Incontinence Flashcards
Which gender is more likely to experience incontinence?
Women 3x more likely
What must be working in our body for us to be continent?
Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control
So we must have functional…
- bladder and urethra
- local innervation
- CNS connections
What are the main muscles in the bladder and what type are these?
Detrusor - smooth muscle of the bladder wall
Internal urethral sphincter - smooth muscle
External urethral sphincter - skeletal muscle thus the only one we have control over
The detrusor muscle of the bladder wall is under inhibition as the bladder fills up
How much does it fill before we:
a) notice
b) actually have to urinate
a) 250ml before we are aware
b) 400-600ml
100ml is the upper limit of normal for how much is left after we urinate
How is the bladder innervated (locally)?
The bladder has parasympathetic, sympathetic and somatic innervation…
Parasympathetic - pro-pish
Sympathetic - anti-pish
Somatic - anti-pishin pants
Describe the parasympathetic innervation of the bladder and the effect of PS stimulation?
Parasympathetic innervation
S2 - S4
Increases strength and frequency of contractions
Describe the sympathetic innervation of the bladder
Sympathetic innervation (alpha effects):
- T10 - S2
- a-adrenoceptor: causes contraction of neck of bladder and internal urethral sphincter
Sympathetic innervation (beta effects):
- T10 - L2
- B-adrenoceptors: causes relaxation of detrusor
Describe the somatic innervation of the bladda
Somatic innervation
S2 - S4
Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter
What action does the CNS have on the bladder?
Centres within the CNS inhibit parasympathetic tone - and promote bladder relaxation and storage of urine
Sphincter closure is mediated by a reflex increases in Alpha-adrenergic and somatic tone
Where does CNS control of the bladder come from?
Pons
Frontal cortex
Caudal part of spinal cord
What is stress incontinence due to?
Stress incontinence due to the bladder outlet being too weak
What are the characteristic features of stress incontinence?
Urine leakage on movements - laughing, coughing, squatting etc
Due to weak pelvic floor muscles
Common in post-menopausal women who have had children
note - post-menopausal women lose catabolic hormones like oestrogen which strengthened pelvic floor muscles
What are the treatments of stress incontinence?
Physiotherapy - main treatment:
- pelvic floor (Kegal) exercises
- vaginal cones - weights held in vagina
Oestrogen cream
Duloxetine
Surgical treatment - if nothing else works
What type of incontinence spawns from the urinary outlet being too strong?
Which gender is this most likely to happen to?
Urinary retention with overflow incontinence
Only type of incontinence that men are more likely to get
What are the main features of overflow incontinence?
What typically causes it?
Overflow incontinence
Prostatism - poor flow, double voiding, hesitancy, post-micturation dribbling
Usually due to urethra being too narrow (strictures) or some form of obstruction
In men - typical of Benign prostatic hypertrophy (BPH)
In women - strictures following radiotherapy for cervical cancer
How is overflow incontinence treated?
Physiotherapy doesnt work for overflow incontinence so straight to medical therapy…
Alpha blockers (eg tamsulosin) - relaxes IUS
Anti-androgen (eg finasteride) - men only - shrinks prostate
Surgery - if ^ ineffective - TURP (trans urethral resection of prostate)
Suprapubic catheterisation
What type of incontinence is related to the bladder being ‘too strong’?
What are the main features
Urge incontinence
This is when the detrusor begins contracting under very low volumes of urine
causes sudden onset urge to urinate
What are the causes of urge incontinence?
Neurological problems such as strokes or MS
Bladder stones
How is urge incontinence treated?
Anti-muscarinics (relax detrusor):
- solifenacin
- oxybutinin, tolterodine - older
Beta-3 adrenoceptor agonist (relax detrusor):
- mirabegron
Bladder re-training sometimes helpful
Neuropathic bladder - is a rarish type of incontinence due to the bladder being underactive
What are the causes of this?
How is it treated?
Secondary to:
- neurological disease - stroke, MS…
- prolonged catheterisation (detrusor atrophy)
Medical treatments not very good
Ironically - best treatment is catheterisation
When is referral to a specialist for urinary incontinence indicated?
Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
However there are indications for instant referral
What are the indications for instant referral for urinary incontinence?
- Vesico-vaginal fistula
- Palpable bladder after micturition or confirmed large residual volume of urine after micturition
- Disease of CNS
- Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
- Severe BPH or prostatic carcinoma
- Patients who have had surgery for previous incontinence
- Others in whom a diagnosis has not been made
If all urinary incontinence management fails - what options are available to patients to contain their incontinence?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
