7b.) Urinary Incontinence

Question 1

Describe when urinary incontinence occurs in terms of pressures

Answer 1

When bladder pressure is greater than urethral sphincter pressure due to either detrusor pressure being too high or urethral sphincter pressure being too low

Question 2

Describe the role of the pelvic floor in incontinence

Answer 2

Pelvic floor muscles help to support the urethra and hence are important for the efficiency of the sphincter mechanisms of the urthera

Question 3

Continence is achieved by the combined effect of what 3 things?

Answer 3

• Smooth muscle of urethra
• Surrounding periurethral striated muscle
• Elasticity of connective tissue

Question 4

State the innervation to the bladder

State the innervation to the external urethral sphincter

Answer 4

Question 5

Desribe the appearance of organs in relation to pelvic floor in someone with a weakened pelvic floor

Answer 5

Question 6

Describe what can happen to the bladder if there is a lower motor lesion e.g. in cauda equina

Answer 6

???

Question 7

Describe what can happen to the bladder if there is a high motor lesion

Answer 7

???

Question 8

Describe 3 broad categories of lower urinary tract symptoms and give examples of each

Answer 8

Question 9

What is urinary incontinence?

Answer 9

Any involuntary leakage of urine

Question 10

Explain why obesity and pregnancy can cause urinary incontinence

Answer 10

Increase (intrabdominal) pressure on bladder

Question 11

Describe the 4 types of urinary incontinence

Answer 11

• Stress urinary incontinence: complaint of involuntary leakage on effort or exertion or on sneezing or coughing
• Urgency urinary incontinence: complaint of involuntary leakage of urine accompanied by or immediately proceeded by urgency
• Mixed urinary incontinence: complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing
• Overflow incontinence: involuntary leakage because the bladder has got too full

Question 12

You can have wet or dry overactive bladder; true or false

Answer 12

True

Question 13

Which type of incontinence is most and least common?

Answer 13

1. Stress (most)
2. Mixed
3. Urgency
4. Other

Question 14

Describe some risk factors for urinary incontinence

Answer 14

• Pregnancy increase pressure on bladder
• Menopause decrease oestrogen which means less muscle tone

Question 15

Describe how you might examine a patient with urinary incontinence

Question 16

State some investigations you might do on someone presenting with urinary incontinence

Answer 16

Question 17

Describe the principles behind probing in video pressure-flow studies

Answer 17

• Probe in bladder: measure abdominal and detrusor pressure
• Probe in anal canal: measure abdominal pressure
• Pressure bladder probe - pressure anal canal probe= detrusor pressure
• Get patient to cough to calibrate as when cough detrusor pressure should stay same and abdo pressure should increase

Question 18

State some conservative managements of incontinence

Answer 18

Question 19

For patients who are unsuitable for surgery but have failed conservative or medical management what might you offer?

Answer 19

Catheter

Question 20

What is the initial management for patients with stress urinary incontinence?

Answer 20

Pelvic floor muscle training (8 contractions 3x a day for at least 3 months)

Question 21

What pharmacological agent can you give to patients with stress urinary incontinence?

Answer 21

• Duloxetine
• Combined Na and serotonin uptake inhibitor which increases activity in striated sphincter (EUS) during filling phase
• Not reccommended as 1st or 2nd line but maybe as alternative to surgery

Question 22

What is the initial management of urgency urinary incontinence

Answer 22

Bladder training

• Schedule of voiding:
  
  • Every hour
  • Must not void in between
  • Intervals increased by 15-0 mins each week until 2-3 hours reached
  • Do for at least 6 weeks

Question 23

What 3 pharmacological agents can you give for urgency urinary incontinence?

Answer 23

Anticholinergics:

• Act on muscuranic receptors (M2, M3)
• Decrease detrusor contraction

B3 adrenoceptor agonist

• Increases bladders capacity to store urine

Intravesical injection of botulinum toxin

• Inhibits release of ACh at pre-synaptic neuromuscular junction casuing targeted flacid paralysis (weakening or loss of muscle tone)
• Lasts 3-6 months

Question 24

What pharmacological agent do we avoid when treating urgency urinary incontinence in patients with dementia?

Answer 24

Anticholinergics as make dementia worse

Question 25

Define enuresis

Answer 25

Bed wetting

Question 26

What do we class as enuresis/bed wetting? *\*Like what are the criteria*

Answer 26

* Involuntary wetting in sleep * At least 2x a week * In children \>5 years * With no CNS defects

Question 27

Differentiate between primary and secondary enuresis

Answer 27

* Primary: always wet bed * Secondary: stopped wetting bed but started again

Question 28

What are some key questions you would ask if a child presents with enuresis?

Answer 28

Question 29

Describe the management of the following in children: * Primary enuresis without day time symptoms * Primary enuresis with day time symptoms * Secondary enuresis

Answer 29

* Primary without daytime: reassurance, alarms with +ve reward system, ?desmopressin * Primary with daytime: refer to secondary care as probably disorder of lower urinary tract * Secondary: identify and treat underlying cause

Question 30

State some possible causes for secondary enuresis in children

Answer 30

* UTIs * Constipation * Diabetes * Psychological problems * Family problems * Physical problems * Neurological problems

Question 31

State and describe the types of surgery you can offer females with stress urinary incontinence who don't want any/any more children

Answer 31

* **Open retropubic suspension:** correct (e.g. lift) anatomical position of proximal urethra and improve urethral support * **Autologous sling procedure**: take strip of tissue from rectus fascia in abdomen and put like a hammock around neck of bladder to offer better support * **Low tension vaginal tapes:** same as above but use mesh- less common now

Question 32

State and describe the surgery offered to a woman suffering with stress urinay incontinence that plans to have children in future Include materials that can be used and how often procedure needs to be repeated

Answer 32

**Intramural bulking agents**: bulks up mucosa around bladder neck to improve ability of urethra to resist abdominal presure by improving urethral coaptation (a.k.a. drawing sides of urethra together). Can use collagen, autologous fat, silicone... Needs to be re-done every 6 months or so

Question 33

State and describe 4 surgeries which can be used to treat urgency urinary incontinence

Answer 33

* **Sacral nerve neuromodulation**: electrical device implanted in back to send electric signals via sacral nerves * **Autoaugmentation**: bladder enlargement * **Augmentation cytoplasty**: bladder enlargement * **Urinary diversion:** re-route urine from normal flow e.g. could have stoma

Question 34

State and describe 2 surgical procedures offered to males for stress urinary incontinence

Answer 34

* **Male artificial urinary sphincter:** cuff around urethra that stimulates action of normal sphincter to circumferentially close shincter. Mechanical device with button in testes * **Male sling procedure:** synthetic sling to support urethra