19: Urinary incontinence

Question 1

Diagnostic evaluationof UI (urinary incontinence) includes ?

Answer 1

a thorough history and physical examination, urine analysis and culture, stress test, cotton-swab test, and use of a voiding diary. Urodynamics (cystometrogram, uroflowmetry) can be used as indicated.

Question 2

Risk factors for UI

Answer 2

age, hormonal status, obesity, diabetes, impaired functional status, some neurologic disorders, pregnancy, vaginal delivery, pelvic surgery, medication (e.g., alpha-blockers), smoking, and genetic factors

Question 3

Stress incontinence is characterized by

Answer 3

leaking with physical activity such as coughing, sneezing, lifting, or exercising.
-intravesical pressures exceed intraurethral pressure

Question 4

Stress incontinence treatment

Answer 4

lifestyle and behavioral modification, incontinence pessaries, and surgical management (supportive slings for the urethra and bladder neck)

Question 5

Urgency incontinence is characterized by ?

Answer 5

leaking associated with urgency and may exhibit detrusor overactivity

Question 6

causes of detrusor overactivity

Answer 6

most idiopathic

-UTI, bladder stones, cancer, diverticula, and neurologic disorders (stroke, multiple sclerosis, Alzheimer disease).

Question 7

urgency incontinence treatment

goal?

Answer 7

lifestyle and behavioral modification, anticholinergic medication. Surgical procedures include sacral and peripheral nerve stimulation, bladder injections, and augmentation cystoplasty
goal: to relax the bladder, suppress involuntary bladder contractions, and enhance urine storage

Question 8

Overflow incontinence is most commonly due to ?

Answer 8

decreased detrusor contractions caused by medications or neurologic disease; (obstruction and postoperative overdistension occur less frequently in women)

Question 9

primary symptom of overflow incontinence is ?

how to treat?

Answer 9

urinary retention with continuous dribbling. It is usually treated with self-catheterization and/or medications to increase bladder contractility (cholinergic agents) and lower urethral resistance (alpha-adrenergic agents).

Question 10

Bypass incontinence is ?

how to treat?

Answer 10

painless, continuous urine leakage usually due to vesicovaginal, urethrovaginal, or ureterovaginal fistulas.
treated surgically with repair of the urinary fistula.

Question 11

most common causes of urinary fistulas in the United States?
In developing countries, total incontinence caused by ? often leads to urinary fistula.

Answer 11

pelvic radiation and pelvic surgery

obstetric trauma/obstructed labor

Question 12

Functional incontinence is ?
causes?
seen most commonly in what patients?

Answer 12

urinary loss due to the physical and/or mental inability to attend to voiding cues.
Causes: physical impairment, dementia and delirium, and medications.
-most commonly in nursing homes and in geriatric and psychiatric patients.

Question 13

mixed (urinary) incontinence

Answer 13

(stress + urgency) Involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing

Question 14

Urinary continence at rest is possible because the ? exceeds the ?

Answer 14

intraurethral pressure exceeds the intravesical pressure.

• Continuous contraction of the internal sphincter
• external sphincter provides about 50% of urethral resistance and is the second line of defense against incontinence

Question 15

Sympathetic control of the bladder is achieved via the ?

Answer 15

hypogastric nerve originating from T10 to L2 of the spinal cord.
-prevents micturition by contracting the bladder neck and internal sphincter

Question 16

Parasympathetic control of the bladder is supplied by the ?

Answer 16

pelvic nerve derived from S2, S3, and S4 of the spinal cord

-allows micturition, contraction of detrusor muscle

Question 17

the somatic nervous system aids in voluntary prevention of micturition by innervating the striated muscle of the ? through what nerve?

Answer 17

external sphincter and pelvic floor

the pudendal nerve

Question 18

stress test is performed by ?

Answer 18

filling the bladder with up to 300 mL of normal saline or sterile water through a catheter. The patient is asked to cough, and the clinician observes to verify the loss of urine
-urine leakage is witnessed by the clinician: genuine stress incontinence

Question 19

postvoid residual (PVR) is obtained by ?
to rule out ?
alternative ?

