Incontinence and Urinary Retention

Question 1

What is the lower urinary tract?

Answer 1

Bladder and urethra which are responsible for storing urine and emptying

Question 2

What is the structure of the urinary bladder?

Answer 2

3 layers
Innermost layer: transitional epithelia
Middle layer: Detrusor smooth muscle
Outermost layer: Adventitia connective tissue

Question 3

What is voiding?

Answer 3

Urination

Question 4

What is the neurological control of urination?

Answer 4

Pontine micrutition centre in the brainstem however there is central control. Involves co-ordination between smooth muscle of detrusor and urethra relaxation to leave no urine in the bladder

Question 5

Effect of sympathetic system on the bladder?

Answer 5

Increases the bladder capacity of the detrusor muscle to enlarge without increasing pressure.

Question 6

Effect of parasympathetic system on bladder?

Answer 6

Detrusor muscle contraction and causes the internal sphincter to relax.

Question 7

How are male urethras affected by pathology?

Answer 7

Enlarged prostate increases urinary retention

Question 8

What is the capacity of the bladder?

Answer 8

500ml

Question 9

What are the sex differences in urination?

Answer 9

Women have a lower void of 30-40cm of H2O with a higher max flow rate than men.

Question 10

What is cystometry?

Answer 10

Measure of detrusor muscle function via pressure-volume relationship. Assesses the pressure of the destrusor muscle in both controlled bladder filling and voiding compared to the synchronous flow-rate.

Question 11

What is the role of cystometry?

Answer 11

Assess detrusor function for bladder compliance, sensation and stability and capacity.

Question 12

What is bladder sensation?

Answer 12

Sensation transmitted via pressure and stretch receptors in the detrusor muscle walls that induces void desire.

Question 13

What is bladder stability?

Answer 13

Contractions of the detrusor muscle.

Question 14

What affects the bladder pressure?

Answer 14

Rectal pressure- high pressure may reduce bladder capacity or the bladder stability and result in urinary urgency. Rectal pressure must be substracted from detrusor muscle pressure to find the detrusor effect.

Question 15

How is bladder pressure determined?

Answer 15

The abdominal pressure + the detrusor muscle pressure

Question 16

LUTS

Answer 16

Lower Urinary tract symptom which affects primarily men over 65 years old

Question 17

How is LUTS categorised?

Answer 17

Categorised into:
Storage
Voiding issues
Post-micrutition issues

Question 18

What are the storage issues?

Answer 18

Includes:
Urgency
Frequency
Nocturia

Question 19

What are the voiding issues?

Answer 19

Hesitancy: difficulty starting urination
Weak stream
Straining: required to empty bladder
Pain/discomfort
Incomplete emptying
Terminal dribbling

Question 20

Why do voiding issues occur?

Answer 20

Commonly caused by increased outflow resistance at the bladder neck or urethra. There may be detrusor muscle failure.

Question 21

What are the post-micrutition issues?

Answer 21

Dribbling

Question 22

BPH

Answer 22

Benign prostactic hyperplasia- enlargement of the prostate due to increased number of cells

Question 23

BPE

Answer 23

Benign prostatic enlargement- enlargement of prostate. In the early stages of urinary obstruction, increase in detrusor muscle pressure in voiding to compensate.

Question 24

BOO

Answer 24

Bladder outflow obstruction- occurs at the base of the bladder in the urethral opening that can occur due to BPE

Question 25

Cause of BOO in women

Answer 25

Neurological issue with the pontine micrutition centre or urethral obstruction. Generally rarer than in men

Question 26

How does BOO present in women?

Answer 26

Characteristic symptoms of acute urinary retention such as hesitancy, straining, incomplete sense of emptying

Question 27

How is BOO treated in women?

Answer 27

Catheterisation or with a catheratisable stoma

Question 28

What is acute urinary retention?

Answer 28

Painful inability to urinate, which is relieved following catheterisation with large volume of urine drained.

Question 29

What can be mistaken for acute urinary retention?

