Incontinence - Stress, urge and mixed

Question 1

According to a WHO survey in 1998, 200 million people worldwide have bladder control problems. Are older men or women more likely to experience continence (controlling their bladder) problems?

Answer 1

• women
• 2 in 5 women over 60/y/o

Question 2

Urine filters from the kidneys down to the bladder through the ureters and then is removed from the bladder via the urethra. What is the name of the special type of muscle that the bladder is composed of?

1 - psoas muscle
2 - detrusor muscle
3 - inguinal muscle
4 - pelvic muscle

Answer 2

2 - detrusor muscle
- this is able to stretch as the bladder fills

Question 3

What type of cells are contained within the bladder that allows the bladder to stretch?

1 - stratified transitional epithelial cells
2 - stratified columnar cells
3 - pseudostratified squamous epithelial cells
4 - squamous epithelial cells

Answer 3

1 - stratified transitional epithelial cells

Question 4

Roughly how much urine can the bladder store?

1 - 100-200ml
2 - 200-300ml
3 - 500-750ml
4 - 1000-2000ml

Answer 4

3 - 500-750ml
- slightly less in women as the uterus takes up space

Question 5

The bladder contains an internal and external sphincter. Which one is autonomous and not under our control?

Answer 5

• internal sphincter
• composed of smooth muscle and opens when the bladder is half full

Question 6

The bladder contains an internal and external sphincter. Is the external sphincter composed of smooth or skeletal muscle?

Answer 6

• skeletal muscle
• under voluntary control and allows us to stop urine flow by contracting called Kegel exercises

Question 7

When the bladder begins to fill, stretch receptors sends a signal to the spinal cord, called the micturition centre. What level is this at in the spinal cord?

1 - L4-L5
2 - L5-S2
3 - S1-S2
4 - S2-S4

Answer 7

4 - S2-S4

Question 8

When the bladder begins to fill, stretch receptors sends a signal to the spinal cord, called the micturition centre in the sacrum at S2-S4. These is also a signal sent to the brain, specifically which part of the brain?

1 - hippocampus
2 - pons
3 - midbrain
4 - medulla

Answer 8

2 - pons
- pontine micturition centre
- pontine storage centre

Question 9

When the micturition centre in the spinal cord is stimulated at S2-S4 by stretch receptors in the bladder, does this affect the sympathetic or parasympathetic system?

Answer 9

• both
• part of micturition reflex
• decreases sympathetic and increased parasympathetic

Question 10

When the micturition centre in the spinal cord is stimulated at S2-S4 by stretch receptors in the bladder this reduces the sympathetic and increases the parasympathetic activity, all part of the micturition reflex. Does this cause the detrusor muscle to contract or relax?

Answer 10

• contract as in rest and digest = parasympathetic

Question 11

When the micturition centre in the spinal cord is stimulated at S2-S4 by stretch receptors in the bladder this reduces the sympathetic and increases the parasympathetic activity, all part of the micturition reflex. Does this cause the internal sphincter to contract or relax?

Answer 11

• relax and allow urine to leave the bladder
• as in rest and digest = parasympathetic
• has a moderate effect on relaxing the external sphincter as well

Question 12

If we want to urinate does the pontine micturition centre or pontine storage centre override the micturition reflex and stop us from urinating?

Answer 12

• pontine storage centre
• as in it stores the urine
• if we want to urinate the pontine micturition centre allows for the micturition reflex to occur

Question 13

Which nerve is important for being able to contract the external sphincter and thus control when to urinate?

1 - hypogastric nerve
2 - sciatic nerve
3 - pudendal nerve
4 - superior gluteal nerve

Answer 13

3 - pudendal nerve

Question 14

Incontenance is the inability to control urine. Leakage or urine typically occurs when the pressure inside the bladder surpasses the pressure within the urethra. At any one time, what % of women are affected by urinary incontenance?

1 - 2.5%
2 - 12.5%
3 - 25%
4 - 50%

Answer 14

3 - 25%

Question 15

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is urge incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - strong, sudden and uncontrolled desired to urinate as a result of detrusor muscle contraction
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 15

2 - strong, sudden and uncontrolled desired to urinate as a result of detrusor muscle contraction

• detrusor muscle contracts increasing pressure in bladder above the closure force of the urethra.

