8. Urinary Incontinence Flashcards

1
Q

What is the muscle of the bladder?

A

Detrusor

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2
Q

What is the innervation of the detrusor muscle?

A

Parasympathetic S2,3,4

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3
Q

What is the innervation of the internal sphincter?

A

Somatic - pudendal nerve S2,3,4

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4
Q

What is the storage phase?

A

Filling of bladder
Compliance - receptive relaxation
Sensation of bladder filling
No detrusor contraction

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5
Q

What is the voiding phase?

A

Voluntary initiation

Complete emptying

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6
Q

What happens if a patient has a lower motor neurone lesion and which nerves are affected?

A

Low detrusor pressure
Large residual volume leading to overflow incontinence
Reduced perianal sensation and lax anal tone
S2,3,4

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7
Q

What happens if a patient has upper motor neurone lesion?

A
Dilated ureters
Thickened detrusor
High pressure detrusor contractions
Poor coordination with sphincters
Detrusor sphincter dyssynergia
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8
Q

What are the lower urinary tract symptoms associated with storage phase?

A

Frequency
Urgency
Nocturia
Incontinence

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9
Q

What are the lower urinary tract symptoms associated with voiding phase?

A
Slow stream
Splitting or spraying
Intermittency
Hesitancy
Straining
Terminal dribble
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10
Q

What are the lower urinary tract symptoms associated with post-micturition?

A

Post-micturition dribble

Feeling of incomplete emptying

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11
Q

What are the types of incontinence?

A

Stress urinary incontinence
Urgency urinary incontinence
Mixed urinary incontinence
Overflow incontinence

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12
Q

What is stress urinary incontinence?

A

The complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

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13
Q

What is urgency urinary incontinence?

A

Complaint of involuntary leakage accompanied by or immediately proceeded by urgency

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14
Q

What is mixed urinary incontinence?

A

Complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing

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15
Q

What does overactive bladder include?

A

Urgency
Increased frequency
Nocturia

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16
Q

What are the risk factors for urinary incontinence?

A

Obs/gynae - Pregnancy and childbirth, Pelvic surgery, Pelvic prolapse
Predisposing - race, family predisposition, anatomical abnormalities, neurological abnormalities
Promoting - menopause, drugs, UTI, obesity, age, increased intra-abdominal pressure

17
Q

What examinations can be done when urinary incontinence is suspected?

A

BMI
Abdominal exam to exclude palpable bladder
Digital rectal examination - prostate
Females - external genitalia (stress test), vaginal exam (prolapse)

18
Q

What investigations should be done if urinary incontinence is suspected?

A

Urine dipstick - UTI, haematuria, proteinuria, glucosuria
Frequency-volume chart, bladder diary, post-micturation residual volume
Invasive urodynamics, pad tests, cystoscopy

19
Q

What are the general lifestyle interventions to help manage urinary incontinence?

A
Modify fluid intake
Weight loss
Stop smoking
Decrease caffeine intake
Avoid constipation
Timed voiding - fixed schedule
20
Q

What is contained incontinence?

A

For patients unsuitable for surgery who have failed conservative or medical management

  • indwelling catheter (urethral or suprapubic)
  • sheath device (analogous to an adhesive condom attached to catheter tubing and bag)
  • incontinence pads
21
Q

What is the initial management for stress urinary incontinence?

A

Pelvic floor muscle training - 8 contractions 3x day, at least 3 months

22
Q

What is the pharmacological management of stress urinary incontinence?

A

Duloxetine - combine noradrenaline and serotonin uptake inhibitor, increases activity in striated sphincter during filing phase, alternative to surgery

23
Q

What are surgery options for stress urinary incontinence in females?

A

Permanent intention - open retropubic suspension procedures, classical autologous sling procedures, low-tension vaginal tapes
Temporary intention - intramural bulking agents

24
Q

Why would someone opt for a temporary intention surgery?

A

If further pregnancies are planned

25
What are the surgery options for stress urinary incontinence in males?
Artificial urinary sphincter | Male sling procedure
26
What is the aim of retropubic suspension procedures?
Correct anatomical position of proximal urethra and improve urethral support
27
What is the aim of classic fascial sling procedures?
Supports the urethra and augments bladder outflow resistance
28
What is the aim of intramural bulking agents?
Improve ability to resist abdominal pressure by improving urethral coaptation Injections under GA/LA, autologous fat, silicone, collagen, hyaluron-dextran polymers
29
What is the aim of the male artificial urinary sphincter surgery?
Cuff simulates action of normal sphincter to circumferentially close the urethra Mechanical (hydraulic) device Fix urethral sphincter deficiency
30
What is the initial management of urgency urinary incontinence?
Bladder training - schedule of voiding (every hour during day, intervals increased by 15-30 mins a week until interval of 2-3 hours) - at least 6 weeks duration
31
What are the possible pharmacological managements of urgency urinary incontinence?
Anticholingerics - act on muscarinic receptors - side effects due to affects on M receptors at other sites Beta 3-adrenoceptor agonist - increases bladders capacity to store urine Intravascular injection of Botulinum toxin - inhibits release of ACh at pre-synaptic neuromuscular junction
32
Where can the side affects from anicholinergics occur?
``` M1 - CNS, salivary glands M2 - heart smooth muscle M3 - smooth muscle, salivary glands M4 - CNS M5 - CNS, eye ```
33
What are the surgical options for urgency urinary incontinence?
Sacral nerve neuromodulation Autoaugmentation Augmentation cystoplasty Urinary diversion
34
What is enuresis in children?
Bed wetting - involuntary wetting during sleep at least 2x week in children aged over 5 years with not CNS defects
35
What are the questions that need to be asked in enuresis in children?
Age Primary or secondary - never achieved sustained continence or restarted after 6+ months of dry nights Do they have daytime symptoms Do they have pain passing urine or pass urine infrequently Are they constipated
36
What is the management for enuresis in children?
Primary enuresis without daytime symptoms - managed in primary care, reassurance, positive reward system, desmopressin Primary enuresis with daytime symptoms - usually caused by disorders of LUT, refer to secondary care Secondary enuresis - treat underlying cause
37
What are possible underlying causes for secondary enuresis?
``` UTI Constipation Diabetes Psychological problems Family problems Physical or neurological problems ```