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Aim of article?
Reviews the cause, incidence, diagnosis and management options for women with stress urinary Incontinence (SUI).
What is urinary Incontinence?
The involuntary loss of urine. SUI is the most common form of the condition. Defined as the involuntary leakage of urine, on effort, exertion, sneezing or coughing.
What is Urge urinary Incontinence?
The involuntary leakage of urine accompanied by or immediately preceded by, urgency.
What is mixed urinary Incontinence?
A combination of stress urinary Incontinence and urge urinary Incontinence.
What is the cause of SUI?
Multifactorial, associated with anatomical and neuromuscular pathologies. In women, it is associated with damage to the pudental or pelvic nerves. Or changes in the urethral position due to pelvic floor dysfunction. Dysfunction is affected by increasing age. Obesity, childbirth and pregnancy.
Which groups are at risk of stress urinary Incontinence?
Pregnant women, post-partum women. Menopausal women, older people and people with disabilities.
What are the risk factors of stress urinary Incontinence?
Increased age. Obstetric history, menopause, surgical procedures. High alcohol and caffeine intake. Smoking and a high BMI over 26.
How does leakage occur in SUI patients?
When intra-abdominal pressure or stress is placed on the urethral sphincter, or when pressure in the bladder exceeds that of the urethra. Therefore occurring during coughing, sneezing, sports or getting up from a chair. This should be distinguished from urge which is caused by an overactive bladder that contracts inappropriately.
According to legislation, who are in prime position to proactively identify women with SUI?
Nurses. I.e. Noticing the smell of urine when changing a leg ulcer dressing.
What are the goals of treatment of stress urinary Incontinence?
Symptom improvement.
What treatments are their for SUI?
Pelvic floor exercises have poor Concordance.

Surgical options are often associated with side effects and complications.

What conservative treatments are available for SUI?
Initial lifestyle advice including:
Fluid intake.
Weight loss.
Exercise
Smoking cessation.

Followed by non invasive procedures such as pelvic floor re-education. Or vaginal cones. And biofeedback, is a process by which information about a normally unconscious physical process is presented to the patient as a visual, auditory or tactile signal.
What is the most common treatment for stress leakage?
Pelvic floor muscle training. Involving voluntary contraction and relaxation of the levator ani muscle, which supports the vagina, bladder and urethra and contributes to the urethral sphincteric mechanism. The goal is to increase the strength and endurance of the levator muscle, thereby enhancing the force of urethral closure under certain conditions.
What are the characteristics of pelvic floor muscle training for SUI?
An accepted first line intervention for treatment of an SUI.
Aim to improve the tone of the pelvic floor muscle.
Effectiveness of treatment is dependent on Concordance.
There are no associated complications or side effects.

Most have poor compliance. Even though benefits are seen after 15 to 20 weeks.
What are the characteristics of electronic devices and biofeedback?
Artificial stimulation of the pelvic floor muscles, which helps to familiarise patients with pelvic floor contractions.

It can be conducted at home.
What are the characteristics of vaginal cones?
Used in addition to pelvic floor exercises to improve muscle tone.

Consists of a series of graded weights 20-90kg: one weight is inserted into the vagina for upto 30 minutes twice daily.

Pelvic floor contractions are essential to keep the weights in place.
What are the characteristics of medication for SUI?
Limited drug therapy is available for SUI.

Current pharmacological agents focus on the symptoms of urge urinary Incontinence rather than SUI, acting on the bladder wall rather than the sphincter.
What are the characteristics of surgery in SUI?
The two common types of surgery are tension free vaginal tape (TVT) and colposuspension.

Other types of surgery for SUI include sling procedures, which are used to support the bladder neck using biological or synthetic material, and injection of bulking materials, such as collagen, into the wall of the urethra.

Patient can expect to stay in hospital for between one and six and a half.
What does this next article talk about?
The management of Incontinence. The article examines ways in which pharmacists can help such people, both by selling Incontinence aids and by giving advice about drug treatment.
What gender does urinary Incontinence affect?
Men AND women. Hard to establish the prevalence due to the taboos surrounding it.
What are the causes of Incontinence?
Age, sex hormones, child birth and hysterectomy, infection and other factors, such as exercise and high impact activities such as HEAVY LIFTING.