Question 16

Incontenance is the inability to control urine. Leakage or urine typically occurs when the pressure inside the bladder surpasses the pressure within the urethra. Which of the following is NOT a risk factor for urge incontenance?

1 - idiopathic
2 - child bearing
3 - diabetes
4 - Urinary tract infection
5 - Obesity
6 - Vaginal prolapse
7 - Neurological disorder
8 - Medications such as diuretics
9 - Caffeine and alcohol (diuretics)

Answer 16

2 - child bearing

Question 17

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is stress incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - unable to control urination due to involuntary bladder contractions and then urination
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 17

1 - small leakage of urine occurs on physical exertion due to stress on bladder

Question 18

Which structure in the pelvis provides a sling like support around the urethra to ensure that when there is an increase in intra-abdominal pressure the urethra is able to close and not leak urine?

1 - detrusor muscle
2 - levator ani muscle
3 - arcus tendineus fasciae pelvis
4 - perineal membrane

Answer 18

3 - arcus tendineus fasciae pelvis
- if this is in place women maintain control of there bladders

Question 19

In stage 2 of labour, termed expulsion which is when the head descends and is the pushing phase, which of the following can occur that can lead to post-natal stress incontenance?

1 - mechanical stretching of bladder neck
2 - Disruption of fascia surrounding bladder neck
3 - hypoxia in tissue surrounding the bladder neck
4 - all of the above

Answer 19

4 - all of the above

Question 20

Is stress or urge incontenance more common?

Answer 20

• stress incontenance = 49%
• urge incontenance = 22%

Question 21

Which of the following is NOT a risk factor for stress incontenance, which is the most common form of incontenance?

1 - Childbearing and vaginal delivery
2 - Obesity (increased abdo pressure)
3 - Age
4 - Chronic cough
5 - Abdominal mass (eg fibroids)
6 - Pelvic surgery
7 - Connective tissue disorders (MS, SLE, RA)

Answer 21

3 - Age
- this form of incontenance is typically a mechanical problem, therefore ageing is not a specific risk factor

Question 22

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is mixed incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - unable to control urination due to involuntary bladder contractions and then urination
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 22

4 - both urge and stress incontenance

Question 23

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is outflow incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - unable to control urination due to involuntary bladder contractions and then urination
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 23

3 - urethra and flow of urine is blocked

• almost always occurs in men
• phimosis
• benign prostate hyperplasia, stricture, trauma, blood clot, calculi, cancer of the bladder, prostate, cervix or colon, STIs (particularly in women)

Question 24

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is overflow incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - unable to control urination due to involuntary bladder contractions and then urination
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 24

5 - bladder fills but does not empty properly causing continuous dribbling

• continuous dribbling or symptoms of stress incontinence with large post-void residual volume
• can be caused by recurrent UTIs
• made worse by constipation or anticholinergics
• often occurs in men with prostatic obstruction

Question 25

There are lots of different types of incontenance, which is the inability to control urine and/or bladder function. What is functional incontenance?

1 - small leakage of urine occurs on physical exertion due to stress on bladder
2 - inability to reach and use the toilet
3 - urethra and flow of urine is blocked
4 - both urge and stress incontenance
5 - bladder fills but does not empty properly causing continuous dribbling

Answer 25

2 - inability to reach and use the toilet
- may be due to frailty or disability

Question 26

All of the following tests can be performed in an attempt identify the cause of urinary incontenance. However, which test is the mainstay to help identify the cause of incontenance (stress, urge or mixed) in secondary care?

1 - urine dipstick
2 - vaginal examination
3 - bladder diary
4 - urodynamics
5 - residual urine assessment

Answer 26

4 - urodynamics
- measures bladder and intra-abdominal pressure
- measure detrusor contractions
- measures urine flow in bladder neck

Question 27

All of the following are causes that can accentuate a patients incontenance, EXCEPT which one?

