Incontinence

Question 1

Which gender is more likely to experience incontinence?

Answer 1

Women 3x more likely

Question 2

What must be working in our body for us to be continent?

Answer 2

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

Question 3

What are the main muscles in the bladder and what type are these?

Answer 3

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

Question 4

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

Answer 4

a) 250ml before we are aware
b) 400-600ml

100ml is the upper limit of normal for how much is left after we urinate

Question 5

How is the bladder innervated (locally)?

Answer 5

The bladder has parasympathetic, sympathetic and somatic innervation…

Parasympathetic - pro-pish

Sympathetic - anti-pish

Somatic - anti-pishin pants

Question 6

Describe the parasympathetic innervation of the bladder and the effect of PS stimulation?

Answer 6

Parasympathetic innervation

S₂ - S₄

Increases strength and frequency of contractions

Question 7

Describe the sympathetic innervation of the bladder

Answer 7

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

Question 8

Describe the somatic innervation of the bladda

Answer 8

Somatic innervation

S₂ - S₄

Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter

Question 9

What action does the CNS have on the bladder?

Answer 9

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

Question 10

Where does CNS control of the bladder come from?

Answer 10

Pons

Frontal cortex

Caudal part of spinal cord

Question 11

What is stress incontinence due to?

Answer 11

Stress incontinence due to the bladder outlet being too weak

Question 12

What are the characteristic features of stress incontinence?

Answer 12

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

Question 13

What are the treatments of stress incontinence?

Answer 13

Physiotherapy - main treatment:

• pelvic floor (Kegal) exercises
• vaginal cones - weights held in vagina

Oestrogen cream

Duloxetine

Surgical treatment - if nothing else works

Question 14

What type of incontinence spawns from the urinary outlet being too strong?

Which gender is this most likely to happen to?

Answer 14

Urinary retention with overflow incontinence

Only type of incontinence that men are more likely to get

Question 15

What are the main features of overflow incontinence?

What typically causes it?

Answer 15

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

Question 16

How is overflow incontinence treated?

Answer 16

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

Question 17

What type of incontinence is related to the bladder being ‘too strong’?

What are the main features

Answer 17

Urge incontinence

This is when the detrusor begins contracting under very low volumes of urine

causes sudden onset urge to urinate

Question 18

What are the causes of urge incontinence?

Answer 18

Neurological problems such as strokes or MS

Bladder stones

Question 19

How is urge incontinence treated?

Answer 19

Anti-muscarinics (relax detrusor):

• solifenacin
• oxybutinin, tolterodine - older

Beta-3 adrenoceptor agonist (relax detrusor):

• mirabegron

Bladder re-training sometimes helpful

Question 20

Neuropathic bladder - is a rarish type of incontinence due to the bladder being underactive

What are the causes of this?

How is it treated?

Answer 20

Secondary to:

• neurological disease - stroke, MS…
• prolonged catheterisation (detrusor atrophy)

Medical treatments not very good

Ironically - best treatment is catheterisation

Question 21

When is referral to a specialist for urinary incontinence indicated?

Answer 21

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

Question 22

What are the indications for instant referral for urinary incontinence?

Answer 22

• 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

Question 23

If all urinary incontinence management fails - what options are available to patients to contain their incontinence?

Answer 23

• Incontinence pads
• Urosheaths
• Intermittent catheterisation
• Long term urinary catheter
• Suprapubic catheter