AschiH
What is urinary Incontinence defined as?
Involuntary loss of urine, which is objectively demonstrable and is a social or hygienic problem.
What is the incidence of Incontinence amongst men women?
1 in 4 women.
Why would a hysterectomy cause Incontinence?
It is an operation which removes the womb. Causing great trauma to the area. Leading to Incontinence, involuntary loss of urine.
What types of Incontinence are there?
Stress Incontinence and urge Incontinence.
What is stress Incontinence?
Involuntary loss of urine during physical exertion.
What is gsi?
Genuine stress Incontinence. The involuntary loss of urine when intravesical pressure exceeds closure pressure in the absence of detrusor activity. Symptoms are caused by involuntary contractions of the detrusor muscle in the bladder provoked by exertion.
What is thought to cause genuine stress Incontinence?
Lack of support in the bladder neck. Most commonly caused by damage to the pelvic floor muscles and ligaments sustained during pregnancy and child birth.
When would gsi occur in men?
It is rare, and is caused by surgery, most commonly radical prostatectomy.
What is the cornerstone of treating gsi?
Pelvic floor physiotherapy with surgical treatment if this is unsuccessful.
What is Urge Incontinence?
Caused by OVER ACTIVITY of the detrusor muscle in the bladder, leading to a rise in pressure within the bladder and as a consequence, leakage of urine. This form of leakage is also called, detrusor instability.
What is the main drug treatment of urinary Incontinence?
ANTICHOLINERGIC drugs. The with antimuscarinic actions, such as oxybutynin, block the transmission through parasympathetic nerves that\'s activate the detrusor muscle.
What side effects limit the use of anticholinergic drugs?
Systemic side effects such as dry mouth, blurred vision, constipation, tachycardia, drowsiness and urinary retention.
What is oxybutynin hydrochloride?
The gold standard that is most commonly used for treating Incontinence. In addition to its antimuscarinic actions, it also has a direct relaxant effect on the detrusor muscle.
What limits the use of oxybutynin hydrochloride?
It\'s systemic side effects, dry mouth, constipation blurred vision and tachycardia.
What is the recommended dose of oxybutynin hydrochloride?
5mg TDS.
What regime in Kings college is used for oxybutynin hydrochloride?
Start treatment with doses of 2.5mg daily. And gradual increase until a balance between side effects and symptom relief is achieved. In the elderly an even lower dose of 2.5mg is advisable.
When is intermittent self catheterisation used?
In the treatment of patients with intractable voiding difficulties. The patient passes a catheter into the bladder to remove residual urine.
What is ditropan XL?
A modified release version of oxybutynin. Uses an osmotic release system. Normal mechanisms of release, increase of water through membrane, release of solubilised drug through the laser drilled orifice. Release of drug only governed by an osmotic gradient that is unaffected by pH or gut motility.
What newer anticholinergic with fewer side effects are available?
Tolterodine (detrusitol).
Propiverine (detrunorm)
Trosoium (Regurin).

All are more expensive but show reduced side effects. There are no studies comparing them to one another with m/r oxybutynin.
Tolterodine?
Appears to have increased affinity for muscarinic receptors in the bladder and reduced activity in the salivary glands than oxybutynin. Thus, tolterodine might cause a few fewer systemic side effects, while maintaining efficacy. Usual dose is 2mg BD. Although lower doses in elderly women.
Propiverine?
Antimuscarinic drug with high specificity for detrusor cholinergic receptors. Has calcium channel blocking activity and dose is 15mg TDS.
Trospium chloride?
An anticholinergic compound with a high affinity for M3 muscarinic receptors.
Tricyclic antidepressants in Incontinence?
Alternative therapy. Inhibiting reuptake of noradrenaline and 5HT at the presynaptic membrane and can, therefore potentiate the bladder relaxant effect of the sympathetic nervous system. Also have anticholinergic properties and act directly on the bladder. Tricyclic can cause dry mouth and sedation. But the sedative effect can be used beneficially in patients for whom nocturia is a problem. Amitryptyline 25-75mg nocte.
Desmopressin for Incontinence?
Long acting analogue of vasopressin. Available as a nasal spray and tablets. 50% urine production reduction of urine after a single dose of 20-40ug. Used for treating enuresis in children can be used for long periods. It is contraindicated in patients with cardiac disease, hypertension or epilepsy.
When are absorbant pants and pads used in Incontinence?
Should NOT be used as first line management for urinary Incontinence, because they encourage women to hide problems rather than seeking professional help. Women should be advised to use Incontinence pads and not sanitary towels as they are more effective, do not leak and do not smell. Those on sale are tena lady pads or liberty. Also obtainable through the NHS.
What are intravaginal devices?
Can be sold in pharmacies, providing support to the bladder neck during exercise. Such as running aerobics or tennis. It is a contifirm device contains 3 small devices and a video. Supports the bladder neck, preventing stress Incontinence. Should only be used following instructions from a health professional. Coloplast have developed it and available by mail order.

There is also a Q tip device which educates the women on her technique in the manoeuvre when it goes up, wrong and down is correct.
How do women feel about SUI?
They maybe extremely embarrassed and distressed, their partners or carers.
What is the most common type of urinary Incontinence?
Stress urinary Incontinence.
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