8. Urinary Incontinence Flashcards
What is the muscle of the bladder?
Detrusor
What is the innervation of the detrusor muscle?
Parasympathetic S2,3,4
What is the innervation of the internal sphincter?
Somatic - pudendal nerve S2,3,4
What is the storage phase?
Filling of bladder
Compliance - receptive relaxation
Sensation of bladder filling
No detrusor contraction
What is the voiding phase?
Voluntary initiation
Complete emptying
What happens if a patient has a lower motor neurone lesion and which nerves are affected?
Low detrusor pressure
Large residual volume leading to overflow incontinence
Reduced perianal sensation and lax anal tone
S2,3,4
What happens if a patient has upper motor neurone lesion?
Dilated ureters Thickened detrusor High pressure detrusor contractions Poor coordination with sphincters Detrusor sphincter dyssynergia
What are the lower urinary tract symptoms associated with storage phase?
Frequency
Urgency
Nocturia
Incontinence
What are the lower urinary tract symptoms associated with voiding phase?
Slow stream Splitting or spraying Intermittency Hesitancy Straining Terminal dribble
What are the lower urinary tract symptoms associated with post-micturition?
Post-micturition dribble
Feeling of incomplete emptying
What are the types of incontinence?
Stress urinary incontinence
Urgency urinary incontinence
Mixed urinary incontinence
Overflow incontinence
What is stress urinary incontinence?
The complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
What is urgency urinary incontinence?
Complaint of involuntary leakage accompanied by or immediately proceeded by urgency
What is mixed urinary incontinence?
Complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
What does overactive bladder include?
Urgency
Increased frequency
Nocturia
What are the risk factors for urinary incontinence?
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
What examinations can be done when urinary incontinence is suspected?
BMI
Abdominal exam to exclude palpable bladder
Digital rectal examination - prostate
Females - external genitalia (stress test), vaginal exam (prolapse)
What investigations should be done if urinary incontinence is suspected?
Urine dipstick - UTI, haematuria, proteinuria, glucosuria
Frequency-volume chart, bladder diary, post-micturation residual volume
Invasive urodynamics, pad tests, cystoscopy
What are the general lifestyle interventions to help manage urinary incontinence?
Modify fluid intake Weight loss Stop smoking Decrease caffeine intake Avoid constipation Timed voiding - fixed schedule
What is contained incontinence?
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
What is the initial management for stress urinary incontinence?
Pelvic floor muscle training - 8 contractions 3x day, at least 3 months
What is the pharmacological management of stress urinary incontinence?
Duloxetine - combine noradrenaline and serotonin uptake inhibitor, increases activity in striated sphincter during filing phase, alternative to surgery
What are surgery options for stress urinary incontinence in females?
Permanent intention - open retropubic suspension procedures, classical autologous sling procedures, low-tension vaginal tapes
Temporary intention - intramural bulking agents
Why would someone opt for a temporary intention surgery?
If further pregnancies are planned
What are the surgery options for stress urinary incontinence in males?
Artificial urinary sphincter
Male sling procedure
What is the aim of retropubic suspension procedures?
Correct anatomical position of proximal urethra and improve urethral support
What is the aim of classic fascial sling procedures?
Supports the urethra and augments bladder outflow resistance
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
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
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
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
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
What are the surgical options for urgency urinary incontinence?
Sacral nerve neuromodulation
Autoaugmentation
Augmentation cystoplasty
Urinary diversion
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
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
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
What are possible underlying causes for secondary enuresis?
UTI Constipation Diabetes Psychological problems Family problems Physical or neurological problems
