Nordin: Urge Incontinence and Pelvic Organ Prolapse Flashcards
What is incontinence?
involuntary loss of urine
may affect 30-40% of women
leakage of small amounts of urine when intraabdominal pressure is increased
Stress incontinence
receptors in bladder dome
beta adrenergic
receptors in trigone and urethral smooth muscle
alpha 1
receptors in deep layers of bladder
muscarinic
parasympathetics are involved w/ emptying
internal sphincter
involuntary alpha 1 receptors
smooth muscle
external sphincter
skeletal muscle supplied by pudendal nerve
voluntary control
somatic receptors
urethral sphincter smooth muscle
contains alpha 1 recetpors
how does estrogen affect urethral function?
less vascular/thinned w/ decreased levels
Sympathetics (T10-L2)
STORAGE
IUS- CLOSE
Bladder dome- RELAX
Somatics
alpha motor neurons in ventral horn
EUS- OPEN (voluntary)
Parasympathetics
bladder musculature
EMPTY
How do you empty the bladder?
Cholinergic muscarinic receptor agonists stimulate receptors on the detrusor muscle> contraction
M2/M3
bladder smooth muscle
Salivary glands–dry mouth
Activating M3 receptors
smooth muscle contraction
activating M2 receptors
inhibits bladder relaxation
B2/B3 adrenergic stimulation
relaxation of detrusor muscles
increase urethral resistance
Alpha adrenergic agonists
block urethral contraction
alpha antagonists
What is the mechanism of urine storage?
distension of bladder>
sympathetics>
B3 relax detrusor muscle>
A1 closure of urethral outlet smooth muscle
How can a cough or sneeze make you pee a bit?
Sudden increase in bladder pressure (cough/sneeze)>
activate somatics>
open external urethral sphincter
Somatic micturition reflex
fluid flow in urethra> initiates bladder contraction>
by way of pudendal nerve and sacral spinal cord
spinal vesicovesical micturition reflex
triggered by noxious stimuli>
bladder contraction
What causes reflex urination/incontinence problems?
damage to micturition loops
Meds that affect continence…
- diuretics
- caffeine
- Anticholinergics–> retention/overflow
- alcohol> irritates bladder
leakage of small amounts of urine when intraabdominal pressure is increased (coughing, laughing, exercise)
Stress incontinence
leakage of large amounts of urine occurring shortly after a sudden urge to urinate mediated by bladder muscle contraction
Urge incontinence
Stress incontinence
Muscles that normally keep urethra closed are prevented from squeezing as tightly as they should d/t :
pelvic floor weakness
loss of elasticity
CT/hormones affecting urethral sphincter
Urge
Inappropriate bladder contractions:
PVC of bladder (hypersensitive and always contraction)
anormal nerve signals
blockage of outlet or weak bladder muscle fxn> frequent/constant dribbing
overflow
common in men with prostate enlargement
urination due to inability to get to a bathroom either from mobility issues, obstacles, communication/cognitive problem
Functional
bladder normal but person can’t get to bathroom!
Temporary condition causing incontinence such as medication, infection, illness
DIAPERS delerium infection atrophic vaginitis (lack of estrogen) drugs psychological disorders excessive urine output reduced mobility stool impaction
Cough, laugh, sneeze, lift, exercise >
intrabdominal pressure exceeds urethral closing pressure>
SMALL AMOUNTS
stress urinary incontinence
What are RF for stress urinary incontinence?
age pregnancy childbirth menopause (estrogen) obesity (increased pressure) chronic coughing (increased abdominal pressure, cough, smoking, constipation, occupation w/ lifting) urethral tone
Involuntary leakage preceded by sudden urge to urinate d/t involuntary bladder contractions (Bladder can be full or not)>
Typically leak LARGER amounts of urine than with stress incontinence, but varies
Also called detrusor instability, “overactive bladder”
Urge urinary incontinence
Specific conditions that can cause urge urinary incontinence?
Urinary tract infection
Bladder stones
Bladder cancer
MC cause of urge urinary incontinence
DETRUSOR OVERACTIVITY OR INABILITY TO SUPPRESS DETRUSOR CONTRACTIONS
In pts w/ mixed incontinence, how do you treat them?
rule out most bothersome sx
Weak bladder muscle (detrusor) or outlet obstruction>
overdistension of bladder>
dribbling/stress incontinence
Overflow
What medications may cause overflow incontinence?
anticholinergics
beta agonists
alpha agonists
How do you tx stress incontinence?
Weight loss if obese, fluid reduction, caffeine reduction, smoking cessation (to decrease chronic cough), control of constipation
pelvic floor exercises
occlusive devices (pessaries)
What medications can be used to tx incontinence?
Estrogen (intravaginal for urethra affect)
Duloxetine (more side effects)
Alpha adrenergic drugs (contract urethral sphincter) (rarely used)
*not used as much
What is a common tx for incontinence?
surgery
sling procedure
bulking agent into urethra
How do you tx urge/overactive bladder?
Bladder retraining/scheduled voiding
Fluid restriction
If possible, eliminate medications and agents (caffeine) that patient is taking that may worsen incontinence
Pelvic Floor Muscle Exercises
What is the key tx for urge/overactive bladder?
Anticholinergics
Beta-agonists (mirabegron)
Estrogen (intravaginal, NOT systemic)
Botulinum toxin injections
What is a kegal?
contraction of levator ani muscles
Pessary
holds things up and in place when there isn’t enough support
Thickens periurethral tissue by increasing vascular engorgement
estrogen (vaginal cream or ring)
systemic worsens incontinence
Medications for SUI?
estrogen
Alpha agonists (not really used)
Duloxetine ( could work for those w/ depression)
Meds for urge incontinence?
Anticholinergic agents (nonselective and selective)
Selective have fewer side effects (dry mouth)
Long acting/extended release also have fewer side effects
Caution with use in frail elderly b/c can cause dementia and narrow angle glaucoma, dementia, GI obstruction, urinary retention
M3 selective drug
tolterodine
M2/M3 less selective drug
oxybutynin
Anticholinergics
Competitive antagonist of acetylcholine at muscarinic receptors>
Relaxes bladder smooth muscle (detrusor muscle) (decreases overactivity and contraction)
Mirabegron
beta agonist>
relaxes bladder dome and detrusor
*risk of urinary retention, esp if combined w/ anticholinergics
botulinum toxin
used for urge incontinence
Bladder training
helps pt establish control over bladder may take 1-3 mos to improve
pelvic organ prolapse
Movement of pelvic organs (uterus, bladder) from normal position downward toward or through the vaginal opening
cystocele
bladder through opening
rectocele
bladder through opening
enterocele
intestines coming out
What are sxs of POP?
Many patients asymptomatic!
Bulge symptoms: bulge/protrusion, heaviness or pressure
Urinary symptoms: Incontinence, frequency, urgency, weak stream, incomplete emptying, need to change position to void
Bowel sxs
Sexual sxs
Pain
What are general RF for POP?
age menopause obseity anything that increases intra abdominal pressure (chronic cough, constipation, repeated heavy lifting) Pregnancy previous hysterectomy
What is treatment for POP?
Observation
Pelvic Floor Muscle Exercises
Pessary use (especially in elderly)
Surgery
