Continence

Question 1

What is the epidemiology of incontinence?

Answer 1

Most common in:

• Woman
• > 50 years old

Question 2

What are the broad categories of causes of incontinence?

Answer 2

1 - Extrinsic to urinary system (environment, habit, exercise)

2 - Intrinsic to urinary system (problem with bladder or urinary outlet)

3 - A mixture of both

Question 3

What structures influence continence?

Answer 3

1 - Bladder & Urethra

2 - Local Innervation

3 - CNS Innervation

Question 4

What is the functions of the bladder?

Answer 4

• Urine storage
• Voluntary voiding

Question 5

What muscular structures are responsible for continence?

Answer 5

Bladder - Detrusor smooth muscle

Internal urethral sphincter - Smooth muscle

External urethral sphincter - Skeletal muscle

Question 6

What happens to the bladder and sphincters during filling of the bladder?

Answer 6

1 - Detrusor muscle relaxes

2 - Sphincters contract

Question 7

What happens to the bladder and sphincters during voluntary voiding?

Answer 7

1 - Contraction of bladder

2 - Involuntary relaxation of internal sphincter

3 - Voluntary relaxation of external sphincter

Question 8

What is the sympathetic nerve supply involved in urinary continence?

Answer 8

Beta-adrenoreceptors (T10-L2) - Causes Detrusor to relax (hypogastric nerve)

Alpha-adrenoreceptors (T10-S2) - Causes neck of bladder and internal urethral sphincter to contract (hypogastric nerve)

Question 9

What is the parasympathetic innervation involved in continence?

Answer 9

S2-S4 (Parasympathetic) - Increases strength and frequency of contractions (pelvic nerve)

S2-S4 (Somatic) - Contraction of pelvic floor muscle and external urethral sphincter (pudendal nerve)

Question 10

How is the contraction of the bladder by the parasympathetic system overcome to allow storage of urine?

Answer 10

• Centres within CNS inhibit parasympathetic tone and promote bladder relaxation

Question 11

How are the urethral sphincters controlled in order to ensure continence is maintained?

Answer 11

By a reflex response:

• Increased alpha-adrenergic activity closing internal sphincter
• Increased somatic activity closing external sphincter

Question 12

Which centres of the CNS are involved in continence?

Answer 12

• Pontine Micturition centre
• Frontal cortex
• Caudal part of spinal cord

Question 13

What is stress incontinence?

Answer 13

Bladder outlet too weak

Question 14

What are the features of stress incontinence?

Answer 14

• Urine leak on movement (coughing, laughing, squatting etc.)
• Weak pelvic floor muscles
• Common in woman with children, after menopause

Question 15

What is urinary retention with overflow incontinence?

Answer 15

When the bladder outlet is ‘too strong’

Question 16

What are the features of urinary retention with overflow incontinence?

Answer 16

• Poor urine flow, double voiding, hesitancy, post-micturition dribbling
• Blocked urethra
• Older men with BPH
• Treated with alpha-blockers to relax sphincter
• May need to be catheterised

Question 17

What is urger incontinence?

Answer 17

When the bladder muscle is too strong

Question 18

What are the features of urge incontinence?

Answer 18

• Detrusor contracts at low volumes
• Sudden urge to pass urine immediately
• Patients know every public toilet
• Can be caused by bladder stones or stroke
• Treated with anti-muscarinics to relax detrusor

Question 19

What medication is used to treat urge incontinence?

Answer 19

Oxybutinin

Question 20

What options are there for treating stress incontinence?

Answer 20

1) Physiotherapy - Kegel exercises, Vaginal cones (small weights to help improve pelvic floor strength)
2) Oestrogen cream
3) Duloxetine

Question 21

What are the 3 main types of incontinence and their key features?

Answer 21

Question 22

What are the general actions of the drugs used to treat incontinence and give one example of each?

Answer 22

Antimuscarinics (Oxybutinin) - Relax Detrusor

Beta-3 adrenoceptor agonists (Mirabegron) - Relax Detrusor

Alpha-blockers (Tamsulosin) - Relax sphincter and bladder neck

Anti-androgen drugs (Finasteride) - Shrink prostate

Question 23

What is a neuropathic bladder?

Answer 23

An underactive bladder

Question 24

What are features of a neuropathic bladder?

Answer 24

• Rare
• Secondary to neurological disease (MS or Stroke)
• Secondary to prolonged cathetarisation
• No awareness of bladder filling, resulting in overflow incontinence
• Only effective treatment is catheterisation

Question 25

What steps should be followed for assessing incontinence?

Answer 25

1 - Careful history (good SH to assess impact)

2 - Intake chart and output diaries

3 - General examination including rectal and vaginal examination

4 - Urinalysis & MSSU

5 - Bladder scan for residual volume

6 - Consider: incontinence clinic, lifestyle changes, physio or medical treatment

Question 26

Under what conditions should referal to incontinence clinic be considered?

Answer 26

Failure after 3 months of:

• Pelvic floor exercises
• Vaginal cones
• Habit retraining
• Medication

Question 27

In what cases could immediate specialist referal be considered?

Answer 27

1 - Vesico-vaginal fistula

2 - Palpable blader after micturition

3 - Disease of CNS

4 - Fibroids, rectocele, cystocele

5 - Severe BPH or prostatic carcinoma

Question 28

If most treatment options for incontinence fail, what other options are there?

Answer 28

1 - Incontinence pads

2 - Urosheaths

3 - Intermittent or long-term catheterisation

Question 29

What is a very broad way to divide urinary incontinence?

Answer 29

Bladder - over and under activity

Outlet (sphincter and pelvic floor) - over and under activity