0430 Urinary Incontinence Flashcards
UI = urinary incontinence
UI definition:
leakage of urine that interferes with one’s quality of life or health
Innervation of the urinary system involves these 3 systems
sympathetic, parasympathetic, and somatic innervation
what system prevents urination from happening during stressful situations?
Sympathetic activation via hypogastric nerve and pudendal nerve
activation of the hypogastric nerve results in:
- detrusor muscle to relax
- blocks parasympathetic transmission at the pelvic ganglia
- promotes an increase in urethral sphincter tone as the bladder fills
activation of the pudendal nerve results in:
causes contraction of pelvic floor -> prevents release of urine
what system promotes urination from happening during relaxing situations……?
parasympathetic excitatory input to the detrusor muscle via the pelvic nerves and plexuses causes
- contraction of the detrusor muscle to allow for voiding
- relaxation of the bladder neck and external sphincter
two types of Bladder dysfunction?
Urge incontinence
Overflow incontinence
what is urge incontinence? when does it occur?
bladder dysfunction
occurs when the bladder pressure»_space; sphincter mechanisms; occurs w/o warning
what tends to open the bladder neck and urethra?
elevated bladder or detrusor pressure
what causes elevated bladder or detrusor pressure?
- increased detrusor overactivity due to a non-neurogenic or neurologic etiology that results in uninhibited detrusor contractions
- poor bladder compliance - loss of viscoeleastic features of the bladder or change in neural-regulatory activity
increased detrusor pressure is common in?
common in the elderly and may be associated with bladder outlet obstruction
causes of poor bladder compliance?
fibrotic scarred bladder, radiotherapy, increased outlet resistance
symptoms of Urge Incontinence? what happens in severe cases?
symptoms: sudden sensations to void but is then unable to suppress it fully; often have frequency and nocturia in addition to urgency and urge incontinence
severe cases: patients may have no sense of urge (or sense of needing to void) but will leak without warning; usually triggered by water sounds, full bladder
Test to diagnose urge Incontinence??
urodynamic exam – must see that bladder is overactive in order to diagnose
behavioral therapy for Urge Incontinence??
- “timed voiding” have patients void every 1-2 hrs to help them stay dry
- restrict fluid intake
- avoid bladder irritants
- bladder retraining – consciously delay voiding and increase interval btwn voids
- Pelvic muscle exercises
Rx for Urge Incontinence?
anticholinergics +/- alpha agonist
Rx for Urge Incontinence in patients with intractable detrusor muscle activity (not responsive to Rx)
- peripheral nerve stimulation
- sacral nerve stimulation
- surgical intervention
- botox injection into the detrusor muscle
treatment for Urge Incontinence when all else fails?
“augmentation cystoplasty” - bladder augmentation – patch of bowel is used to increase bladder capacity
What is overflow incontinence? When does it occur?
Bladder dysfunction
occurs Excess fluid overwhelms the bladder capacity or when the volume exceeds the bladder viscoelastic properties.
when is overflow incontinence often seen? 3 scenarios
- obstruction (urethral stricture disease or prostatic obstruction)
- poor bladder contractility that results in incomplete bladder emptying (lots of reasons)
- pelvic floor prolapse
what are sx of overflow incontinence?
extreme frequency or constant dribbling, leakage w/ activity, nocturia and urgency
Treatment of overflow incontinence?
Relieve obstruction (many ways..)
Treatment of overflow incontinence caused by urethral stricture?
urethral dilation, internal urethrotomy or urethroplasty
Treatment of overflow incontinence caused by prostatic obstruction?
TRUS (transurethral resection)
Treatment of overflow incontinence caused by previous surgeries or pelvic prolapse?
sling incision or excision, urethrolysis, surgical correction of prolapse, or clean intermittent catherization for those who cannot tolerate surgery
Treatment of overflow incontinence caused by poor detrusor contractility?
clean intermittent catherization
why don’t you want to use indwelling catheters for long-term treatment of overflow incontinence?
predisposes them to bladder calculi and ultimately to squamous cell carcinoma of the bladder
What is stress incontinence?
when does it occur?
