Lecture 14 - urinary incontinence Flashcards
Lower motor neuron lesion
E.g. cauda equina
- PS affected at S2,3,4
- can’t void
- reduced perianal sensation
- lax anal tone
- Low detrusor pressure as can’t contract
- Large residual urine - overflow incontinence
Upper motor neurone lesion
The PS aren’t inhibited as much
- Detrusor sphincter dyssynergia
- High pressure detrusor contractions
- Poor coordination with sphincters
Detrusor muscle hypertrophy - dilates ureter and kidneys due to back pressure
Stress incontinence
Involuntary leaking on effort or exertion as well as:
- cough
- laugh
- sneezing
Urgency incontinence
Involuntary leaking associated with immediate urgency - can’t hold it in
Mixed urinary incontinence
Involuntary leaking associated with urgency, exertion, effort and sneezing or coughing
Overflow incontinence
Involuntary leaking due to
- lower urinary tract lesion
- chronic retentionq
Most common type of incontinence
Stress incontinence
Risk factors for incontinence
Family predisposition Pregnancy and vaginal delivery Pelvic prolapse Menopause - decreased oestrogen so less anal tone Obesity Age
Examination for incontinence
BMI
Abdominal exam - palpable bladder in chronic retention
Male: DRE
Females:
- external genitalia stress test
- vaginal exam - atrophic after menopause
Investigations for incontinence
Urine dipstick:
- UTI
- haematuria
- proteinuria
- glucosuria
Non invasive urodynamics
- voiding patterns - bladder diary
- frequency - volume chart
- post micturition residual volume
Optional:
- invasive urodynamics - pressure flow studies +/- video
- pad tests
- cystoscopy - if haematuria
Pressure flow studies
Detrusor pressure and function
Residual volume
Abdominal pressure
Bladder pressure
Detrusor pressure
= Total pressure - abdominal pressure
Coughing increases abdominal pressure but destrusor pressure stays the same
Management of incontinence
Modify fluid intake Weight loss Stop smoking Decrease caffeine intake Routine voiding schedule every 4 hours Avoid constipation
Pelvic floor muscle training - 8 contractions 3x a day for atleast 3 months
Failed conservative management
Indwelling catheter
Sheath device
Incontinence pads
Pharmological management
Duloxetine
= combined noradrenaline and serotonin uptake inhibitor
- Increased activity in striated sphincter during filling phase
- Not first line as feel nauseous
Surgery for incontinence
Females:
- sling
- Vaginal tapes
- suspension
Temporary - intramural bulking agents of urethra
Males:
- artificial urinary sphincter - gold standard
- Male sling procedure
Retropubic suspension procedure
Correct anatomical position of proximal urethra and improve urethral support
Bladder training
Void every hour during the day without voiding in between
Intervals increased by 15 - 30 mins per week until 2 -3 hours reached
- At least 6 weeks duration
Anticholinergics
[don’t give to patients with glaucoma]
Acts on m2, m3 muscarinic receptors
- Decreases parasympathetic stimulation
Beta 3 adrenoreceptor agonist
Increases bladder’s capacity to store urine as relaxes smooth muscle of bladder
Botulinum toxin
Intravesicular injection
Inhibits release of Ach at presynaptic neuromuscular junctions - flaccid paralysis
Can causes retention
Enuresis in children
Involuntary bedwetting during sleep at least 2x a week in children above 5 with no CNS defects
Primary enuresis
Never achieved sustained continence at night
Secondary enuresis
Restarted bedwetting having been dry at night for more than 6 months
