Red flags

  • Macroscopic haematuria without concurrent UTI

  • unexplained microscopic haematuria if aged >40yo

  • Recurrent or persistent UTI associated wiht haematuria if >40yo

  • Pelvic mass arising from urinary tract or pelvis

  • suspected prostatic malignancy

Consideration for referral

  • bladder palpable after voiding

  • pelvic organ prolapse

  • associatedfaecal incontinence

  • new or worsening incontinence with neurologiacl disease

  • symptoms of voiding difficulty

  • recurrent UTI

  • suspected or recurrent urogenital fistulae

  • recurrent or continued incontinence following previous continence surgery

  • previous pelvic cancer surgery or radiation treamtent

Stress incontinence

leakage associated with physical activity or increased intra-abdominal pressure:

  • coughing

  • sneezing

  • rising from chair

  • 25-45% females aged ≥30yo

  • atrophy/damage to pelvic floor muscles, ligaments, fascia

  • associated with childbirth and menopause

Urgency incontinence

assoiced with, or immediately after, sudden need to void

  • volume lost = variable

  • complete incontience may occur

  • detrusor muscle overactivity

  • may be neurogenic

  • 2ary to an underlying pathology or idiopathic

  • overactivity can result from any condition that causes loss of neuro control

    • stroke (most common)

    • MS

    • spinal cord injury

    • spina bifida

  • 2ary causes:

    • UTI

    • STI

    • interstital cystitis

    • atrophic vaginitis

    • bladder diverticula

    • prior pelvic radiation

    • surgical treatment

  • idiopathic = poorly understood

  • occurs with aging

  • closely linked with overactive bladder syndrome

Overactive bladder syndrome

idiopathic urological condition comprising urgency, frequency and often nocturia

  • = urgency incontinence with no known cause

  • but may occur with no incontinence

  • frequency generally ≥ 8/day

  • loss of neurological control of detrusor muscle activity = thought to contribute

mixed incontinence

combination of stress and urgency

  • 1/3 of women

  • more common with age as multiple diseases begin to occur

  • managmenet focuses on dominant but all causes considered/addressed

Overflow

obstruction at bladder neck or an impairment of detrusor contractility

  • leakage occurs from an over-filled bladder

  • often without urgency

  • more commonly seen in men

  • caused by

    • urethral obstruction

    • prlapse of pelvic organs

    • neruological damage

    • conditions that reduce sensation in bladder

      • stroke

      • MS

      • DM

Other causes:

  • functional incontinence

  • post void dribbling

    • urine remaining in urethra

  • urogenital fistula

    • passage opens between bladder/urethra and vagina

Medications:

  • Sympathomimetics

    • tightening of urinary sphincter

      • urinary retention

      • overflow incontincence

  • Alpha blockers

    • relaxes urinery sphincter and urethra

    • potentially causing stress incontinence

  • ACEi

    • cause cough

  • TCA

    • Anticholinergic effect interfere with bladder contraction

    • cause constipation

      • leading to urinary retention and overflow incontinence

  • Antihistamine

    • anticholinergic effect

  • Antipsychotics

    • anticholinergic effect

    • also decrease phsyical mobility

      • abrupt urgency

  • CCB

    • interfere with blaadder contraction

    • worsen constipation

  • Diuretics

    • increase urine production

  • iron

    • constipation

  • Opiods

    • interfere with bladder contraction

    • worsen constipation

  • Sedatives

    • slow mobility and cause urgency incontinence

History:

  • frequency

  • frequency of leakage

  • triggers

  • pads/protective devices

  • diet and fluid intake

    • including cafferine adn etoh

  • lower urinary tract symptoms

  • other genitourinary tract symptoms

  • constipation and faecal incontinence

  • sexual function

  • past history of:

    • bladder surgery

    • hysterectomy

    • childbirth

    • previous uti

    • previous sti

  • medicine use

  • smoking

    • associated with bladder overactivity

Examination

  • assessment of patient’s general health staus

  • consideration of presence of systemic conditions

  • abdomina l examination

  • cough stress test

    • lie flat on back and cough

    • external urethral meatus for leakage during first cough

  • pelvic examination

Investigations

  • dipstick

    • haematuria

    • glycosuria

    • signs of infection

  • bladder diary

    • cover 3/y

    • document

      • fluids

        • amount

        • types

      • frequency void

      • episodes of urgency, incontinence, pad/clothing change

    • noraml amount = 200-400mL

    • normal freq

      • 2-8time/daily

      • one/night

    • bladder diary

  • post void residual bladder volume

    • significant voiding symptoms

    • recurrent uti

    • symptomatic pelvic organ prolapse

    • bladder distension

  • Urodynamic testing

    • measures

      • how well bladder and urethra store/release urine

Pelvic organ prolapse

  • frequent cause

  • pelvic floor damage in childbirth

Anterior

  • front wall of vagina herniated inward

    • usually caused by bladder nad/or urethra shifting position

  • cystocoele

  • urethrocoele

  • cystourethrocele

Posterior

  • weakening of musculatrue and connective tissue or damage to rectovaginal septum

  • rectum herniate into vagina

  • rectocoele

  • enterocoele

Apical

  • tissue supporting uterus weakens

  • uterus slips downwards

Vaginal vault prolapse

  • roof of vagina collapses

Managment

General advice

  • weight loss for any with BMI ≥30

  • avoid excessive fluid intake/drinking late at night

  • decrease caffeine and etoh

  • avoid constipation

  • stop smoking

  • increase phsyical activity

Stress incontinence

  • pelvic floor exercises

    • more likley to report cure or imporvement

    • 3/12

    • individualised

  • surgical

    • mid-urethral slings

    • intramural urethral bulking agents

  • pharmacological

    • duloxetine

    • not subs

    • second-line to surgical treatmnet

Pelvic floor exercises

  • strengthen muscules under uterus, bladder, bowels

  • tensing, holding and then relaxing muscles

  • 3x8 od

  • contraction held \~10sec

Urgency/overactive

  • treat cause and train bladder
bladder training

  • more aware of voiding and incontinence patters

  • learn to contorl

  • sceduled times are set for voiding

  • times between voiding gradually increased

  • if urgency occurs

    • ‘hold on’ for short time - 10min

    • squeezing, holding pelvic floor

    • distraction

    • squeezing fists tightly or pushing ball of food hard onto floor

pharmacological

  • oxybutyinin

    • 5mg od gradually increase to 5mg tds

    • max = 4x daily

    • elderly 2.5mg

    • anticholinergic

    • reduce symptoms of urgency

    • increase bladder capacity

    • main side effect = dry mouth

Pelvic floor first app

https://itunes.apple.com/au/app/pelvic-floor-first/id757727900?mt=8

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