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 2 nd 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