incontinence Flashcards
4 types of incontinence. which is the most common?
- urge/OAB
- stress
- overflow
- mixed (most common)
the detrusor muscle of the bladder wall responds to ____ by contracting
Ach
the inner sphincter of the bladder tightens due to what?
activation of alpha adrenergic receptors
what provides extra support of the bladder?
pelvic floor muscles
where is the mictrution center of the brain? what does it do?
pons: coordinates PSNS stimulation and SNS inhibition
if you lose the pontine inhibition (inhibition of the pons) what happens?
neurogenic bladder = incontinence
what drugs can cause urine retention ?
sympathomimetics or anti-cholinergics
bladder is a ___ pressure system
low
what is vesicoureteral reflux? what can it cause?
urine backflow into ureter = renal damage
for mixed incontinence, consider forces involved in ___ and how they are affected by things like _____
micturition menopause (decrease estrogen = decrease muscle tone)
increase in bladder wall tone/contractility is not a problem until what?
supportive structures are weakened
stress incontinence, common more in women or men?
women
what is stress incontinence? what does it come from?
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)
OAB is equal in women and men, but women are ___ times more likely to have _____
3x
incontinence
what is a hallmark of OAB?
urgency: sensation that is difficult to defer (can’t wait to pee)
what causes OAB?
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
urge incontinence is defined as what?
when OAB leads to incontinence
urge incontinence is common in what population? why?
older/postmenopausal women
- shorter urethra = less muscle holding tension
- estrogen withdrawal
how much urine comes out with urge incontinence?
moderate to large amounts
what does “LUTS” stand for?
lower urinary tract symptoms
overflow incontinence is ______ ______ and results from ______ _______
less common, urinary retention
what are the symptoms of overflow incontinence?
dribble small amounts frequently
- trouble starting stream, weak
- feel bladder isnt empty
what causes overflow incontinence? (2)
- blockage or narrowed by prolapse
2. muscle/nerve problem (DM, drugs- anti-depressants, smooth muscle relaxers)
what type of incontinence?strong sudden urges to pee?
OAB
what type of incontinence? hard to completely urinate
urge
what type of incontinence?get up 2+ times at night
retention/ outlet problem
what type of incontinence? urinate >8x in 24hrs
OAB
what types of food may cause frequency and urgency?
caffeine, alcohol, milk, citrus, spices
nighttime incontinence without daytime symptoms, consider…
LE edema and fluid shifts
- edema in legs during the days goes to the kidneys at night
sleep apnea can be associated with what?
incontinence (don’t know why)
neurogenic bladder: Spastic bladder dysfunction results from …
neurologic lesions above the level of the sacral cord
neurogenic bladder: Flaccidity of the detrusor muscle is caused by …
Flaccidity of the detrusor muscle is caused by disruption of the lower motor neurons of the pelvic nerve
what can cause an involuntary contraction of the bladder?
when a specific level of stretch is reached
5 parts of Dx of incontinence
- history
- pelvic exam
- neurologic if appropriate
- UA
- cystometry
pelvic exam for incontinence dx
- check pelvic floor, urethra angle (kinked b/c of prolapse may cause obstructive symptoms).
- check for atrophic vag (post-menopausal women: stress incontinence)
what is cystometry?
measures relationship of pressure and volume in bladder, residual volumes, compliance, flow rates and capacity
4 kinds of txt for intcontinence
- behavioral
- exercises/devices
- medical
- surgery
behavioral txt for all types of incontinence.
Diet modification, bedtime fluid restriction
behavioral txt for urge incontinence
timed voiding with increasing intervoiding times results in increased bladder capacity
4 kinds of exercises/devices for incontinence txt
Kegel exercises
Vaginal cones
Pessaries
InterStim device stimulates pudendal nerve, has 80% efficacy
what does a vaginal cone do?
improves strength and tone
what are pessaries for?
pushes on neck of bladder. provides support that is no longer there
- for pelvic floor collapse
what is the main txt type for OAB and urge? how does it work? what are the preferred agents?
medical - anticholinergics to decrease detrussor muscle tone. (trospium/Sanctura for the least ADRs )
what drug can be prescribed for stress incontinence? how does it work?
SNRI- duloxetine/ Cymbalta : blocks the reuptake of serotonin and NE in the spinal cord
what are the concerns with cymbalta?
suicide in younger patients taking it
surgery is mostly an option for what type of incontinence?
stress
what are two surgery options for stress incontinence?
burch procedure and suburethral slings
what is the burch procedure? when is it used?
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
what is the most popular suburethral sling?
“tension free vaginal tape”
if its a mechanical problem, its likely a _____ fix
mechanical
tension free urethral sling (vaginal tape) will not help if ______ _____
prolapsed uterus
what is intradetrusor botox injection used for?
OAB if neurogenic bladder from spinal cord injury or MS
what is neuromodulation for OAB?
stimulation of S3 afferents with implanted electrodes- thought to reprogram central voiding reflex
what are the two types of enuresis (bedwetting) ?
primary and secondary
below age ___, enuresis is not really a uncommon or a concern
7
what is primary vs secondary enuresis
primary: haven’t ever learned to not wet the bed
secondary: they were trained but have since regressed
enuresis: make sure they aren’t drinking within ___ hrs of going to bed
3
enuresis: Alertness should be maintained for symptoms of common underlying problems such what three things?
constipation, stress, cystitis/UTI
PE for enuresis
- abd and pelvic exams
- neuro exam of lower extremities
- assessment of the “anal wink”
- inspect and palpate lumbosacral spine
Dx of enuresis
UA for UTI, otherwise behavioral assessment, then imaging down the line
Txt of enuresis (3 parts)
- motivational therapy (sticker chart)
- enurersis alarms (detect wetness and wake the pt)
- desmopressin (ADH hormone) - we should naturally produce more of this at night
conditions that may cause or mimic OAB( weeds)
- 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
