B8.049 Prework: Adult Urinary Incontinence Flashcards
what is urinary incontinence
complaint of involuntary loss of urine
what is urinary incontinence a risk factor for
prolonged hospitalization falls UTI contact dermatitis institutionalized care depression/anxiety, social isolation
epidemiology of UI
15-30% of older adults
up to 50% of patients in nursing facilities
types of UI
stress urge mixed overflow neurogenic
stress UI
involuntary leakage on exertion/physical activity, or on sneezing or coughing (anything that increased intraabdominal P)
urge UI
involuntary leakage associated with urgency
mixed UI
involuntary leakage associated with urgency and also with exertion, sneezing, or coughing
overflow
involuntary leakage associated with incomplete bladder emptying
neurogenic
incontinence related to an underlying neurologic disease
bladder overactive
urgency
sphincter underactive
stress
bladder underactive
overflow
urethral obstruction
overflow/urgency
CNS structures involved in micturition
periaqueductal gray
pontine micturition center
onuf’s nucleus
neural regulation of urine storage
guarding reflex
during bladder filling:
-afferent nerve inputs stimulate sympathetic output to bladder and proximal urethra
-pudendal firing activated to control external sphincter
GOAL: bladder relaxation, icnreased outflow resistance
hypogastric nerve
T10-L2 sympathetic contracts bladder outlet inhibits detrusor B3 receptors in bladder a1 receptors in internal sphincter
pudendal nerve
somatic control of external sphincter
ACh receptors
neural regulation of emptying
termination of inhibitory signals from periaqueductal grey to pontine micturition center
- descending signals inhibit guarding reflex
1. urethral sphincter relaxation by inhibition of Onuf’s nucleus
2. activation of parasympathetic pathways
pelvic nerve
S2,3,4 parasympathetic M2, M3 receptors in bladder contracts detrusor inhibits bladder outlet
summary of filling/storage phys
bladder accommodates increasing volumes of urine at low pressures by:
-inhibition of the parasym system provided by sym and somatic reflex activity
bladder outlet must remain closed during filling phase by spinal reflex activity that activates sym and somatic pathways (guarding reflex)
summary of emptying phys
when ready to empty bladder, PAG activates PMC which causes micturition via parasym pathways in sacral cord
sym and somatic nerves are inactive
bladder outlet open
symptoms of stress UI
leakage of urine associated with physical activity, coughing, sneezing
can also be seen in men after prostate surgery
symptoms of urgency incontinence
sudden need to void but cant get to the toilet fast enough
“overactive bladder”
symptoms of overflow incontinence
sensation of abdominal fullness
dribbling of urine
intermittent urine stream
risk factors for UI
gender (2x more in women) age (younger = stress, older=urge) pregnancy (stress in 40%) parity smoking obesity diabetic neuropathy
reversible causes of UI
delirium, dementia infection atrophic vaginitis psychosocial: depression pharma endocrine disorders restricted mobility stool impaction
drugs that can cause UI
sedatives diuretics a blockers narcotic alcohol
changes in the bladder with aging
increased urine production at night bladder hyperactivity increases bladder contractility decreases bladder capacity decreases striated sphincter muscle weakens prostate enlarges vaginal atrophy
physical exam components in the eval of UI
mental status, cognition mobility neuro exam -perineal sensation -sphincter tone abdomen -obesity, surgical scars -palpation of bladder
GU physical exam in men
penis -meatus DRE -sphincter tone -stool impaction -prostate size, tenderness, consistency
GU physical exam in women
pelvic exam
- perineal sensation
- urethral mobility
- vaginal atrophy
- prolapse
- prior vaginal surgery
- cough stress test
- rectal exam to assess sphincter tone, stool impaction
options for post void residual measurement
measure 10-15 min after urination
- bladder scanner
- can be falsely elevated with ascites present - straight cath
- invasive, more accurate
what is a normal PVR
<50 cc normal
>200 cc too high
consider urology referral for UI if….
>3 rbc/hpf pelvic organ prolapse recurrent UTI male incontinence severe incontinence neuro disease high PVR behavioral and medical treatment not sufficienct
urologic workup for UI
urodynamic testing
cystoscopy
prostate volume
behavior treatments for UUI/SUI
timed voiding modification of fluid intake avoid bladder irritants (caffeine) bladder retraining (increase time in between voids) pelvic floor exercises +/- biofeedback weight loss quit smoking
treatment considerations for overflow incontinence
indwelling vs intermittent cath
a blocker in males while awaiting urology eval (relax bladder neck)
urological eval to determin obstruction vs. underactive detrusor as cause
meds for UUI
anticholinergics
-nonselective for M3
-selective for M2
B3 agonists
mechanism of anticholinergics for UUI
inhibits muscarinic receptors in detrusor to prevent contraction
side effects: dry mouth, constipation, dry eyes, urinary retention
anticholinergics non selective for M3
oxybutynin tolterodine fesoterodine trospium solifenacin
anticholinergics selective for M3
darifenacin
mechanism for B3 agonists for UUI
stimulate B3 receptors in the detrusor to inhibit contraction
side effects: HTN, nasopharyngitis, headache, rare urinary retention
B3 agonist
mirabegron
can be used in combo with anticholinergics
treatment for overflow UI
alpha blockers
mechanism of a blockers for overflow UI
relaxation of smooth muscle in prostate, bladder neck
side effects: intraoperative floppy iris syndrome in men undergoing cataract surgery
nonselective a blockers
terazosin
doxazosin
alfuzosin
a1 selective a blcokers
tamsulosin
silodosin
trasvaginal estrogen in UI
helpful for atrophic vaginitis
low systemic absorption
neuromodulation in UUI
sacral nerve stimulation
percutaneous tibial nerve stimulation
chemodenervation in UUI
onabotulinum injection into detrusor muscle of bladder
surgical options/ vaginal devices for SUI in women
vaginal devices -pessary surgical options -urethral bulking agents -midurethral sling -pubovaginal sling
devices for SUI in men
penile clamp
male sling
artificial urinary sphincter
neurological lesions associated with urinary incontinence
cortical -stroke -Parkinsons -MSA suprasacral spinal cord lesions sacral spinal cord lesions -spina bifida -cauda equina peripheral lesions -radial pelvic surgery -diabetes
cortical lesions
spastic bladder
normal sphincter
suprasacral spinal cord lesions
spastic bladder
spastic sphincter
sacral spinal cord lesions
flaccid bladder
flaccid sphincter
peripheral lesions
spastic/flaccid bladder
normal sphincter
what is autonomic dysreflexia
unregulated sympathetic stimulation
occurs primarily in patients with SCI above T6
cause of autonomic dysreflexia
noxious stimuli below level of injury
-bladder or bowel distention, UTI, sacral decubitus ulcers
symptoms/signs of autonomic dysreflexia
symptoms: headache, flushing, mental status changes
signs: hypertension, bradycardia
treatment of autonomic dysreflexia
can lead to stroke, MI, seizures, pulm edema monitor HR and BP remove noxious stimuli NO paste above level of lesion captopril 25 mg
types of catheters
indwelling
-urethral
-suprapubic
intermittent
implications of catheterization
bacteriuria -asymptomatic vs active infection? -pyelonephritis stone formation urethral injury hematuria restricted mobility health care costs
alternatives to catheterization
absorbant pads
condom catheters
bladder augmentation
urinary diversion
