incontinence

Question 1

4 types of incontinence. which is the most common?

Answer 1

1. urge/OAB
2. stress
3. overflow
4. mixed (most common)

Question 2

the detrusor muscle of the bladder wall responds to ____ by contracting

Answer 2

Ach

Question 3

the inner sphincter of the bladder tightens due to what?

Answer 3

activation of alpha adrenergic receptors

Question 4

what provides extra support of the bladder?

Answer 4

pelvic floor muscles

Question 5

where is the mictrution center of the brain? what does it do?

Answer 5

pons: coordinates PSNS stimulation and SNS inhibition

Question 6

if you lose the pontine inhibition (inhibition of the pons) what happens?

Answer 6

neurogenic bladder = incontinence

Question 7

what drugs can cause urine retention ?

Answer 7

sympathomimetics or anti-cholinergics

Question 8

bladder is a ___ pressure system

Answer 8

low

Question 9

what is vesicoureteral reflux? what can it cause?

Answer 9

urine backflow into ureter = renal damage

Question 10

for mixed incontinence, consider forces involved in ___ and how they are affected by things like _____

Answer 10

micturition 
menopause (decrease estrogen = decrease muscle tone)

Question 11

increase in bladder wall tone/contractility is not a problem until what?

Answer 11

supportive structures are weakened

Question 12

stress incontinence, common more in women or men?

Answer 12

women

Question 13

what is stress incontinence? what does it come from?

Answer 13

comes from an inc. in intrabd pressure and weakened urethral sphincter/pelvic floor muscles (from childbirth or lack of hormones)
-leak a small amount during activities (cough, laugh, sneeze, exercise)

Question 14

OAB is equal in women and men, but women are ___ times more likely to have _____

Answer 14

3x

incontinence

Question 15

what is a hallmark of OAB?

Answer 15

urgency: sensation that is difficult to defer (can’t wait to pee)

Question 16

what causes OAB?

Answer 16

bladder doesnt relax and fill well (from a higher detrussor tone), so it takes less urine to sense stretch and signal the need to pee

Question 17

urge incontinence is defined as what?

Answer 17

when OAB leads to incontinence

Question 18

urge incontinence is common in what population? why?

Answer 18

older/postmenopausal women

• shorter urethra = less muscle holding tension
• estrogen withdrawal

Question 19

how much urine comes out with urge incontinence?

Answer 19

moderate to large amounts

Question 20

what does “LUTS” stand for?

Answer 20

lower urinary tract symptoms

Question 21

overflow incontinence is ______ ______ and results from ______ _______

Answer 21

less common, urinary retention

Question 22

what are the symptoms of overflow incontinence?

Answer 22

dribble small amounts frequently

• trouble starting stream, weak
• feel bladder isnt empty

Question 23

what causes overflow incontinence? (2)

Answer 23

1. blockage or narrowed by prolapse

2. muscle/nerve problem (DM, drugs- anti-depressants, smooth muscle relaxers)

Question 24

what type of incontinence?strong sudden urges to pee?

Answer 24

OAB

Question 25

what type of incontinence? hard to completely urinate

Answer 25

urge

Question 26

what type of incontinence?get up 2+ times at night

Answer 26

retention/ outlet problem

Question 27

what type of incontinence? urinate >8x in 24hrs

Answer 27

OAB

Question 28

what types of food may cause frequency and urgency?

Answer 28

caffeine, alcohol, milk, citrus, spices

Question 29

nighttime incontinence without daytime symptoms, consider...

Answer 29

LE edema and fluid shifts | - edema in legs during the days goes to the kidneys at night

Question 30

sleep apnea can be associated with what?

Answer 30

incontinence (don't know why)

Question 31

neurogenic bladder: Spastic bladder dysfunction results from ...

Answer 31

neurologic lesions above the level of the sacral cord

Question 32

neurogenic bladder: Flaccidity of the detrusor muscle is caused by ...

Answer 32

Flaccidity of the detrusor muscle is caused by disruption of the lower motor neurons of the pelvic nerve

Question 33

what can cause an involuntary contraction of the bladder?