Answer 29

Acute surgical conditions that cause abdominal pain and fluid depletion

Question 30

How is AUR managed?

Answer 30

Phytotherapy: medicines from plants or herbs Alpha blockers and 5-alpha reductase inhibitors to reduce bladder capacity

Question 31

5-alpha reductase inhibitors

Answer 31

Better for long term use by preventing symptomatic progression of acute urinary retention and provide imporvement in symptoms of flow.

Question 32

Detrusor failure

Answer 32

Reduced strength or duration of detrusor muscle contraction. This can occur due to lower motor neuron lesion affecting the bladder or prostate obstruction or urethral stricture

Question 33

What is urinary incontinence?

Answer 33

Storage issue with involuntary urine loss that becomes

Question 34

What are the types of urinary incontinence?

Answer 34

Stress incontinence Urge incontinence Mixed incontinence Outflow incontinence

Question 35

What is stress incontinence?

Answer 35

Weakness of the urinary outlet that causes incontinence when bladder is put under pressure such as coughing or sneezing

Question 36

What is urge incontinence?

Answer 36

Sudden compelling urge to void due to high pressure

Question 37

What is mixed incontinence?

Answer 37

Combination of urge and stress incontinence

Question 38

What is outflow incontinence?

Answer 38

Dribbling or leaking urine constantly due to an overfull bladder

Question 39

What is a fistula?

Answer 39

Abnormal connection between bladder and brain

Question 40

What is an overactive bladder?

Answer 40

Sudden urge to urinate that can occur without incontinence.

Question 41

What is urinary incontinence in men?

Answer 41

Overactive bladder, overflow incontinence, prostate enlargement.

Question 42

What is urinary incontinence in women?

Answer 42

Stress incontinence, urge incontinence, mixed incontinence,

Question 43

What are the risk factors for urinary incontinence?

Answer 43

Pregnancy/childbirth/menopause Increasing age Obesity Constipation Pelvic organ prolapse Chronic cough/smoking Excessive weight lifting

Question 44

How does increased abdominal pressure affect the bladder?

Answer 44

Reduces renal blood flow and function. Applies pressure to the bladder neck and reduces urinary output and causes genuine stress incontinence.

Question 45

What is genuine stress incontinence?

Answer 45

Caused by increased intrabdominal pressure where there is weakening of the urethral sphincter that causes involuntary urine loss.

Question 46

Which type of person is urinary incontinence most prevalent?

Answer 46

Elderly people-mixed and urge urinary incontinence

Question 47

What are the quality of life issues with urinary incontinence?

Answer 47

Distress, embarrassment, inconvenience, threat to self-esteem, loss of personal control, desire for normalisation

Question 48

How is female stress urinary incontinence treated?

Answer 48

Behaviour therapy pharmacological agents Surgical treatment

Question 49

What are the behaviour therapies?

Answer 49

Biofeedback, pelvic floor exercises and vaginal weights.

Question 50

What are the pharmacological agents?

Answer 50

Oestrogens (inhibits urinary output), tricyclic antidepressants, duloxetine.

Question 51

What is the surgical treatments for incontinence?

Answer 51

Elevation of the bladder neck with a mid-urethral sling

Question 52

What is the function of the surgical incontinence?

Answer 52

It either enhances urethral resistance and/or supports bladder neck which differs in the access to the bladder neck access

Question 53

What is the intramural urethral injections?

Answer 53

Use of bulking agents such as collagen which keeps it closed.

Question 54

What are the types of sling procedures?

Answer 54

Proximal urethral slings Mid urethral slings

Question 55

Proximal urethral slings

Answer 55

Attachment using the rectus fascia

Question 56

What is single incision mid urethral tape?

Answer 56

Effective treatment for stress incontinence with a single incision and less risk

Question 57

How is an overactive bladder treated?

Answer 57

Botox Behaviour therpay Anti-cholinergic Neuromodulation with interstim therapy by stimulation of sacral nerves