Urinary Incontinence

Question 1

There are three ways to classify urinary incontinence. What are they?

Answer 1

transient, chronic, and functional UI

Question 2

how is transient UI defined?

Answer 2

it arises suddenly, lasts less than 6 months, and it can be reversed

Question 3

what are the subtypes of chronic UI?

Answer 3

stress UI, urge UI, mixed UI, and overflow UI

Question 4

what is stress UI?

Answer 4

with coughing, sneezing, or physical exertion

Question 5

what is urge UI?

Answer 5

with sudden compelling desire to void

Question 6

what is mixed UI?

Answer 6

coexistence of stress and urgency UI

Question 7

what is overflow UI?

Answer 7

urinary retention from detrusor underactivity or outflow obstruction

Question 8

what is functional UI?

Answer 8

physical or cognitive impairment limits mobility or ability to process information about bladder fullness

Question 9

what are the risk factors for women getting UI?

Answer 9

parity and menopause

Question 10

what are the risk factors for men getting UI?

Answer 10

BPH

Question 11

what plays a role in stress incontinence?

Answer 11

the urethra is more mobile because you lose support of the bladder neck and urethra–> the pelvis floor muscles and ligaments lose strength so there is more motion

Question 12

what should the physical exam look like in a patient with UI? (3 main components of a UI workup)

Answer 12

functional assessment: mental status, mobility, BMI; abdominal exam: assess for masses, palpable bladder, CVA tenderness; urogenital exam

Question 13

what is the cotton swab test?

Answer 13

there should be less than a 30 degree change when the patient cough; if you see more then that is consistent with urethral hypermobility

Question 14

what are the urological tests you would order for a patient with UI?

Answer 14

UA with calorimetric reagent test +microscopy +/- post-void residual volume; voiding diaries; pad testing

Question 15

what makes a pad test positive?

Answer 15

greater than a 4 g increase in weight of the pad after 24 hours

Question 16

when are urodynamic studies valuable?

Answer 16

if incontinence diagnosis is uncertain after initial assessment; if symptoms do not correlate with physical findings; if previous treatment failed; DO NOT DO THIS IN THE INITIAL WORKUP

Question 17

what things does a urodynamic study measure?

Answer 17

the filling volume, the intravesical pressure, the detrusor pressure, the abdominal pressure, and the flow rate

Question 18

what can be said about the bladder function and neurologic control of urination in functional UI?

Answer 18

bladder function or neurologic control of urination are normal in functional UI

Question 19

how can functional UI be addressed/managed?

Answer 19

by providing alternative receptacles (male urinal) or planning to void without waiting for the bladder to be as full

Question 20

there is a mnemonic that helps us remember reversible causes of UI. What is it and what does it stand for?

Answer 20

DIPPERS:
Delirium
Infection (acute UTI)
Pharmaceuticals
Psychological morbidity 
Excess fluid intake/ urine output 
Restricted mobility 
Stool impaction

Question 21

what is important to remember to do during the management of any case of UI?

Answer 21

you need to periodically reconsider the goals and preferences of management

Question 22

what is the recommended conservative management for stress incontinence?

Answer 22

appropriate fluid intake, constipation management, electrical stimulation, mechanical devices, pelvic floor muscle strengthening, smoking cessation, and weight loss

Question 23

what are the pharmacologic ways we treat urge incontinence?

Answer 23

antimuscarinics, intravaginal estrogen, and mirabegron

Question 24

what is the pharmacologic ways we treat overflow UI?

Answer 24

alpha-adrenergic antagonists

Question 25

how would you describe treatment of UI?

Answer 25

a step wise approach- you start with the more conservative management and then escalate to medications and physical devices and then surgical intervention if needed

Question 26

what are some examples of non-surgical devices that can be used to treat UI?

Answer 26

pessaries, external or internal catheters, penile clamps in men

Question 27

when is it appropriate to use vaginal estrogen in cases of UI?

Answer 27

for women with urogenital atrophy and LUTS

Question 28

when are anticholinergic drugs used for UI?

Answer 28

for urge incontinence (they act directly on detrusor muscle to decrease overactive bladder)

Question 29

when are b3-adrenergic agonists used in the treatment of UI?

Answer 29

for urge incontinence- for women with contraindications

Question 30

what drugs are the most commonly used for UI?

Answer 30

anti-muscarinics

Question 31

which class of drugs are preferred for UI due to their fewer adverse effects?

Answer 31

selective M3 antimuscarinics- but they are expensive

Question 32

what is the problem with the anti-muscarinics used for UI?

Answer 32

there are a lot of adverse effects, so for this reason they are not first-line therapy for geriatric patients

Question 33

what are 3 invasive interventions for UI?

Answer 33

stress incontinence surgery, neuromodulation for urge UI, intravesical onabotulinumtoxin A for urge UI (botox)