Answer 33

when a specific level of stretch is reached

Question 34

5 parts of Dx of incontinence

Answer 34

1. history 2. pelvic exam 3. neurologic if appropriate 4. UA 5. cystometry

Question 35

pelvic exam for incontinence dx

Answer 35

- check pelvic floor, urethra angle (kinked b/c of prolapse may cause obstructive symptoms). - check for atrophic vag (post-menopausal women: stress incontinence)

Question 36

what is cystometry?

Answer 36

measures relationship of pressure and volume in bladder, residual volumes, compliance, flow rates and capacity

Question 37

4 kinds of txt for intcontinence

Answer 37

1. behavioral 2. exercises/devices 3. medical 4. surgery

Question 38

behavioral txt for all types of incontinence.

Answer 38

Diet modification, bedtime fluid restriction

Question 39

behavioral txt for urge incontinence

Answer 39

timed voiding with increasing intervoiding times results in increased bladder capacity

Question 40

4 kinds of exercises/devices for incontinence txt

Answer 40

Kegel exercises Vaginal cones Pessaries InterStim device stimulates pudendal nerve, has 80% efficacy

Question 41

what does a vaginal cone do?

Answer 41

improves strength and tone

Question 42

what are pessaries for?

Answer 42

pushes on neck of bladder. provides support that is no longer there - for pelvic floor collapse

Question 43

what is the main txt type for OAB and urge? how does it work? what are the preferred agents?

Answer 43

medical - anticholinergics to decrease detrussor muscle tone. (trospium/Sanctura for the least ADRs )

Question 44

what drug can be prescribed for stress incontinence? how does it work?

Answer 44

SNRI- duloxetine/ Cymbalta : blocks the reuptake of serotonin and NE in the spinal cord

Question 45

what are the concerns with cymbalta?

Answer 45

suicide in younger patients taking it

Question 46

surgery is mostly an option for what type of incontinence?

Answer 46

stress

Question 47

what are two surgery options for stress incontinence?

Answer 47

burch procedure and suburethral slings

Question 48

what is the burch procedure? when is it used?

Answer 48

an invasive urethropexy: neck of the bladder is suspended from nearby ligaments with sutures. -when the bladder or urethra has fallen out of its normal position

Question 49

what is the most popular suburethral sling?

Answer 49

"tension free vaginal tape"

Question 50

if its a mechanical problem, its likely a _____ fix

Answer 50

mechanical

Question 51

tension free urethral sling (vaginal tape) will not help if ______ _____

Answer 51

prolapsed uterus

Question 52

what is intradetrusor botox injection used for?

Answer 52

OAB if neurogenic bladder from spinal cord injury or MS

Question 53

what is neuromodulation for OAB?

Answer 53

stimulation of S3 afferents with implanted electrodes- thought to reprogram central voiding reflex

Question 54

what are the two types of enuresis (bedwetting) ?

Answer 54

primary and secondary

Question 55

below age ___, enuresis is not really a uncommon or a concern

Answer 55

7

Question 56

what is primary vs secondary enuresis

Answer 56

primary: haven't ever learned to not wet the bed secondary: they were trained but have since regressed

Question 57

enuresis: make sure they aren't drinking within ___ hrs of going to bed

Answer 57

3

Question 58

enuresis: Alertness should be maintained for symptoms of common underlying problems such what three things?

Answer 58

constipation, stress, cystitis/UTI

Question 59

PE for enuresis

Answer 59

1. abd and pelvic exams 2. neuro exam of lower extremities 3. assessment of the "anal wink" 4. inspect and palpate lumbosacral spine

Question 60

Dx of enuresis

Answer 60

UA for UTI, otherwise behavioral assessment, then imaging down the line

Question 61

Txt of enuresis (3 parts)

Answer 61

1. motivational therapy (sticker chart) 2. enurersis alarms (detect wetness and wake the pt) 3. desmopressin (ADH hormone) - we should naturally produce more of this at night

Question 62

conditions that may cause or mimic OAB( weeds)

Answer 62

- Bladder detrusor muscle may contact inappropriately due to nerve damage/ infection, surgery, tumors, Parkinson's, MS, stroke - UTIs - Polyuria - Transitional cell carcinoma of the bladder - Underlying neurologic abnormalities - BPH