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Urology/Renal > Neuropathic bladder/urinary incontinence > Flashcards

Neuropathic bladder/urinary incontinence Flashcards

1
Q

why are women more likely to have incontinence than men?

A

they have a weak bladder neck mechanism
bladder does not contract very strongly
the urethral sphincter is supported by pelvic floor muscles which are not very strong

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2
Q

why are men more likely to have obstructive causes of LUTS than women?

A

there is both a bladder neck sphincter and a distal urethral sphincter
bladder can contract quite strongly and develop high pressures
urethra is much longer
the distal urethral sphincter is also supported by the pelvic floor
it is the bladder neck mechanism that contributes a lot to obstruction and retention

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3
Q

why is there a bladder neck mechanism in males?

A

to prevent retrograde ejaculation

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4
Q

where does the ejaculatory duct joint the urethra?

A

prostatic urethra

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5
Q

is the bladder neck mechanism in males a urinary sphincter?

A

no it is a gential sphincter to prevent retrograde ejaculation

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6
Q

what does the cortex do in micturition?

A

senses whether the bladder is full

allows voluntary initiation of voiding

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7
Q

what does the PMC/PAG allow you to do?

A

co-ordination of bladder contraction and sphincter relaxation

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8
Q

what are the spinal reflexes of micturition?

A
  • reflex bladder contraction when the bladder is full (but overridden by higher centres) - contrplled by the sacral micturition centre
  • guarding reflex - controlled by Onuf’s nucleus
  • sympathetic - receptive relaxation
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9
Q

from what spinal levels are the sympathetic fibres to the bladder?

A

T10-L2

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10
Q

what does the sympathetic NS do in micturition?

A

inhibits detrusor contraction - ie bladder relaxation

SMOOTH muscle sphincter contraction

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11
Q

what does the parasympathetic NS do in micturition?

A

detrusor contraction

SMOOTH muscle sphincter relaxation

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12
Q

what does the somatic pudendal nerve do?

A

contraction and relaxation of the STRIATED muscle sphincter - you don’t usually use this, but only when you are desperate and trying not to go

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13
Q

what are the storage symptoms of LUTS?

A

frequency
nocturia
incontinence
urgency

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14
Q

what are the voiding symptoms of LUTS?

A 
slow stream
splitting or spraying 
hesitancy 
straining 
terminal dribble 
intermittency
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15
Q

what are the post micturition symptoms?

A

post micturition dribble

feeling of incomplete emptying

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16
Q

what is the definition of frequency?

A

passing water more often

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17
Q

what is the definition of urgency?

A

a sudden, compelling desire to void which is difficult to defer

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18
Q

nocturia definition?

A

going to the toilet 2 or more times per night - nocturia is going to the toilet in the middle of the night with the intention of going back to sleep

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19
Q

incontinence definition?

A

involuntary loss of urine

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20
Q

intermittency definition?

A

urinating in a stop-start fashion

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21
Q

Hesitancy defintion?

A

delay in initiation of micturition

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22
Q

What parameters can you get from a bladder diary?

A
  • 24 hour urine volume
  • volume produced /day
  • volume produced/night - if you know what time they went to sleep and woke up
  • frequency of urination/day
  • frequency of urination/night
  • frequency of incontinence
  • frequency of nocturia
  • nocturnal volume ÷ 24 hour volume
  • functional capacity - the maximum value in the bladder diary that the bladder has held
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23
Q

what is the normal urinary frequency per day?

A

2-8

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24
Q

what is the normal urinary frequency at night?

A

0-1

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25
Q

what is the normal volume per day produced for a 70kg male?

A

2L, should be less than 2.7 L

26
Q

what is the normal volume of urine produced per night?

A

900mL

27
Q

what is the normal nocturnal volume ÷ 24 hour volume?

A

1/3 = 33%

28
Q

what is the functional capacity of the bladder?

A

> 400ml

29
Q

what os the normal incontinence/day?

A

0

30
Q

what is urgency/urge incontinence?

A

incontinence associated with an urgent desire to void which is difficult to defer, usually the result of overactivity of the detrusor muscles

31
Q

what is stress incontinence?

A

occurs when there is an increase in intra-abdominal pressure eg after a cough or sneeze with weak pelvic floor muscles

32
Q

what is mixed incontinence?

A

a combination of both stress and urge incontinence

33
Q

what is continuous incontinence?

A

due to a fistula, eg communication between the badder and the vagina, just keep leaking urine from the vagina

34
Q

what is overflow incontinence?

