Incontinence

Question 1

What are the causes of incontinence?

Answer 1

Extrinsic to the urinary system - environment, habit, physical fitness…
Intrinsic - problem with bladder or urinary outlet
Often both

Question 2

What are some extrinsic factors of incontinence?

Answer 2

Physical state and co-morbidities
Reduced mobility
Confusion
Drinking too much
Medication - diuretics
Constipation
Home and social circumstances

Question 3

What does continence depend on?

Answer 3

Effective function of the bladder and integrity of the neural connections which bring it under voluntary control - bladder, urethra, local innervation and CNS connections

Question 4

Describe the muscles of the bladder

Answer 4

Detrusor muscle is smooth muscle
Internal urethral sphincter is smooth muscle
External urethral sphincter is striated muscle

Question 5

What is involved in urine storage?

Answer 5

Detrusor muscle relaxation with filling to normal volume 400-600ml combined with sphincter contraction

Question 6

What is involved in voluntary voiding?

Answer 6

Voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder

Question 7

What is the local innervation of the bladder?

Answer 7

T10-L2 sympathetic - detrusor to relax
T10-S2 Sympathetic - contraction of bladder neck and internal urethral sphincter
S2-4 Parasympathetic
S2-4 Somatic

Question 8

Describe CNS connections for the urinary bladder

Answer 8

Centres inhibit parasympathetic tone and promote bladder relaxation
Sphincter closure is mediated by reflex increase in a-adrenergic and somatic activity
Pontine micturition centre, frontal cortex and caudal part of spinal cord

Question 9

What is the cause of stress incontinence?

Answer 9

Bladder outlet is too weak

Question 10

What are the characteristic features of stress incontinence?

Answer 10

Urine leak on movement, coughing, laughing and squatting
Weak pelvic floor muscles
Common in women with children

Question 11

What is the treatment for stress incontinence?

Answer 11

Physiotherapy, oestrogen cream and duloxetine
Surgical option - TVT/ colposuspension

Question 12

What are the different management options for stress incontinence?

Answer 12

Kegel exercises
Vaginal cones
Biofeedback
Pelvic floor stimulators

Question 13

What is the reason for urinary retention with overflow incontince?

Answer 13

Bladder outlet is too strong

Question 14

What are the characteristic features of urinary retention with overflow incontinence?

Answer 14

Poor urine flow, double voiding, hesitancy, post micturition dribbling, blockage of urethra and older men with BPH

Question 15

What is the treatment for urinary retention with overflow incontinence?

Answer 15

Alpha blocker to relax the sphincter or anti-androgen to shrink the prostate
Surgery
Catheterisation

Question 16

What is the cause for urge incontinence?

Answer 16

Bladder muscle is too strong

Question 17

What are the characteristic features of urge incontinence?

Answer 17

Detrusor contracts at low volume
Sudden urge to pass urine immediately
Can be caused by bladder stones or stroke

Question 18

What is the treatment for urge incontinence?

Answer 18

Anti-muscarinic to relax detrusor muscle
Bladder retraining

Question 19

What are the main drugs used for incontinence?

Answer 19

Anti-muscarinics, beta-3 adrenoceptor agonists, alpha blockers and anti-androgen drugs

Question 20

What causes neuropathic bladder?

Answer 20

Underactive bladder

Question 21

What are the characteristic features of neuropathic bladder?

Answer 21

Secondary to neurological disease - MS or stroke
Secondary to prolonged catheterisation
No awareness of bladder filling resulting in overflow incontinence

Question 22

What is the treatment for neuropathic bladder?

Answer 22

Catheterisation
Parasympathetomimetics may be helpful

Question 23

When is urinary incontinence referred?

Answer 23

After failure of initial management - max. 3 months of pelvic exercises, cone therapy, habit retraining and medication
If needed at onset - fistula, palpable bladder, disease of CNS…
Faecal incontinence

Question 24

What are the options if treatment fails?

Answer 24

Incontinence pads, urosheaths, intermittent catheterisation, long term urinary catheter and suprapubic catheter