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MBBS IV - Junior Clerkship WCS > JC69 (Surgery) - Urinary incontinence > Flashcards

JC69 (Surgery) - Urinary incontinence Flashcards

1
Q

Differentiate urinary incontinences and enuresis

A

Urinary incontinence: condition where involuntary loss of urine is a social/hygienic problem and is objectively demonstrable

Enuresis: any involuntary loss of urine
Nocturnal enuresis is normal in babies/ kids

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2
Q

Describe the physiological mechanisms for urinary continence

A

Anatomical support by
→ Intact pelvic floor holding bladder neck + urethra in place (esp in F)

Intrinsic urethral mechanism by
→ Coaptation of mucosa
→ Compression by submucosa and internal/external sphincters

Prostate as continence device in M → above factors less important

Neurological control by CNS and spinal cord

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3
Q

Somatic neural control of micturition

Anatomical structures involved in coordination and control
Parasympathetic, sympathetic and reflex control

A
  1. Pudendal nerve: from S2-S4 Onuf’s nucleus (anterior horn)
    » Innervates striated sphincter, anterior levators, superficial perineal muscles
    » Close external sphincter muscle in urethra
  2. Pontine micturition center
    Inputs (3):
    » Corticol input from frontal lobes to inhibit micturition
    » Afferent sensory input from stretch receptors in bladder Detrussor muscles
    » Cerebellar input for coordinated voiding
    Output (1):
    » Sympathetic output from T10-L2 to Hypogastric nerve, merge with parasympathetic fibers to form pelvic plexus
    » Contracts internal sphincter muscle in urethra
  3. Sacral micturition center
    » Communicates with pontine center for micturition reflex
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4
Q

Define normal void volume, residual volume

Define urinary frequency and nocturia

A

Normal void: 200-400mL
Normal residual: <150mL

Frequency: >8 voids during daytime, >Q2H

Nocturia: >2 voids during sleep, each void preceded and followed by sleep

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5
Q

Physiology of urine storage and voiding

Anatomical structures involved
High pressure or low pressure?

A

Urine storage:

  • Bladder expands for low-pressure storage
  • Bladder outlet closed at rest and even at high intra-abdominal pressure
  • No involuntary bladder contraction

Urine voiding:

  • Periodic voluntary urine expulsion at low pressure
  • Coordinated contraction of bladder smooth muscles + relax sphincter muscles to remove anatomical obstruction at outlet
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6
Q

Anatomical abnormalities that lead to urinary incontinence?

A

Bladder:

  • Detrussor overactivity (idiopathic, neurogenic)
  • Low bladder compliance (SCI, cystitis, hysterectomy)

Sphincter abnormalities

  • Extrinsic sphincter = Urethral HJypermobility due to weak pelvic floor muscle support
  • Intrinsic sphincter deficiency (ISD) = abnormal urethral muscle, blood flow, innervation
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7
Q

Physiological pathway for micturition reflex and voluntary inhibition of micturition

A

Involuntary micturition/ micturition reflex:
- Intravesical pressure in bladder&raquo_space; sensory input into pontine micturition center&raquo_space; relaxation of sphincter muscles and THEN detrusor contraction&raquo_space; induce involuntary emptying

Voluntary micturition: block somatic neural efferent activities

Stop micturition:
- Cortical input from frontal lobe into pontine micturition center&raquo_space; inhibit micturition

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8
Q

Prevalence of urinary incontinence
Demographics
Most prevalent type

A

F&raquo_space; M Mostly post-menopausal women
50-70 years old

Stress incontinence at 50%, Mix incontinence at 36%

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9
Q

5 major types of incontinence

A

Urge incontinence (UUI)

Stress incontinence (SUI)

Overflow incontinence

Functional incontinence

Mixed incontinence: urge + stress incontinence

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10
Q

Define Urge incontinence and underlying mechanism

A 
Urge incontinence (UUI): strong desire to void that is difficult to defer and a/w leakage
→ Often mixed with SUI (mixed incontinence) and may be worsened by anxiety/stress
→ Mechanism: detrusor overactivity leading to inappropriate bladder contraction
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11
Q