A

occurs in the presence of a FULL bladder

35
Q

what is social incontinence?

A

occurs in those with dementia

36
Q

How is overactive bladder defined?

A

urgency with frequency, with or without nocturia, when appearing in the absence of local pathology

37
Q

How is detrusor overactivity diagnosed?

A

urodynamics

38
Q

How is an overactive bladder managed?

A 
behavioural therapy 
antimuscarinic drugs 
B3 agonists 
botox 
sacral neuromodulation
surgery
39
Q

what behavioural therapy is offered to those with overactive bladder?

A
  • cut out alcohol and caffeine from diet
  • going to the toilet less often to train the bladder to hold more urine = bladder drill
  • fluid volume chart helps with this
40
Q

how do anti-muscarinic agents work?

A

competitive inhibitors of Ach
this blpocks the parasympathetic NS and causes the detrusor muscle to relax, increasing bladder capacity
the reduces urinary frequency, urgency and urge incontinence in those with OAB
they tend to be specific for the M3 receptor, which is present in the bladder

41
Q

Give examples of anti-muscarinic agents for OAB

A

oxybutynin
tolterodine
solifenacin
they are used as first line pharmacological treatment when bladder training is ineffective

42
Q

Give an example of a beta 3 agonist and explain how it works for OAB

A

mirabegron
beta-3 adrenergic receptor agonist that causes relaxation of the detrusor smooth muscle of the urinary bladder and increases bladder capacity, by increasing sympathetic activity.

43
Q

Hoe does botox work for OA?

A

it is a neurotoxin and blocks the neuromuscular junction for Ach release, so the bladder relaxes

44
Q

what is a common side effect of anti-muscarinic agents?

A

dry mouth (remember secretions are parasympathetic and this drugs are anticholinergics)

45
Q

what is a side effect of botox?

A

paralysis of the bladder requiring catheterisation due to incomplete bladder emptying

46
Q

what is sacral modulation?

A

insertion of an electrode into the S3 nerve root to modulate afferent signals from the bladder to the brain, as these are the signals that cause urgency

47
Q

what is the surgical option for OAB?

A

augmentation cystoplasty

48
Q

what are the causes of stress incontinence in females?

A

• secondary to birth trauma - causes denervation of the pelvic floor and urethral sphincter
weakening of fascial support of bladder and urethra
• neurogenic
• congenital

49
Q

How is stress urinary incontinence managed in women?

A

pelvic floor physio
mainstay is surgery: sling, colposuspension, bulking agents, artificial sphincter
(duloxetine is an SSRI that strengthens the female sphincter)

50
Q

what are the causes stress incontinence in males?

A

neurogenic

iatrogenic eg radical prostatectomy

51
Q

How is stress incontinence in males treated?

A

artificial sphincter or male sling

52
Q

What are the different causes of urinary obstruction that cause voiding problems?

A

BPE -men
urethral stricture
prolapse/mass - mainly in women

53
Q

what is the treatment of voiding symptoms that are not caused by obstruction?

A

it is likely they have detrusor underactivity
so use long-term catheter to empty their bladder
or sacral neuromodulation

54
Q

what is the management of men with BPO with no ED?

A

1st line: alpha antagonist

2nd: 5 alpha reductase inhibitor
specialist: TURP

55
Q

what is the management of men with BPO and ED?

A

1st: PDE5 inhibitor
2nd: alpha agonist
specialist: TURP/ intracavernosal injections/ penile implant

56
Q

What are the treatments from 1st to specialist for men with OAB?

A

1st: antimuscarinic
2nd: b3 agonist/alpha antagonist
specialist: botox

57
Q

what are the treatments for mixed stress and urge incontinence in men?

A

1st antimuscarinic

2nd: B3 agonist
specialist: TURP/botox

58
Q

what are the treatments for women with OAB?

A

1st: antimuscarinic
2nd: B3 agonist
specialist: botox

59
Q

What are the treatments for women who have stress urinary incontinence?

A

1st: physiotherapy
specialist: surgery

60
Q

What is an unsafe bladder?

A

one that puts the kidneys at risk of damage

61
Q

what are the risk factors for an unsafe bladder?

A

raised bladder pressure
vesico-ureteric reflux
chronic infection due to residual urine and stones

62
Q

What are the causes of raised bladder pressure?

A

prolonged detrusor contraction

loss of bladder compliance (eg loss of receptive relaxation due to loss of symp NS)

Urology/Renal (14 decks)

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