bladder and uterus up so that the angle of the bladder and urethra is decreased.
          • Surgical: last resort:
            • Bladder neck suspension surgeries: change the angle of the bladder and the urethra, decreasing stress incontinence.
            • Bladder sling surgery: mesh or body tissue to create a sling to hold the bladder up inside the pelvis.
            • Uterus removed: prevent increase in pressure.
            • Anterior vaginal wall repair.
          • Complications of urinary incontinence:
            • Skin around the perineum: break down easily
            • Urinary tract infections.
            • Embarrassment and difficulty in daily activities