Answer 19

catheterization of the bladder after voiding. -use to rule out urinary retention and infection.
-alternative is to measure the postvoid residual with an ultrasound bladder scanner. The upper limits of a normal postvoid residual have been reported as 50 to 100 mL.

Question 20

cotton swab test purpose?

Answer 20

to diagnose a hypermobile urethra associated with stress incontinence
-insert lubricated cotton swab into the urethra to the angle of the urethrovesical junction When the patient strains as if urinating, the UVJ descends and the cotton swab moves upward. The change in cotton swab angle is normally less than 30 degrees and a value of greater than 30 degrees is consistent with a hypermobile urethra

Question 21

Urodynamics evaluates

Answer 21

urethral function (urethrocystometry, urethral pressure profilometry), bladder filling (cystometry), and bladder emptying (uroflowmetry and voiding cystometry or pressure flow studies).

Question 22

cystometry measures ?

Answer 22

the pressure and volume relationship of the bladder during filling and/or pressure flow study during voiding
-assesses bladder sensation, bladder capacity, detrusor activity, and bladder compliance

Question 23

hammock theory

Answer 23

the urethra lies on the supportive layer of the endopelvic fascia and anterior vaginal wall
-during a cough the urethra is compressed against this hammock-like supportive layer with a resultant increase in urethral closure pressure

Question 24

stress incontinence Lifestyle and behavioral modifications include ?

Answer 24

weight loss, caffeine restriction, fluid management, bladder training, pelvic floor muscle exercises (Kegel exercises), and physical therapy (biofeedback, magnetic therapy, and electrical stimulation)

Question 25

medical therapy for stress incontinence

Answer 25

limited, none FDA approved
Alpha-adrenergic agonists (midodrine, pseudoephedrine), beta-adrenergic receptor antagonists and agonists (clenbuterol, propranolol), TCAs (imipramine), and SNRIs (duloxetine), estrogen

Question 26

? are used to physically elevate and support the urethra, which restores normal anatomic relationships

Answer 26

Incontinence pessaries and other intravaginal devices

Question 27

stress incontinence sx treatment

Answer 27

abdominal retropubic urethropexies (Burch procedures), bladder neck slings (aim to resuspend the hypermobile urethra), and tension-free midurethral slings (tension-free vaginal tape, transobturator tape) (provide reinforcement at the midurethra to the pubic bone, suburethral vaginal hammock, and pubococcygeus muscles)

Question 28

intrinsic sphincter deficiency may benefit from ?

Answer 28

periurethral or transurethral placement of bulking agents to improve sphincter tone

Question 29

medications for urgency incontinence

Answer 29

Oxybutynin, Tolterodine, Fesoterodine (Toviaz), Solifenacin (Vesicare), Trospium (Sanctura), Darifenacin (Enablex)

Question 30

Surgical treatments for urgency incontinence include ?

Answer 30

sacral and peripheral neuromodulation, bladder injections, and augmentation cystoplasty, Posterior tibial nerve stimulation, Botulinum toxin (not FDA approved), augmentation cystoplasty

Question 31

Treatment strategy in overflow incontinence is geared toward ?

Answer 31

relieving urinary retention, increasing bladder contractility, and decreasing urethral obstruction

Question 32

Medical management of overflow incontinence

Answer 32

agents to reduce urethral closing pressure (prazosin, terazosin, phenoxybenzamine) and striated muscle relaxants (diazepam, dantrolene) to reduce bladder outlet resistance. Cholinergic agents (bethanechol) are used to increase bladder contractility. Intermittent self-catheterization to avoid UTIs and retention

Question 33

Patients with overflow incontinence due to bladder outlet obstruction caused by a continence procedure benefit from ?

Answer 33

surgical correction of the obstruction

Question 34

diagnosing vesicovaginal and ureterovaginal fistulas

Answer 34

Methylene blue or indigo carmine instilled into the bladder in a retrograde fashion can be visualized leaking through the fistula into the vagina
-If a ureterovaginal fistula is present, the retrograde dye test will be negative and the IV dye test will be positive.

Question 35

how to identify the number and location of the fistulas after dye tests

Answer 35

Cystourethroscopy and the voiding cystourethrogram (VCUG) 
IV pyelogram (IVP) and retrograde pyelogram (localized)