Incontinence

Question 1

Bladder nerve supply: which nerves affect storage, voiding and voluntary function?

Answer 1

• Storage - hypogastric nerve (sympathetic)
  
  • Storage of urine requires relaxation of the detrusor muscle and simultaneous contraction of both the internal and external urethral sphincters. The bladder and IUS are primarily under the control of the sympathetic nervous system.
• Voiding - pelvic splanchnic nerve (parasympathetic)
  
  • Causes the detrusor muscle to contract and the internal urethral sphincter to relax
• Voluntary - Pudendal nerve (somatic)

Question 2

What happens as the bladder empties?

Answer 2

• The detrusor muscle found in the wall of the bladder remains relaxed to allow the bladder to store urine, and contracts during urination to release urine.
• Urethral relaxation
• Sphincter co-ordination

Normal bladder emptying only occurs in the absence of obstruction or anatomical shunts (Cystocele, Diverticulum)

Question 3

How does the brain control bladder emptying?

Answer 3

• Cortical influence is important - makes sure that we only urinate when and where it is appropriate.
• Urination is partly controlled by reflexes and is partly under conscious control.
• As the bladder fills, it sends sensory information to the pontine micturition centre in the CNS, and when the bladder is full, these signals indicate that it must be emptied soon.
• Activation of parasympathetic pathway (voiding) & Inhibition of Sympathetic pathway (storage)
  
  • remember there is still the EUS under voluntary control to hold pee in

Question 4

What happens as the bladder fills?

Answer 4

• Accommodate increasing volume at constantly low pressure.
• Cortical activity: Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance.
• Activates Sympathetic pathway & reciprocal inhibition of the Parasympathetic pathway
• Mediates contraction of bladder base and proximal urethra.

Question 5

Define Stress urinary incontinence

Answer 5

Involuntary leakage on effort or exertion, on sneezing or coughing

Question 6

Define urge urinary incontinence

Answer 6

Involuntary leakage accompanied by or immediately preceded by urgency

Question 7

Mixed urinary incontinence

Answer 7

Involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing

Question 8

Risk factors of urinary incontinence (8)

Answer 8

• Age
• Parity
• Menopause
• Smoking
• Increased intra-abdominal pressure
• Pelvic floor trauma
• Denervation
• Connective tissue disease
• Surgery

Question 9

What is the main risk factor for stress incontinence?

Answer 9

Pregancy and childbirth

Question 10

When taking a history from a patient who has presented with urinary incontinence what sorts of things do you want to ask them?

Answer 10

• Age
• Parity
  
  • mode of deliveries, weight of heaviest baby
• Smoking
• HRT
• Medical conditions
  
  • DM, anti-HTN medications, Glaucoma, Heart/kidney/liver problems, Cognitive problems, anti-depressants and anti-psychotics
• Previous Pelvic floor muscle training (PFMT), surgical treatment of stress urinary incontinence or Pelvic Organ Prolapse
• Impact on QOL (0-10)
• Fluid intake
• Prolapse symptoms - Vaginal Lump/ Dragging sensation in vagina
• Bowel symptoms - anal incontinence, constipation, faecal evacuation dysfunction, IBS

Question 11

What symptoms may a patient complain of due to being irritating?

Answer 11

• Urgency ; Sudden compelling desire to void that is difficult to defer.
• Increased daytime frequency (>7)
• Nocturia (>1)
• Dysuria
• Haematuria

Question 12

What incontinence related symptoms may a patient complain of?

Answer 12

Stress UI

Urgency UI

Coital Incontinence

Severity: How many incontinence pads/day

Question 13

What would a patient record if asked to do a 3 day Urinary diary?

Answer 13

• Fluid intake - quantity and quality
• Urine output
• Daytime frequency
• Nocturia
• Average voided volume

Question 14

What urinary investigations/examinations may be done to assess a patient?

Answer 14

• 3 day urinary diary
• Urine dipstick
• Urinalysis - multistix + MSSU
• Post voiding residual volume assessment - only if have voiding difficulties
• Urodynamics -
• Examinations:
  
  • General, abdominal, neurological, gynae, pelvic floor assessment (oxford scale)

Question 15

What are you looking for during a pelvic floor assessment?

Answer 15

• Prolapse
• Stress incontinence
• Uro-genital atrophy changes
• Pelvic mass
• Pelvic floor tone, strength, awareness

Question 16

What does the management of incontinence involve?

Answer 16

• Lifestyle changes i.e smoking, weight loss, diet (constipation), alcohol and caffeine
• Physio - reinforce cortical awareness of muscle groups, hypertrophy of existing muscle fibres and general increase in muscle tone and strength
• Medical treatments
• Surgery

Question 17

What is the gold standard drug for treatment of moderate to severe stress urinary incontinence?

Answer 17

Yentreve (Duloxetine) +/- pelvic floor muscle training - this is a selective serotonin and norepinephrine reuptake inhibitor (anti-depressant) - it increases urethral sphincter contraction during the storage phase of urination cycle.

It should be given if PFMT has failed or if the patient is in secondary care and does not want or fit surgery/ has had failed surgery

Question 18

What is Culposuspension?

Answer 18

• An operation to treat stress incontinence (leakage of urine when you exercise, sneeze or strain).
• Involves lifting the neck of your bladder, and stitching it in this lifted position

Question 19

What anatomical defect do stress and urge incontinence arise from in females?

Answer 19

Defect in the anterior vaginal wall and pubo-urethral ligament - Urethral/bladder neck closure dysfunction and USI

Question 20

What is tension-free transvaginal tape used for?

Answer 20

• An operation used in the treatment of stress urinary incontinence.
• It is the first choice procedure in the surgical treatment of Sress UI
• In this procedure, a synthetic tape is placed around the urethra to form a sling – this supports the urethra to prevent leakage.
• 80% Cure at 11 years follow-up.

Question 21

Conservative management of overactive bladder symptoms - stress/urge incontinence?

Answer 21

• Lifestyle
  
  • Normalise fluid intake
  • Reduce caffeine, fizzy drinks, chocolate
  • Stop smoking + alcohol
  • Weight loss
• Bladder training programme with continence nurse
  
  • Timed voiding with gradually increasing intervals

Question 22

Pharmacological treatment of overactive bladder symptoms

Answer 22

• Antimuscarinic
  
  • Oral - solifenacin, fesoteridine
  • Transdermal - Kentera patches
• Tri-cyclic antidepressants
  
  • Imipramine

Question 23

What is ‘overactive bladder’?

Answer 23

• Overactive bladder (OAB) is the name for a group of urinary symptoms. It is not a disease.
• The detrusor muscle contracts before the bladder is full

Symptoms:

• Frequency
• Urgency
• Urgency incontinence

Question 24

Types of incontinence

Answer 24

Question 25

What do anti-cholinergics do?

Answer 25

• Anticholinergic drugs block the action of the neurotransmitter acetylcholine.
• This inhibits nerve impulses responsible for involuntary muscle movements and various bodily functions.
• These drugs can treat a variety of conditions, from overactive bladder to chronic obstructive pulmonary disorder.