1 - bowel function (constipation)
2 - mobility/dexterity (unable to reach the toilet)
3 - medication
4 - nutrition
5 - medical conditions
6 - psychological conditions

Answer 27

4 - nutrition

• most of these causes can be treated if clinician is aware of them

Question 28

When conducting a history with a patient, in reference to their urination habits, which of the following are RED flags to be aware of?

1 - Haematuria
2 - Persistent UTI
3 - Constitutional symptoms
4 - Poor renal function
5 - Abnormal neurology include saddle anaesthesia
6 - Recent back trauma or pelvic surgery
7 - all of the above

Answer 28

7 - all of the above

Question 29

When managing a patient with urinary incontenance the treatment can be divided into 4 sections:

• Lifestyle advice/patient education
• MDT/non-pharmacological
• Medical management
• Surgical management

Which of the following is NOT a lifestyle intervention for incontenance?

1 - Smoking cessation (reduce cough)
2 - Reduced fluid intake at specific times
3 - Weight reduction (reduce abdo pressure)
4 - Managing constipation (reduce abdo pressure)
5 - Reduce alcohol and caffeine intake
6 - Botulinum toxin

Answer 29

6 - Botulinum toxin
- limits detrusor muscle contractions

Question 30

Physiotherapy and pelvic floor strengthening can have a 66% improvement. These are called Kegel exercises. Although these exercises can strengthen the pelvic floor muscles, especially the levator ani muscles. Which of the following muscles is NOT part of the levator ani muscle group?

1 - Puborectalis
2 - Iliococcygeus
3 - Pubococcygeus
4 - Coccygeus

Answer 30

4 - Coccygeus

• the courses typically last 6 weeks

Question 31

In some patients the use of anti-cholinergic (anti-muscarinics) can be used. These act by competitively binding against ACh, therefore reducing parasympathetic activity and detrusor muscle contraction. Which of the following is the core anti-muscarinic that we need to be aware of used to treat urinary incontenance?

1 - bisoprolol
2 - doxazosin
3 - digoxin
4 - solifenacin

Answer 31

4 - solifenacin

Question 32

In some patients the use of beta-3 agonist can be used. These act by binding with beta-3 receptors on the bladder and increasing cyclic adenosine monophosphate that induces detrusor muscle relaxation. Which of the following is the core beta-3 agonist that we need to be aware of used to treat urinary incontenance?

1 - bisoprolol
2 - doxazosin
3 - mirabegron
4 - solifenacin

Answer 32

3 - mirabegron
- better side effect profile than anti-cholinergics

Question 33

Solifenacin an anti-muscarinics that competitively binds against ACh, reducing parasympathetic activity and detrusor muscle contraction. However, it has a large adverse events profile, especially in the elderly. Which of the following are common?

1 - cognitive impairment, hallucinations
2 - blurred vision
3 - dry mouth
4 - tachycardia
5 - nausea, constipation
6 - urinary retention
7 - all of the above

Answer 33

7 - all of the above
- all are associated with the inhibiting the parasympathetic system

Question 34

In males who experience benign prostate hyperplasia (BPH), medications can limit this. Which drug is typically prescribed for this, and is a core drug for us?

1 - bisoprolol
2 - doxazosin
3 - digoxin
4 - solifenacin

Answer 34

2 - doxazosin
- tamsulosin is also common
- both are alpha blockers that reduces smooth muscle tone in the prostate

• transurethral resection of the prostate (TURP) is also a surgical option for BPH

Question 35

If medications and conservative management fails then surgery can be performed. One of the most common of these is called Tension-free vaginal tape (TVT) sling, which has a success rate of 80-90%. However, which of the following are common complications to this procedure?

1 - pelvic/abdominal/perineal/leg/groin pain
2 - dyspaerunia
3 - penile trauma on intercourse
4 - abnormal vaginal discharge and bleeding
5 - urinary and faecal incontinence
6 - bladder and bowel disturbance
7 - all of the above

Answer 35

7 - all of the above

Question 36

Which of the following is the most common procedure used for patients with stress incontenance?

1 - Tension-free vaginal tape (TVT) sling
2 - Urethral bulking
3 - Urethropexy
4 - all equally used

Answer 36

3 - Urethropexy