Define stress incontinence and underlying mechanisms

A 
Stress incontinence (SUI): leakage a/w Increase abdominal pressure
→ Mechanism: due to poor urethral sphincter function
→ Triggers: cough, sneeze, laughing, heavy lifting
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12
Q

Define overflow incontinence and underlying mechanism

A

Overflow incontinence: constant dribbling (esp at night) with associated retention of urine
→ Mechanism: BOO/DUA leads to abnormally distended bladder with large residual volume→ bladder over-distension with continuous dribbling
→ Signs: significant post-void residual, palpable bladder
→ Complications: UTI, bladder stones, obstructive uropathy

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13
Q

Define functional incontinence and underlying mechanism

A

Functional incontinence: urine leakage due to inability to get to toilet
→ Causes: impaired mobility (eg. elderly), dementia, lack of carer
→ Usually dx of exclusion as other types also present in functionally limited individuals

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14
Q

List general modifiable and unmodifiable risk factors of urinary incontinence (not specific to type)

A

Unmodifiable:

  1. White ethnicity
  2. Age > 50, post-menopausal
  3. Female sex

Modifiable:

  1. Smoking, Caffeine
  2. Obesity, Poor mobility
  3. Fluid intake level
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15
Q

Diseases/ Conditions associated with Urinary incontinence

A

Urogenital tract damage:

  • Vaginal childbirth
  • Anatomical disorders - VVF, ectopic ureter, urethral diverticulum
  • Iatrogenic: pelvic, perineal and prostate surgery
  • Radiation therapy

Neurological damage:

  • CVA
  • Parkinsons
  • MS, SCI

UTI
DM
Medications

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16
Q

Ddx structural causes of urinary incontinence

A

Congenital duplex ureter

Infection

Iatrogenic - e.g. post-postatectomy sphincteric injury

Birth injury: vesico-vaginal fistula, stress incontinence

Neoplastic

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17
Q

Mechanisms of poor bladder compliance

A
  1. Increase viscoelasticity of bladder wall
  2. Filing rate exceeds rate of stress relaxation
  3. Over-filling beyond distensibility
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18
Q

Reversible, transient causes of urinary incontinence

A 
D – delirium
I – infection
A – atrophic vaginitis or urethritis
P – pharmaceuticals (see RHS)
P – psychological disorders
E – endocrine disorders
R – restricted mobility
S – stool impaction
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19
Q

Drug and food causes of urinary incontinence

A 
Diuretics – urge
Caffeine – urge
Alcohol – urge
Anticholinergics – overflow
Alpha-agonists – overflow
Beta-agonists – overflow
Sedatives/antidepressants – overflow
ACEI (cough) – stress
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20
Q

Ketamine cystitis

  • Cause
  • Physiological defect
  • Presentation
A

Cause: Chronic ketamine abuse

Defect: Small, poor compliance bladder

Presentation: Urge incontinence, urinary frequency, obstructive uropathy

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21
Q

Urge incontinence

  • Common causes
A
  1. Idiopathic overactive bladder (OAB)**
    a) Neurogenic OAB:
    - Brain: CVA, PD, Tumor, MS …etc
    - Spine: injury, tumor, myelodysplasia …etc

b) Non-neurogenic OAB:
- Chronic BOO: BPH, urethral strictures, Pelvic mass
- Cystitis, bladder cancer
- Bladder stones

  1. Drugs: Diuretics, Caffeine, Alcohol
22
Q

Stress incontinence

  • Most common causes in male and female
A

Male:

  • Prostate surgery**
  • Spinal cord injury
  • Drugs: a-blockers, ACEi

Female:

  • Urethral hypermobility - poor pelvic floor support to urethra/ bladder neck, caused by birth trauma, increase IAP
  • Intrinsic sphincteric deficiency: neuromuscular damage after pelvic surgeries
23
Q

Overflow incontinence

Common causes in Male and female

A

Male:
1. Bladder outlet obstruction: BPH**, Spinal cord lesions

  1. Detrussor underactivity:
    - Neuropathies and lower spinal cord disease
    - Acute overdistension (e.g. post-op)
    - Drugs: a-agonist, anticholinergics, antidepressants

Female:

  1. Detrussor underactivity: (more common)
    - post-menopausal UG atrophy
    - neuropathies and lower SC diseases
    - Acute overdistension, eg. post-operative
    - Drugs: α-agonists, anticholinergics, antidepressants
  2. Bladder outlet obstruction
    - External compression: fibroids, pelvic tumours
    - Others: advanced POP, over-correction from prev OT
24
Q

Patient presents with Incontinence a/w sense of urgency, triggered by running water, hand-washing, cold exposure

Most likely cause of incontinence?
Relevant history/ risk factors/ etiologies

A

Urge incontinence

Relevant history:

  • Other LUTS, esp storage symptoms
  • Hx of bladder pathologies, eg. UTI, stones, BPH
  • Hx of neurological conditions, eg. stroke, SCI, and DM
  • Drug Hx, eg. diuretics, and fluid intake incl caffeine/alcohol
25
Q

Patient presents with Incontinence a/w physical exertion, coughing, laughing, lifting, rising from bed

Most likely type

Relevant history/ risk factors/ etiologies

A

Stress incontinence

  • Chronic ↑abd pressure: chronic cough, obesity
  • Obstetric history: multiparity, perineal tears
  • Hx of prostate surgery: radical prostatectomy, TURP (usu not)
26
Q

Patient presents with feeling of incomplete emptying, suprapubic discomfort, dribbling without any warning/ triggers

Most likely type of incontinence

Relevant history/ risk factors/ etiologies

A

Overflow incontinence

Relevant history:

  • Other LUTS, esp voiding symptoms
  • LL neurological symptoms and Hx of spinal cord diseases
  • Hx of BPH or any other prostate pathology
  • Gynaecological history, eg. fibroids, pelvic organ prolapse
  • Drug history, eg. α-agonists, anticholinergics, antidepressants
27
Q

Idiopathic overactive bladder

  • Cause of which type of urinary incontinence
  • Presentation
  • Triggers
  • Etiologies
A

Urge incontinence***

Presentation:
- Strong sense to void, then involuntary loss of urine

Triggers:
- worsened by anxiety/stress

  • Etiologies:
    Neurogenic OAB:
    Brain: CVA, NPH, PD, brain tumour, TBI, MS
    SC: injury, tumour, transverse myelitis, myelodysplasia

Non-neurogenic OAB due to bladder pathology
Chronic BOO: BPH, urethral stricture
Cystitis (infection/inflammation) and tumour
Bladder stones and bladder foreign body
Drugs: diuretics, caffeine, alcohol

28
Q

Complications of overflow incontinence

A
  1. UTI
  2. Bladder stone formation
  3. Obstructive uropathy, worsen renal function
29
Q

Patient presents with leaking of urine before reaching toilet, old-age

Most likely type of incontinence, causes

A

Functional incontinence: urine leakage due to inability to get to toilet

Causes: impaired mobility (eg. elderly), dementia, lack of carer

30
Q

Outline history taking for urinary incontinence

A

Patient: Old age? Post-menopausal?

HPI:
Incontinence: Duration, type, frequency, volume/ number of pads, triggers and constant vs intermittent
Associated symptoms: Obstructive symptoms
Voiding/drinking habit: voiding diary if possible

PMH:
Neurological and mental health history
Gynaecological and Obstetic, Menstrual history
Urological history: UTI, surgeries …etc
Medication and social history: drug abuse, chronic drug use, caffeine/ smoking/ alcohol

Impact on quality of life

31
Q

Outline list of P/E for urinary incontinence

A
  1. Post-void abdominal examination:
    → Palpable bladder indicates urinary retention - overflow incontinence
    → Abdominal mass compress on bladder
  2. Pelvic examination in women → pelvic masses, organ prolapse, atrophic changes
  3. Rectal examination:
    → Feel for: anal tone (± faecal soiling), faecal impaction, rectal mass, BPH
    → Test reflexes: anal reflex, bulbocavernous reflex (BCR, S2-4)
  4. Genital examination:
    - Atrophy, cystocele, rectocele, skin excoriations, pelvic masses
  5. Neurological examination if any suspicion of spinal cord/brain pathologies
32
Q

