Incontinence

Question 0

What is stress urinary incontinence (SUI)?

Answer 0

Complaint of involuntary leakage on effort or exertion, or on sneezing/coughing

Question 1

Define urinary incontinence

Answer 1

Complaint of any involuntary leakage of urine

Question 2

What is urge urinary incontinence (UUI)?

Answer 2

Involuntary leakage immediately proceeded by or accompanied by urgency

Question 3

What is mixed urinary incontinence?

Answer 3

Involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing

Question 4

What is overflow incontinence?

Answer 4

Involuntary release of urine from an overly full bladder, often in the absence of any urge to urinate

Question 5

Which is the most common type of urinary incontinence?

Answer 5

Stress urinary incontinence

Question 6

Prevalence with age of urinary incontinence?

Answer 6

Gradually increases
10% age 20-24
40% age 90+

Question 7

Risk factors for urinary incontinence?

Answer 7

Pregnancy
Pelvic surgery
Hysterectomy
Pelvic prolapse
Bowel dysfunction
Obesity
Dietary factors eg caffeine, alcohol
Multiparity
Drugs
Menopause

Question 8

In general, what increases your risk of urinary incontinence?

Answer 8

Anything that weakens the pelvic floor

Question 9

What history if urinary incontinence is suspected would you take from the patient?

Answer 9

Categorise type
Ask patient to keep a voiding diary
No. of pads used a day
Determine if leakage is continuous or intermittent
Intravesicular inflammatory condition eg UTIS, stone, tumour - these can make it worse
Any previous surgery of pelvic floor? Denervation of parts of bladder?
Childbirth? -indicate SUI due to sphincter damage

Question 10

What should be recorded in a voiding diary?

Answer 10

Volume of urine produced
Frequency
Precipitating factors
Number of pads used each day

Question 11

What examinations would you do of the patient?

Answer 11

Weight
Height
Abdominal exam to exclude palpable bladder
Digital rectal exam - prostate/constipation
In females, examine external genitalia and a vaginal exam (for prolapse, fistulae)
Check perianal sensation and reflexes as this is supplied by same nerve root as sphincter muscles

Question 12

What does management of urinary incontinence depend on?

Answer 12

Symptoms
Degrees of nuisance
Effects of treatment on other symptoms
Previous/current treatment

Question 13

What lifestyle changes can be made in managing urinary incontinence?

Answer 13

Modify fluid intake
Stop smoking
Avoid constipation
Weight loss
Decrease caffeine
Have timed voiding on a fixed schedule

Question 14

What investigations would you do for urinary incontinence?

Answer 14

Urine dipstick to check for UTIS, haematuria, proteinuria, glucosuria
Frequency - volume chart and bladder diary (at least 3 days)
Post-micturition residual volume in patients with voiding dysfunction

Optional

• invasive urodynamics
• pad tests
• cystoscopy

Question 15

What are urodynamics? What can it measure?

Answer 15

Term for investigating lower urinary tract symptoms
Measure electrical activity of external urethral sphincter - muscle tone
Post void residual volume
Peak flow rate

Question 16

What can be used to strengthen pelvic floor muscles?

Answer 16

Pelvic floor muscle training - 8 contractions, 3x a day for at least 3 months
Duloxetine - NA and serotonin uptake inhibitor
Void bladder and stop mid-stream - uses muscles of pelvic floor

Question 17

What specific management is there of urge urinary incontinence?

Answer 17

Bladder training

• schedule voiding every hour
• don’t void in between - wait or leak
• increase intervals by 15-30 mins a weak until interval is 2-3 hours
• 6 weeks of training needed

Question 18

How would you manage patients who are unsuitable for surgery and have failed other methods of incontinence management?

Answer 18

Indwelling catheter - urethral/suprapubic
Sheath device
Incontinence pads

Question 19

What pharmacological management is there of incontinence?

Answer 19

Duloxetine - combined NA and serotonin uptake inhibitor. Increase activity of external urethral sphincter during filling phase. Offered as an alternative to surgery

Anticholinergics - act on M3 receptors that cause detrusor muscle to contract.

Botulinum toxin - inhibits Ach release. Prevents detrusor muscle contraction ad pelvic nerve cannot release Ach to act on M3 receptors

Question 20

What surgical management is there for females (permanent intention)?

Answer 20

• low tension vaginal tapes are most common. Minimally invasive technique with success rate >90%. Support the mid urethra with a polypropylene mesh
• open retropubic suspension procedure supports the urethra and increases bladder outflow resistance. Involves autologous transplantation of fascia lata/rectus fascia

Question 21

What surgical management is there for treatment of females with temporary intention?

Answer 21

Intramural bulking agents improve ability of urethra to resist abdominal pressure by improving urethral coaptation
Inject autologous fat, silicone, collagen, or hyaluron-dextran polymers

Question 22

What is the gold standard surgical management for males?

How does it work?

Risks?

Answer 22

Artificial urinary sphincter - gold standard in urethral sphincter deficiency

Cuff is a mechanic (hydraulic) device that stimulates action of a normal sphincters to circumferentially close the urethral.

Problems include infection, erosion, device failure.

Question 23

What other surgical management is there for males?

Answer 23

Male sling procedure corrects SUI in men from iatrogenic cause
It is an emerging treatment using bone-anchored tape
Long term results unknown

Question 24

What are some iatrogenic causes of urinary incontinence (in males)?

Answer 24

Radical prostatectomy
Colorectal surgery
Radical pelvic radiotherapy