INCONTINENCE

Question 1

What proportion of women under the age of 65 are affected by a degree of urinary incontinence?

Answer 1

8.5%

Question 2

What proportion of women over the age of 65 are affected by a degree of urinary incontinence?

Answer 2

11.6%

Question 3

What proportion of women over the age of 85 are affected by a degree of urinary incontinence?

Answer 3

43.2%

Question 4

What are the 5 main types of urinary incontinence?

Answer 4

Stress incontinence - also called effort incontinence

Urge incontinence - also called detrusor overactivity

(Mixed incontinence)

Overflow incontinence

Functional incontinence

Total incontinence

Question 5

What is the aetiology of stress urinary incontinence?

Answer 5

Insufficient strength of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.

Question 6

What are the risk factors for developing stress urinary incontinence?

Answer 6

Increasing age
Increasing parity
Obesity
Genital prolapse
Postmenopausal state
Previous pelvic floor surgery
Constipation
Smoking / chronic cough

Question 7

What are the classic features of stress urinary incontinence?

Answer 7

Small amounts of leakage
Associated with coughing, sneezing, laughing or running
Frequency of micturition

Question 8

What is the aetiology of urge incontinence?

Answer 8

Involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. It is normally caused by the detrusor muscles of the bladder being overactive.

Question 9

What are the risk factors for developing urge urinary incontinence?

Answer 9

Increasing age
History of nocturnal enuresis
Neurological disorders
Previous incontinence surgery - leading to nerve damage
Alcohol or coffee
Poor fluid intake - leading to concentrated urine which can irritate detrusor
Spinal tumours
UTI

Question 10

What are the classic features of urge urinary incontinence?

Answer 10

Urgency
Frequency
Nocturia

Question 11

What is mixed urinary incontinence?

Answer 11

This is a commonly seen picture where the patient suffers from both stress and urge (detrusor overactivity) incontinence. The history will show elements of both leakage on abdominal pressure and urgency of micturition.

Question 12

What is the aetiology of overflow incontinence?

Answer 12

The bladder will fill up as usual, but as it is obstructed the patient will not be able to empty it completely. At the same time, pressure from the urine that is still in the bladder builds up behind the obstruction, causing frequent small leaks.

Question 13

What are the risk factors for overflow urinary incontinence?

Answer 13

BPH
Bladder stone
Constipation
Weak detrusor muscles

Question 14

What are the classic features of overflow incontinence?

Answer 14

Urgency 
Frequency
Hesitancy
Straining to void
Poor flow
Recurrent UTI

Question 15

What is the aetiology of functional incontinence?

Answer 15

This is not a pathology of the bladder. It occurs when the person recognizes the need to urinate but cannot make it to the bathroom for reasons not associated with their urinary system.

Question 16

What are the risk factors for functional urinary incontinence?

Answer 16

Confusion / delirium
Dementia
Poor eyesight
Poor mobility - Parkinson's disease
Depression
Anxiety
Inebriation due to alcohol 
Peripheral autonomic neuropathies - diabetes

Question 17

What is the aetiology of total incontinence?

Answer 17

Total incontinence occurs when your bladder does not store any urine at all. It can result in you either passing large amounts of urine constantly, or passing urine occasionally with frequent leaking.

Question 18

What are the causes of total incontinence?

Answer 18

Birth bladder defect
Injury to spinal cord - eg surgery
Bladder fistulae - Obstructed labour is common cause

Question 19

What investigations might you do for someone that was experiencing incontinence where the aetiology was unclear?

Answer 19

Urine dip to exclude UTI
Complete a bladder diary

Urodynamic studies:
Uroflowmetry - identify voiding disorders
Cystometry - will confirm or exclude detrusor overactivity
Videocystourethrography

Cystoscopy - excludes polyps, calculi and malignancy (rarer causes of incontinence)

Ultrasound - pelvic masses

Radiological investigations - identifying fistulae

Question 20

What are the conservative management options for treating stress urinary incontinence?

Answer 20

Weight loss
Reduction in caffeine intake
Quit smoking - to treat chronic cough
Physiotherapy - pelvic floor exercises or insertion of vaginal cones

Question 21

What are the medical management options for treating stress urinary incontinence?

Answer 21

Oestrogen replacement can improve symptoms in postmenopausal women, however long term use is required to maintain this effect.

Duloxetine (serotonin noradrenaline reuptake inhibitor, SNRI) - increases the tone of urethral sphincter. Most useful when used in conjunction with pelvic floor exercises.

Question 22

What are the surgical management options for treating stress urinary incontinence in women?

Answer 22

Insertion of a tension free vaginal tape through a small vaginal incision over the mid-urethra.

Question 23

How is urge (or detrusor overactivity) urinary incontinence treated?

Answer 23

Primarily through antimuscarinic medications such as:
Oxybutynin
Tolterodine
Solifenacin
Trospium

Also, Mirabegron which activates beta-3 adrenergic receptors is used to treat detrusor overactivity

Question 24

What are the main side effects of antimuscarinic medications used in the treatment of urge incontinence?

Answer 24

Think about what atropine does:

Dry mouth
Reduced visual accommodation 
Constipation
Glaucoma
Confusion

Question 25

How do we manage overflow incontinence?

Answer 25

Catheterization is often necessary

Indoramin, an alpha blocker, has been shown to relax sphincter mechanism but is rarely used due to side effects.