7.8- Urinary Incontinence

Question 1

60% of women post-partum will experience urinary incontinence. For the majority this goes away within a year, however it remains with 12%. Define Urinary incontinence

Answer 1

It is the involuntary loss of urine that is objectively demonstrable + impact on QoL (social/hygienic problem)

Question 2

State the types of urinary incontinence

Answer 2

Stress incontinence
Urgency Incontinence
Overflow incontinence
Anatomical
Autonomic

Question 3

Risk factors of stress incontinence are those of pelvic organ prolapse. Define Stress incontinence

Answer 3

Involuntary loss of urine due to increased intraabdominal pressure or weakness of pelvic support

Question 4

Define Urgency incontinence
Give the RFs associated with urge incontinence

Answer 4

Involuntary loss of urine due to urgency (not reaching bathroom on time)
Lifestyle factors: Fizzy drinks, spicy food, tea, coffee, smoking, decreased mobility
Comorbidities: Diabetes, stroke
Diuretics incl. alcohol

Question 5

Define Overflow incontinence
State the 2 common causes of it
What specific investigation would be useful to diagnose this

Answer 5

Involuntary loss of urine due to overfilling of bladder => pressure exceeds that of sphincter. It is characterized by incomplete bladder emptying => PVR (post-voidal residual) and dribbling of urine.
Typically caused by pelvic organ prolapse in women causing outlet obstruction (Cystourethrocele)!! as well as detrusor underactivity (as opposed to urgency which would be overactivity)

Question 6

A patient presents with a constant leakage of urine that is not in excessive quantities. What do they likely have?
What type of urinary incontinence is being displayed here?
What RF can lead to this?

Answer 6

Vesicovaginal! or ureterovaginal or urethrovaginal Fistula
Anatomical incontinence
RF: Previous abdominal/pelvic surgeries, IBD (crohn’s), IBS, chemoradiation, infection

Question 7

Give the 2 most common causes of anatomical urinary incontinence

Answer 7

Fistula and congenital ectopic ureter

Question 8

What is the main cause of autonomic incontinence?

Answer 8

Spinal trauma
Others include: Cauda equina, conus medullaris, and complication of a surgery affecting nerves governing micturition

Question 9

What nerves/nerve roots govern mictruition

Answer 9

Parasympathetic via S2-S4 -> detrusor contract, sphincter relax
Sympathetic via T10-L2 -> detrusor relax, sphincter contract
Pudendal nerve S2-S4 -> motor innervation to urethral sphincter

Question 10

What level are pathological fractures most common in

Answer 10

T10-L2, more specifically T12/L1

Question 11

State the general workup of a patient presenting with urinary incontinence (no details just steps in the workup)

Answer 11

Routine:
History
Abdo + pelvic examination
Labs and general investigations
Urinalysis + PVR (post-voidal residual)
Extra:
+/- Urodynamic testing
+/- Cystourethroscopy (most invasive)

Question 12

How would you contrast a person with urgency incontinence from stress incontinence

Answer 12

First, it is important to note that a patient may have both

Urge incontinence is characterized by Sudden urge (not being able to reach toilet before leaking) frequency, !Nocturia (waking up to pee at night)!, Enuresis
Stress incontinence is typically characterized by exacerbating factors like coughing, laughing, lifting…

Question 13

You are asked to take a history of a patient presenting with urinary incontinence. Go for it

Answer 13

1) Onset + description - precipitating factors, dysuria (constant vs occasional vs exacerbating factor)
2) Severity (quantify) + impact on QoL: wearing pads, self-isolating, avoiding exercise, !toilet mapping!
3) Urgency vs stress: Sudden urge (not being able to reach toilet before leaking) frequency, !Nocturia!, Enuresis
4) RFs:
Lifestyle factors: Fizzy drinks, spicy food, tea, coffee, smoking, decreased mobility
Comorbidities: Diabetes, stroke
Diuretics incl. alcohol
5) Rule out UTI (fever, Dysuria, flank pain)
5) Inv./tx to date: voiding diary, urological studies/successful tx
6) Recent trauma to head or spine

Question 14

What findings may you find on a pelvic exam of a patient presenting with incontinence

Answer 14

Inspection: Perineal skin irritation, infection, hygiene. Constant flow? fistula
Bimanual:
1) weakness of vaginal walls/prolapse (ask patient to strain to assess strength and check for urine leakage during that)
2) vaginal atrophy

Question 15

What findings are you assessing for on urinalysis in a patient presenting with urinary incontinence

Answer 15

looking for evidence of UTI (blood, nitrates, pyuria)
Glycosuria (diabetes) also do OGTT, HBA1c for that

Question 16

When conducting urinalysis, a post-voidal residual may be performed as well at the bedside via x-ray. What is this testing for? What results would warrant further investigation?

Answer 16

It tests for how much urine is left after voiding
>50ml is abnormal
Note that this may be different based on bladder size and age

Question 17

Briefly state what urodynamic studies are assessing

Answer 17

Study investigating both the phase of bladder filling (cystometry) and bladder emptying (uroflowmetry)

Question 18

You are conducting urodynamic studies assessing the bladder filling. What is this called and how is it conducted?
How would you use that to determine if a patient is having stress or urinary incontinence?

Answer 18

Cystometry. It assesses the pressure/volume relationship on bladder filling. 500 ml of saline is inserted into urinary catheter to fill the bladder and the pressure is recorded. Intrabdominal pressure is measured via rectal or vaginal catheter. Detrusor pressure is P bladder - P intraabdominal as P bladder = P detrusor + P intraabdominal
Urge incontinence is characterized by detrusor hyperactivity => P bladder and P detrusor will both be equally elevated
Stress incontinence is characterized by increased intraabdominal pressure (and weakness of pelvic floor muscles) => P bladder and P abdomen .