First-line investigations for urinary incontinence

A
  1. Voiding diary: Frequency/ Volume charts
  2. Urinalysis, C/ST to r/o UTI
  3. RFT, Fasting glucose - obstructive uropathy, diabetic nephropathy
  4. Uroflowmetry - flow rate and post-void residual volume
  5. Urodynamic studies - Gold standard, for complicated incontinence:
33
Q

Outline the recorded metrics and estimated metrics in Voiding Diary

A

Recorded: 24-72h

  • Fluid intake, physical activity
  • Frequency
  • Void volume
  • Incontinence episodes and triggers

Estimations:

  • 24h urine volume
  • Frequency
  • Nocturia
  • Functional bladder capacity
34
Q

Urodynamic studies

  • Indications
  • Functions
A

Indication: Gold standard, for complicated incontinence

  • Detrusor overactivity
  • Voiding dysfunction
  • Unclear clinical diagnosis
  • Previous surgery for stress incontinence
  • Any neurological deficits

Functions:

  • Find etiology of incontinence
  • Assess Detrusor function
  • Assess pelvic floor prolapse
  • Find urodynamic risk factors for urinary tract deterioration
35
Q

List all metrics measured in Urodynamic studies

+ advantage of video UDS

A
  1. Flowmetry - Flow rate and residual urine
  2. Filling phase - Instability or hypotonia
  3. Voiding phase - Obstruction
  4. Video: shape of bladder, bladder neck, any reflux
    - Better evaluation of bladder neck descent and urethra, clearly quantify anterior wall prolapse
  5. Electromyography - striated sphincter function:
    → Leak point pressure (LPP): Pabd or Pdet required to overcome outlet resistance and produce incontinence
    → Urethral pressure profilometry (UPP): measures urethral pressure along its length
36
Q

General lifestyle management for all types of urinary incontinence

A

Lifestyle modifications:

  1. Weight-reduction
  2. Less caffeine, alcohol intake, don’t reduce fluid intake
  3. Use incontinence pads
37
Q

List non-pharmacological/ physiotherapy for urinary incontinence

A

Pelvic floor (Kegel) exercises

Biofeedback: placement of vaginal pressure sensor → live feedback of strength of pelvic floor contractions

Bladder training: timed voiding with controlling of urgency by distraction or mental relaxation techniques

38
Q

List medical treatment options for urinary incontinence

A

Medical therapy: check for C/I to anticholinergics, usually require ~4w to see full benefit

  • Anticholinergics, eg. oxybutynin, tolterodine, solifenacin
  • Beta-3 agonist: Mirabegrone
  • Vaginal oestrogen: suitable for postmenopausal women with vaginal atrophy
  • Desmopressin: suitable for persistent nocturia
39
Q

List surgical treatment options for urinary incontinence (excluding stress incontinence)

A

Surgical therapy:

  • Sacral Nerve neuromodulation
  • Posterior Tibial Nerve Stimulation (PTNS)
  • botox injection
  • augmentation cystoplasty
  • urinary diversion
40
Q

Surgical treatment options specific to stress incontinence

A

For stress incontinence only:

  • Transurethral injection: bulking agents (eg. silicon, collagen)
  • Mid-urethral sling (MUS): tension-free vaginal tape (TVT) in F, trans-obturator tape (TOT) in M
  • Burch coloposuspension: suture lateral vaginal walls to iliopectineal ligaments
  • Artificial urinary sphincter: most effective Tx for M, pump to deflate sphincter
41
Q

Describe bladder training for urinary incontinence

A

Train Central control of voiding: timed voiding according to a schedule, stop voiding under urgency

controlling urgency by distraction or mental relaxation techniques

42
Q

Antimuscarinic therapy for urinary incontinence

MoA
Effective time

A

MoA: Bladder contraction involves M3 receptors

Antimuscarinic drug acts as competitive antagonist against muscarinic receptros

> > Inhibits post-synaptic M3 receptors, stop Phospholipase3/IP3 pathway and Calcium influx

> > Reduce smooth muscle contaction

Time: 3-4 weeks before effect

43
Q

List examples of antimuscarinic therapy for urinary incontinence and differences

Options if dry mouth cannot be tolerated?

