Incontinence and Urinary Retention Flashcards
What is the lower urinary tract?
Bladder and urethra which are responsible for storing urine and emptying
What is the structure of the urinary bladder?
3 layers
Innermost layer: transitional epithelia
Middle layer: Detrusor smooth muscle
Outermost layer: Adventitia connective tissue
What is voiding?
Urination
What is the neurological control of urination?
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
Effect of sympathetic system on the bladder?
Increases the bladder capacity of the detrusor muscle to enlarge without increasing pressure.
Effect of parasympathetic system on bladder?
Detrusor muscle contraction and causes the internal sphincter to relax.
How are male urethras affected by pathology?
Enlarged prostate increases urinary retention
What is the capacity of the bladder?
500ml
What are the sex differences in urination?
Women have a lower void of 30-40cm of H2O with a higher max flow rate than men.
What is cystometry?
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.
What is the role of cystometry?
Assess detrusor function for bladder compliance, sensation and stability and capacity.
What is bladder sensation?
Sensation transmitted via pressure and stretch receptors in the detrusor muscle walls that induces void desire.
What is bladder stability?
Contractions of the detrusor muscle.
What affects the bladder pressure?
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.
How is bladder pressure determined?
The abdominal pressure + the detrusor muscle pressure
LUTS
Lower Urinary tract symptom which affects primarily men over 65 years old
How is LUTS categorised?
Categorised into:
Storage
Voiding issues
Post-micrutition issues
What are the storage issues?
Includes:
Urgency
Frequency
Nocturia
What are the voiding issues?
Hesitancy: difficulty starting urination
Weak stream
Straining: required to empty bladder
Pain/discomfort
Incomplete emptying
Terminal dribbling
Why do voiding issues occur?
Commonly caused by increased outflow resistance at the bladder neck or urethra. There may be detrusor muscle failure.
What are the post-micrutition issues?
Dribbling
BPH
Benign prostactic hyperplasia- enlargement of the prostate due to increased number of cells
BPE
Benign prostatic enlargement- enlargement of prostate. In the early stages of urinary obstruction, increase in detrusor muscle pressure in voiding to compensate.
BOO
Bladder outflow obstruction- occurs at the base of the bladder in the urethral opening that can occur due to BPE
Cause of BOO in women
Neurological issue with the pontine micrutition centre or urethral obstruction. Generally rarer than in men
How does BOO present in women?
Characteristic symptoms of acute urinary retention such as hesitancy, straining, incomplete sense of emptying
How is BOO treated in women?
Catheterisation or with a catheratisable stoma
What is acute urinary retention?
Painful inability to urinate, which is relieved following catheterisation with large volume of urine drained.
What can be mistaken for acute urinary retention?
Acute surgical conditions that cause abdominal pain and fluid depletion
How is AUR managed?
Phytotherapy: medicines from plants or herbs
Alpha blockers and 5-alpha reductase inhibitors to reduce bladder capacity
5-alpha reductase inhibitors
Better for long term use by preventing symptomatic progression of acute urinary retention and provide imporvement in symptoms of flow.
Detrusor failure
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
What is urinary incontinence?
Storage issue with involuntary urine loss that becomes
What are the types of urinary incontinence?
Stress incontinence
Urge incontinence
Mixed incontinence
Outflow incontinence
What is stress incontinence?
Weakness of the urinary outlet that causes incontinence when bladder is put under pressure such as coughing or sneezing
What is urge incontinence?
Sudden compelling urge to void due to high pressure
What is mixed incontinence?
Combination of urge and stress incontinence
What is outflow incontinence?
Dribbling or leaking urine constantly due to an overfull bladder
What is a fistula?
Abnormal connection between bladder and brain
What is an overactive bladder?
Sudden urge to urinate that can occur without incontinence.
What is urinary incontinence in men?
Overactive bladder, overflow incontinence, prostate enlargement.
What is urinary incontinence in women?
Stress incontinence, urge incontinence, mixed incontinence,
What are the risk factors for urinary incontinence?
Pregnancy/childbirth/menopause
Increasing age
Obesity
Constipation
Pelvic organ prolapse
Chronic cough/smoking
Excessive weight lifting
How does increased abdominal pressure affect the bladder?
Reduces renal blood flow and function.
Applies pressure to the bladder neck and reduces urinary output and causes genuine stress incontinence.
What is genuine stress incontinence?
Caused by increased intrabdominal pressure where there is weakening of the urethral sphincter that causes involuntary urine loss.
Which type of person is urinary incontinence most prevalent?
Elderly people-mixed and urge urinary incontinence
What are the quality of life issues with urinary incontinence?
Distress, embarrassment, inconvenience, threat to self-esteem, loss of personal control, desire for normalisation
How is female stress urinary incontinence treated?
Behaviour therapy pharmacological agents
Surgical treatment
What are the behaviour therapies?
Biofeedback, pelvic floor exercises and vaginal weights.
What are the pharmacological agents?
Oestrogens (inhibits urinary output), tricyclic antidepressants, duloxetine.
What is the surgical treatments for incontinence?
Elevation of the bladder neck with a mid-urethral sling
What is the function of the surgical incontinence?
It either enhances urethral resistance and/or supports bladder neck which differs in the access to the bladder neck access
What is the intramural urethral injections?
Use of bulking agents such as collagen which keeps it closed.
What are the types of sling procedures?
Proximal urethral slings
Mid urethral slings
Proximal urethral slings
Attachment using the rectus fascia
What is single incision mid urethral tape?
Effective treatment for stress incontinence with a single incision and less risk
How is an overactive bladder treated?
Botox
Behaviour therpay
Anti-cholinergic
Neuromodulation with interstim therapy by stimulation of sacral nerves