Question 19

You are conducting urodynamic studies and are assessing bladder voiding. What is this called? What information does it provide?

Answer 19

Uroflowmetry
Measure total volume voided (post-voidal residual), peak flow (obstruction), and detrusor activity (neurological)
Differentiates if the problem is overflow incontinence, outflow obstruction, or weak detrusor (neurological such as stroke)

Question 20

T or F: Leaking during physical activity is a feature of only stress incontinence

Answer 20

False urge incontinence may also have it as many have symptoms of both

Question 21

What is the pathophysiology of urge incontinence?

Answer 21

Overactive bladder/hyperactive detrusor (which is why P detrusor increases with P bladder.

This means that the detrusor muscle in uninhibited and has involuntary contractions on bladder filling (kinda similar to how rubbing the uterus makes it contract)

Question 22

Urge incontinence is characterised by hyperactivity of the detrusor muscle. How might this occur. Give 4 reasons

Answer 22

Spinal cord injury (conus medullaris)
Neuromuscular disorders
MS
Altered microflora
Bladder neck obstruction
Idiopathic

Question 23

Give 5 symptoms of urge incontinence

Answer 23

Urgency (directly when feeling to void)
Incontinence (not able to reach toilet)
small Volume but high frequency
Nocturia 2 or more times/night
+/- mixed with stress incontinence

Question 24

How would you confirm the diagnosis of urge incontinence once youve finished the history?

Answer 24

It is often enough by itself but with urodynamic studies via cystometry showing equally increased pressure of detrusor and bladder on bladder filling

Question 25

Give the full management plan of a patient presenting with nocturia, urgency, and frequency. The patient does not have a fever and is negative on urinalysis for blood, nitrates, and pyuria

Answer 25

Conservative: Physiotherapy -> Behavioural therapy/bladder training via biofeedback
+ Urge incontinence RF reduction => cut down on smoking, alcohol (diuretic), fizzy drinks, coffee, tea, spicy food. control diabetes (compliance)

Medical: Anticholinergic agents (oxybutynin)
Or beta 3 agonist (much more SE)

Surgical:
Cystoscopy + Intravesical Botox Injections
Clam Ileocystoplasty
Urinary Diversion (rarely performed)

Question 26

What is clam ileocystoplasty?

Answer 26

Its in the name. It uses an intestinal segment to enlarge the bladder.
GA -> segment of intestine used as graft (sutured back) -> bladder incision -> suture intestinal segment there.

Question 27

What is urinary diversion

Answer 27

Ureters attached to bowel (very invasive)

Question 28

What is the mechanism of action of anticholinergic agents?

Give an example

What are the side effects of anticholinergic agents? give 3

Give one contraindication. If it is contraindicated, what would you give a patient with urge incontinence instead?

Answer 28

Oxybutynin, tolteridine
Anti cholinergic = antiPNS => Symptoms: tachycardia, blurred vision, urine retention, xerostomia!

Contraindications: Narrow angle glaucoma, SVT, Gastric retention

Instead, I would give B3 agonist

Question 29

What age group does Urge incontinence typically present at?
Same question for stress incontinence

Answer 29

Urge -> 45-49
Stress -> post-menopausal => 52+

Question 30

What is the pathophysiology of Stress incontinence?

Answer 30

Urethral hypomotility (insufficient pelvic support => prolapse)
and/or Instrinsic sphincter deficiency.

Question 31

What can cause the intrinsic sphincter deficiency seen in stress incontinence?

Answer 31

Neuromuscular damage (Pudendal or PNS/SNS)
Deficiency of estrogen in post-menopausal women

Question 32

How would you manage a patient presenting with stress incontinence but no evidence of prolapse. Give the full management plan.

Answer 32

Conservative: Same as prolapse => RF modification (weight, dietitian referral, Kegel exercises by physiotherapy referral, smoking cessation, laxative for constipation)
+ Biofeedback/bladder training
+ Urge incontinence RF reduction => cut down on smoking, alcohol (diuretic), fizzy drinks, coffee, tea, spicy food. control diabetes (compliance)
+ Incontinence Pessary (normal pessary but with a knob)

Medical: Local oestrogen cream (PV)
Laxatives for chronic constipation
SNRI: Duloxetine (it increases pudendal nerve activity)

Surgical: urethral bulking (bulking agents inserted into urethra)
Autologous slings
Mesh TVT/TOT (currently suspended)
Burch Colposuspension

Question 33

Briefly explain the procedure of autologous slings.

Answer 33

The procedure for autologous slings for stress urinary incontinence involves surgically harvesting a strip of the rectus fascia/fascia lata (patient’s own tissue) and using it to create a supportive sling around the urethra or bladder neck.

This sling acts to support the bladder and urethra, preventing involuntary leakage of urine during physical activities that increase abdominal pressure, such as coughing or sneezing

Question 34

Very very briefly explain Mesh TVT vs TOT

Answer 34

TVT is tension-free vaginal tape: Mesh inserting a synthetic mesh tape under the mid-urethra to provide support ands prevent leakage
TOT is TransObturator Tape: Exactly the same (miurethra) but here it is a synthetic mesh tape passed through the obturator foramen

Question 35

Very briefly explain Burch Culposuspension

Answer 35

Burch colposuspension procedure involves surgically lifting and securing the bladder neck to the iliopectineal ligament of the pelvis, thereby providing support to the urethra and reducing stress urinary incontinence.