A

Oxybutyninmost common: extended release, in transdermal or intravesical gel or rectal suppository, less systemic S/E

Tolterodine: less salivary gland S/E
Solifenacin: selective to M2, M3
Darifenacin: selective to M3
Quaternary: Less CNS S/E, e.g. Trospium chloride, Propantheline

Change to Tolterodine/ Transdermal, intravesical oxybutynin

44
Q

S/E of antimuscarinic therapy

C/I

A

M1: Cognitive impairment
M2: Tachycardia, constipation
M3: Dry mouth, blurry vision, dizziness

C/I: 
Uncontrolled acute close angle glaucoma 
UC/ Toxic megacolon
MG 
IO
45
Q

Beta-3 agonists for urinary incontinence

Example
MoA
S/E

A

Mirabegron

MoA:
Activate adenyl-cyclase, ATP to cAMP > PKA > lower Ca influx > Smooth muscle relaxation

S/E:
Hypertension, Headache, UTI, Nasopharyngitis
Severe S/S:
CVD, CVA

46
Q

Botox injection for urinary incontinence

MoA
Onset, repeat time

A

Botulinum toxin A injection - Intradetrusor injection

MoA:
Heavy chain binds to SV2 receptor
> endocytosis into presynaptic nerve terminal
> Light chain cleaves SNAP-25 protein on SNARE protein complex
> Stop exocytosis of Ach vesicles into NMJ
> Paralyze detrusor muscle
Block expression of TPRV1 and P2X3 receptors in Type C nerve
> decrease urgency

Onset: 1-2 weeks, repeat every 6-9 months

47
Q

Botox injection for urinary incontinence

S/E
C/I

A 
S/E: 
Urinary retention needing CISC 
UTI 
Haematuria 
Systemic absorption (rare)
C/I: 
Active UTI 
Bleeding diathesis 
MG 
Pregnancy/ breast feeding 
Allergy
48
Q

Sacral neuromodulation for urinary incontinence

MoA
Complications

A

Temporary electrode inserted percutaneously&raquo_space; into S3 sacral foramen with sacral nerve

Modulate local neural reflexes, inhibit bladder contraction

Stimulation shows big toe dorsiflexion, anal wink, cremasteric reflex

Complications:

  • Surgery: Bleeding, infection, pain
  • Implant: Mechanical failure, migration, Battery life (7y), Lower limb weakness
49
Q

Augmentation cystoplasty for urinary incontinence

MoA
Complications

A

MoA:
Open bladder down to urethral orifice, patch defect with bowel segment (distal ileum)
Impair bladder contraction, lower detrusor pressure, increase bladder capacity, decrease strength of contraction

Complications:
Surgical: bleed, infection, leakage, ileus
Long term:
- CISC, mucus perforation, rupture
- Hypercholremic hypokalemic metabolic acidosis
- Malabsorption: fat, Vitamin B12, Bile acid&raquo_space; Calcium oxalate stones, gallstones, anaemia
- Malignancy: Adenocarcinoma

50
Q

Outline specific medical and surgical treatment options for Stress incontinence

A

General:

  • Stop smoking, fluid management, lose weight
  • Use incontinence pad

Medication:

  • Duloxetine: SNRI → ↑5HT/NA activity in Onuf’s nucleus → ↑urethral sphincter activity
  • Estrogen therapy

Surgical:

  • Transurethral injection: bulking agents (eg. silicon, collagen) injected
  • Mid-urethral sling (MUS): tension-free vaginal tape (TVT) in F, trans-obturator tape (TOT) in M
  • Burch coloposuspension: suture lateral vaginal walls to iliopectineal ligaments
  • Artificial urinary sphincter: most effective Tx for M, pump to deflate sphincter
51
Q

Transvaginal tape for stress incontinence

MoA
Complications (intra-op and post-op)
A

Reinforce functional pubourethral ligaments

Secure fixation of midurethra to pubic bone, reinforce suburethral vaginal hammock

Intra-op complications: 
- Bladder, urethral perforation 
- Hematoma, hemorrhage 
- Nerve damage 
Post-op complications:
- Urinary retention
- De novo urgency 
- UTI 
- Tape erosion
52
Q

Gold standard treatment for male stress urinary incontinence

A

Artificial urinary sphincter: pump to deflate sphincter every time before voiding

MBBS IV - Junior Clerkship WCS (131 decks)

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