8.2 Urinary Incontinence Flashcards
At what vertebral level does the spinal cord end?
L2
What nerve supplies detrusor muscle?
Parasympathetic via the pelvic nerve (S2, S3, S4)
What is the levator ani?
The pelvic floor muscle
What are the 2 main phases of bladder continence?
Storage phase
Voiding phase
What occurs to continence when there is a lesion of the lower motor neurone?
Low detrusor muscle pressure -> large residual volume of urine Overflow incontinence (esp. when lying down at night)
What neurones must be affected to influence continence?
S2 S3 S4
What other symptoms are associated with a lower motor neurone lesion?
Reduced perianal sensation
Lax anal tone
What happen to continence in an upper motor neurone lesion?
Detrusor sphincter dyssynergia
High pressure detrusor contractions
Poor coordination with external sphincter
Leads to thickened detrusor muscle and dilated ureters
What 3 categories are considered in lower urinary tract symptoms?
Storage
Voiding
Post-micturation
What are storage symptoms?
Increased frequency
Urgency
Nocturia
Incontinence
What are voiding symptoms?
Slow stream Splitting or spraying Intermittency Hesitancy Straining Terminal dribble
What are post-micturition symptoms?
Post-micturation dribble
Feeling of incomplete emptying
Increase in abdominal pressure can cause incontinence. Give some examples of things that would cause an increase in abdominal pressure
Coughing
Obesity
Pregnancy
What are the 4 main types of incontinence?
Stress urinary incontinence
Urgency urinary incontinence
Mixed urinary incontinence
Overflow incontinence
What is stress incontinence?
The complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing
What is Urgency urinary incontinence?
The complaint of involuntary leakage of urine accompanied by or immediately preceded by urgency
What is mixed urinary incontinence?
The complaint of involuntary leakage of urine with urgency and also with exertion, effort, sneezing or coughing
What is overflow incontinence?
When people have chronic painless retention
What are the symptoms of an overactive bladder?
Urgency
Increased frequency
Nocturia
Urgent urinary incontinence
What is the most common type of incontinence?
Stress urinary incontinence
What are the obs and gynae risk factors for urinary incontinence?
Pregnancy and childbirth (esp vaginal delivery)
Pelvic surgery
Radiotherapy (makes bladder less compliant)
Pelvic prolapse
What are the predisposing risk factors to urinary incontinence?
H
What are the promoting risk factors of urinary incontinence?
Menopause -> less oestrogen Drugs UTI Increased abdominal pressure Obesity Age Co-morbidities Cognitive impairment (dementia)
What should be done in a urinary incontinence consultation?
History - categorise the type of UI
Examination - BMI, Abdominal exam to exclude a palpable bladder, digital rectal examination (males-prostate), limited neurological examination - perianal sensation and anal tone
Females - examine external genitalia (stress test), vaginal exam (prolapse)
What are investigations done for UI?
Urine dipstick Frequency-volume chart Bladder diary Post-micturition residual volume Invasive urodynamics Pad tests Cystoscopy
What is the conservative management of UI
Modify fluid intake Weight loss Stop smoking Decrease caffeine intake Avoid constipation Timed voiding - fixed schedule
When is contained incontinence used?
Used for patients unsuitable for surgery who have failed conservative or medical management
Give examples of contained incontinence
Indwelling catheter (urethral/suprapubic)
Sheath device
Incontinence pads
What is the initial management of SUI?
Pelvic floor muscle training
- 8 contractions x3/day
- at least 3 months duration
What is the pharmacological management of SUI?
Duloxetine - increases activity in the striated sphincter during filling phase (alternative to surgery). Makes people feel nauseous
What surgery is done for SUI in females?
Permanent intention
- open retropubic suspension procedures
- classical autologous sling procedures
- low-tension vaginal tapes
Temporary intention
- intramural bulking agents
What surgery can be done for males with SUI?
Artificial urinary sphincter
Male sling procedure
What is the function of retropubic suspension procedures?
To correct the anatomical position of proximal urethra and improve urethral support
What is the function of classical facial sling procedures?
To support the urethra and augment bladder outflow resistance
What are the benefits and disadvantages of low-tension vaginal tapes?
Good - high success rates, minimally invasive technique, supports mid urethra
Bad - 10% of patients get pain and vaginal problems
What are intramural bulking agents?
Injections (autologous fat/silicone/collagen/hyaluronic-dextran polymers) under GA/LA into the mucosa of the urethra. Improves the ability of the urethra to resist abdominal pressure by improving urethral coaptation. Needs regular top up
What is the male urethral sphincter?
Used to treat long term male wetness due to urethral sphincter deficiency (neurological/surgical/post pelvic radiotherapy). Cuff simulates action of normal sphincter to circumferentially close the urethra. Button in the scrotum. Mechanical device. Gold standard
What is the initial management of UUI?
Bladder training - schedule voiding, at least 6 weeks in duration, increasing intervals between voiding
What are the pharmalogical managements for UUI?
Anticholinergenics - block muscarinic receptors (M2, M3), side affects as muscarinic receptors in other organs. Dryness of mouth, constipation.
Beta 3 adrenoceptor agonist - relax the bladder, increasing the bladders capacity to store urine.
What are common types of anticholinergics?
Oxybutynin
Solifenacin
What is mirabegron?
A type of beta3-adrenoceptor agonist. Shouldn’t be given to people with high blood pressure.
If patients have heart conditions and high BP, what can be used for pharmacological management of UUI?
Intravascular injection of botulinum toxin to bladder. Potent biological neurotoxin. Inhibits release of Ach at pre-synaptic neuromuscular junction causing targeted flaccid paralysis. Acts for 3/6 months.
What is the surgical intervention for UUI/?
Sacral nerve neuromodulation
Autoaugmentation
Urinary diversion
- only done in fit young people as a last option
What is enuresis?
Involuntary wetting during sleep at least twice a week in children aged 5+ with no CNS defects
What key questions need to be asked during enuresis?
Age? Primary or secondary? Daytime symptoms? Pain passing urine? Infrequent urination? Constipated?
What is primary enuresis?
Enuresis having never achieved sustained continence at night
What is secondary enuresis?
Enuresis restarting after having been dry at night for 6+ months
What is the management of primary enuresis without daytime symptoms?
Reassurance, alarms with positive reward. Desmopressin
What is the management of primary enuresis with daytime symptoms?
Usually caused by disorders of the lower urinary tract
Refer to secondary care
How is secondary enuresis managed?
Identify underlying cause and treat.
what causes SUI?
Pelvic floor laxity (chilbirth)
bladder neck sphincter impairment
surgery affecting the urethra or prostate
what is Duloxetine?
a serotonin and noradrenaline reuptake inhibitor used to treat stress incontinence
How do low-tension vaginal tapes help SUI?
proximal urethra is lifted with an artificial sling, increases in intra-abdominal pressure compress the urethra
What is UUI?
Urgency urinary incontinence is the sudden strong urge to void followed immediately by the involuntary loss of urine. Part of over reactive bladder syndrome
what is overreactive bladder syndrome?
overactivity of the detrusor muscle
what are the causes of overflow incontinence?
chronic urinary retention
outlet obstruction (faecal impaction, benign prostatic hypertrophy)
atonic bladder
bladder neck stricture
what are the causes of continuous incontinence?
vesicovaginal fistulae
ectopic ureter bypassing urine from the kidney to the urethra or vagina
what is functional incontinence?
incontinence due to severe cognitive impairment or mobility issues, preventing use of toilet.bladder function is normal
