Incontinence Flashcards
Describe the physiologcal differences in storage vs voiding of the bladder [2]
Storage
* Sympathetically mediated relaxation of bladder detrusor muscle + increased tone of internal urethral sphincter (pudendal nerve)
Voiding (emptying)
* When full, parasympathetic (S2-S4) sacral nerve roots mediate detrusor muscle contraction, and sympathetic mediation sphincter relaxation
What are the different classifications of urinary incontinence? [4]
overactive bladder (OAB)/urge incontinence:
- due to detrusor overactivity
stress incontinence:
- leaking small amounts when coughing or laughing
mixed incontinence:
- both urge and stress
overflow incontinence:
- due to bladder outlet obstruction, e.g. due to prostate enlargement
Why does UI increase when ageing? [+]
- As age, detrusor gets weaker
- Bladder gets smaller as age
- Increased night time production of urine
- Women: reduced urethral closing pressure
- Men: increased incidence prostatic enlargement
- Increased incidence comorbidity and medication
Describe how you investigate for UI? [4]
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture: UTI can contribute
- urodynamic studies (not routinely required): Cytometry is a urodynamic test that involves the insertion of a urinary catheter and the gradual filling of the bladder. A rectal probe is used at the same time to measure pressure as the bladder fills and then during voiding. Helps to measure detrusor pressure and bladder capacity.
Stress: get increase intra abdominal pressure overcomes detrusor
Functional incontinence: don’t have access to a toilet (e.g can’t get out of hospital bed)
Overflow incontinence: bladder fills up but unable to empty bladder. But if so full, the pressure overcomes the internal sphincter and leak urine.
True fistula: connection betwen vagina and ureter/ bladder/ urethra: continuous leakage of urine.
Which questions should you ask when enquiring about incontinence to determine if its stress or urge? [2]
“Do you lose urine during physical exertion, coughing, laughing or sneezing?” Yes – 2x more likely to have stress UI
“Do you ever experience such a strong and sudden urge to void that you leak before reaching the toilet?” Yes – 4x more likely to have urge UI
go over bmj
Which medications may impact incontinence?
Diuretics
Anticholinergics
Sedatives
What things would you peform in a physical exam to ass incontience? [4]
Abdominal exam + Post-void bladder scan
– Urinary retention
External PV
– prolapse, fistula, atrophic vulvovaginitis
- Digital vagina exam to assess pelvic floor muscle strength
- Stress/ cough test (best performed with full bladder)
PR
- constipation
- cauda equina
- BPH
CNS
- neurological disease
perineal sensation (sacral nerves S2-4)
- gait disturbance/ Parkinsonism, lower limb exam (incl pedal oedema)
atrophy..
Which investigations would you perform for incontinence? [4]
Urinalysis
* Haematuria (bladder neoplasia)
* Glucosuria (diabetic polyuria)
* Nitrites/ leucocytes - UTI
US abdomen – hydronephrosis/ abdominal mass
Urodynamic flow studies – prior to surgery
Rarely spinal MRI (cauda equina)
Describe the lifestyle, behavioural, medical and surgical treatment can offer for incontinence [+]
Conservative managment:
Lifestyle:
* Reduce caffeine, modify fluid intake (aim 2L/day), lose weight if BMI>30
Behavioural:
* Pelvic floor muscle exercises
3-month trial 8 contractions 3x/day; Continue if successful
* Bladder Training (Increase time interval between voids and to diminish sense of urgency) for 6 weeks minimum
Medical managment:
- Oxybutynin
- tolterodine
- mirabegron - used if concerns about anticholinergics
Surgical procedures
* Consider electrical stimulation +/or biofeedback
* Men: following radical prostate surgery, MS or stroke
How can you tx overflow incontinence? [4]
- Relieve/ treat obstruction
- Intermittent self-catheterisation
- Indwelling catheter
- Suprapubic catheters: lower rates symptomatic UTI and by-passing
Describe lifestyle [2], medical [1] and surgical [3] management for stress incontinence
Lifestyle:
- Patients should be advised to have a consistent fluid intake of around 1.5-2 litres, avoiding either excess or insufficient amounts.
Pelvic floor muscle training:
- NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
Medical management:
- Duloxetine
Surgical procedures:
- e.g. retropubic mid-urethral tape procedures
- Colposuspension: this is an operation that may be completed open or laparoscopically and involves lifting the bladder neck upward with stitches placed to hold it in place.
- Autologous rectus fascial sling: a sling is made from the patient’s own fascia and is used to support the urethra and the pelvic floor muscles.
Describe medical [3] and surgical [1] management for overactive bladder syndrome
Anticholinergics:
- directly relax urinary smooth muscle-> reduce involuntary detrusor contractions and increase bladder capacity
- Oxybutynin most cost-effective: advised avoid frail elderly women
- Tolterodine reduced dry mouth s/e
Review 4-weekly
- Mirabegron: agonist of beta-3 receptor in - detrusor smooth muscle (s/e hypertension)
Botulinum A
Surgery:
* Nerve stimulation: sacral nerve stimulation, percutaneous posterior tibial nerve stimulaiton
Which population should oxybutynin be avoided in? [1]
Why? [1]
avoided in ‘frail older women’
- Oxybutynin and tolterodine have both been associated with cognitive adverse events and effects on sleep architecture and quality.
What are the mechanisms of Detrusor overactivity? [3]
- Central inhibitory pathway malfunction
- Sensitisation of peripheral afferent terminals in the bladder
- Bladder muscle overactivity
Intra-vesicular injection of which drug can improve urge incontinence? [1]
Botulinum toxin
What is the classic presentation of urge incontinence?
A sudden need to pass urine, with incontinence if one does not make it to the toilet in time
What is the main differential in a female patient constantly leaking urine? [1]
Vesico-vaginal fistula
What is the minimum recommended number of days that should be recorded in a bladder diary? [1]
3
QuesMed
What is the gold-standard surgical treatment for stress incontinence? [1]
Mid-urethral sling
Which medications are most likely to cause functional incontinence? [1]
Opioids and those with a sedating effect
NICE Guidelines
In order to assess which type of urinary incontinence the woman has, take a detailed history, perform an examination, and categorize the symptoms as: [4]
In order to assess which type of urinary incontinence the woman has, take a detailed history, perform an examination, and categorize the symptoms as:
- Stress urinary incontinence.
- Urgency urinary incontinence with or without overactive bladder syndrome.
- Mixed urinary incontinence.
- Incontinence due to another cause, such as overflow incontinence (caused by chronic urinary retention), a urogenital fistula, or urethral diverticulum.