Urethral dysfunction
urine is leaked with any increase in abdominal pressure (coughing, laughing, sneezing, walking, getting out of a chair, bending over)
in severe cases, urine is leaked even with minimal activity.
etiologies of stress incontinence? 2
anatomic incontinence
intrinsic sphincter deficiency (ISD, bladder neck dysfunction)
how can anatomical changes cause stress incontinence?
what usually cause this?
urethral hypermobility results in displacement of the proximal urethra BELOW the pelvic floor, which makes it so that the abdominal pressure that normally aids in the closing of the urethra is not transmitted
usually due to loss of pelvic floor muscles as a result of hormonal changes, trauma, pelvic denervation
how can intrinsic sphincter deficiency (ISD, bladder neck dysfunction) cause stress incontinence?
usually due to surgical failure in the treatment of stress incontinence, myelodysplasia, trauma, radiation, alpha adrenergic blockers, hormonal
non-pharmacological treatment for stress incontinence?
Pelvic floor exercises to augment closure of external urethral sphincter and prevent descent and rotation of the bladder neck and urethra
Rx for stress incontinence?
Alpha-agonists (pseudoephedrine)
Antidepressants (imipramine or duloxetine)
why are Alpha-agonists (pseudoephedrine) used for stress incontinence?
bladder neck and proximal urethra have abundant alpha receptors; activation of these receptors -> incresase smooth muscle tone
What surgeries are used to treat stress incontinence due to anatomic variations? 3
anatomic stress incontinence corrected by
1) restoring the bladder neck to its normal retropubic position with a retropubic bladder suspension or
2) by improving urethral support with a sling procedure
coaptation - closes the proximal urethra in patients with well-supported bladder neck via injecting bulking agents into the bladder neck or proximal urethra
T/F incontinence usually are of one type only
False. Mixed incontinence is very common
Stress + urge
Stress + overflow
Urge + overflow
what type of incontinence does anti-cholinergics cause?
Urinary retention -> frequency and overflow incontinence
what type of incontinence does diuretics cause?
Overwhelms the bladder’s capacity and cause uninhibited detrusor contractions -> urge incontinence
what type of incontinence does sedatives cause?
Confusion -> stress incontinence
what type of incontinence does Alpha-adrenergic agonist cause?
increase tone of the smooth muscles of the bladder neck and proximal sphincter –> urinary retention
what type of incontinence does Alpha-adrenergic antagonist cause?
decrease tone of smooth muscles of the bladder neck and proximal sphincter; women treated with these drugs for HTN may develop or have an exacerbation of stress incontinence
what type of incontinence does excessive urine production cause?
some etiologies?
Excessive intake, DM, hypercalcemia, CHF, and peripheral edema can lead to polyuria, which can lead to overflow incontinence
what type of incontinence does stool impaction cause?
Impacted stool -> urge or overflow urinary incontinence
what is the provocative stress test in testing for urinary incontinence?
test leakage by increasing abdominal pressure at a reasonable bladder volume, 150 cc
if you perform a urinalysis on a patient with incontinence, and there is evidence of pyuria or bacteria, what should you do next?
perform culture to r/o infection
if you perform a urinalysis on a patient with incontinence, and there is evidence of hematuria and/or irritative voiding symptoms, what should you do next?
perform cytology
How is the post-void residual (PVR) test carried out?
What are normal PVR? abnormal PVR?
measured with pelvic US or directly with catheter
• normal 200mL
an abnormal PVR can be due to bladder outlet obstruction or poor bladder contractility. How do you differentiate btwn the two?
urodynamic testing
what is urodynamics used for? What does it measure?
used to dx etiology of patient’s urinary incontinence by assessing bladder:
- storage
- overactivity (urge)
- compliance (urge)
- abnormal bladder neck (stress)
- bladder emptying or overflow (obstruction)
purpose of measuring bladder compliance in urodynamics?
to diagnose stress incontinence and r/o obstruction as a cause of overflow or urge incontinence
action of alpha agonists on the bladder
increase urethral sphincter tone
action of ACh on the bladder
contraction of detrusor muscles
action of ß agonists on the bladder
relaxation of detrusor muscle
decrease urethral sphincter tone using what agent using what agent
alpha antagonists
action of anticholinergics on the bladder
relaxation of detrusor muscle
action of botox on the bladder
relaxes the detrusor msucle
