Incontinence

Question 1

Definition of urinary incontinence?

Answer 1

Involuntary leakage of urine

Question 2

What percentage of women > 65 are affected?

Answer 2

12%

Question 3

How do the SNS and PSNS affect bladder filling and emptying (think in terms of bladder and sphincter)? Where is the central control of bladder emptying found?

Answer 3

SNS = storage (bladder relaxation and sphincter constriction)
PSNS = pee (bladder constriction and sphincter relaxation)
Central control in cerebral cortex and pontine switching centre

Question 4

What are the two components of the external urethral sphincter?

Answer 4

The urethral mucosa on the inside and the muscles and ligaments of the pelvic floor on the outside

Question 5

Name 5 causes of urinary incontinence

Answer 5

Stress incontinence - defect in pelvic floor/urethral sphincter deficiency
Urge incontinence - detruser muscle overactivity/neurological incoordination
Overflow incontinence - from inability of bladder to empty
Fistulae - often from pregnancy or surgery
Congenital
Urethral diverticulum
Other (UTI, faecal impaction, meds - alpha blockers, immobility)

Question 6

Compare the usual Hxs of a woman with stress vs urge incontinence

Answer 6

Stress - involuntary loss of urine on exertion (heavy lifting or something)
Urge - strong, sudden and uncontrollable desire to urge

Question 7

Name 4 important questions to ask to gauge severity of incontinence

Answer 7

Frequency
Nocturia
Pad usage
QoL

Question 8

Name 3 symptoms that can accompany incontinence

Answer 8

Prolapse symptoms
Dysuria
Haematuria
Bowel symptoms

Question 9

Name 3 signs of incontinence on examination

Answer 9

Demonstrable incontinence (get them to cough)
Atrophy, erythema, scarring of vulva/vagina (vulvitis from incontinence)
Pelvic floor muscle strength (put fingers up vagina and get woman to squeeze)

Question 10

Name 3 Ix for urinary incontinence. Which is best for distinguishing between urge and stress incontinence?

Answer 10

Bladder diary
MSU
Post-void residual
Urodynamics (look at urine flow, bladder contraction, urethral pressures)
Cystoscopy (if suspicious of obstructive lesion)

Urodynamics best for making diagnosis if unsure clinically

Question 11

What is the usual urodynamic result for stress incontinence? For urge incontinence?

Answer 11

Stress - involuntary leakage of urine with increased abdo pressure, without a detrusor contraction
Urge - involuntary detrusor contractions during filling phase (empties when filling)

Question 12

What is the difference between overactive bladder syndrome and detrusor overactivity?

Answer 12

OBS = description of symptoms of urinary urge, frequency and nocturia, which may or may not be due to destrusor overactivity

Question 13

Compare the non-surgical and surgical management of stress vs urge incontinence

Answer 13

Stress:
Non-surgical - pelvic floor exercises, pads, pessary
Surgical - Burch colposuspension, mid-urethral slings

Urge:
Non-surgical - fluid restriction (1.5L/day), bladder retraining (physio), anticholinergics (oxybutynin, tolterodine) - blocks detrusor constriction, tricyclic antidepressants (anticholinergic effect), oestrogen
Surgical - cystoscopy + hydrodistension or Botox injection, sacral nerve stimulation

Question 14

Name 5 causes of stress incontinence

Answer 14

Increased abdo pressure (pregnancy, obesity, chronic cough, constipation)
Damage to pelvic floor (pregnancy and delivery, surgery)

Question 15

Name 5 causes of urge incontinence

Answer 15

Idiopathic
Psychosomatic
Neurological (like MS)
Complication of incontinence surgery
Outflow obstruction
Bladder stones or Ca