Urinary Incontinence

Question 1

What physical changes occur in the urinary tract with ageing?

Answer 1

Shortening of the urethra
Post-menopausal atrophy of the urothelium
Reduced bladder sensation
Reduced detrusor muscle function
Increased residual bladder volume
Less effective urethral closure.

Question 2

What is the prevalence of urinary incontinence?

Answer 2

Up to 20% of women and 10% of men >65yrs.

Question 3

What are some of the social effects of urinary incontinence?

Answer 3

Restriction of social activities
Carer strain
Increased financial strain

Question 4

What are the two main types of urinary incontinence?

Answer 4

Stress incontinence
Urge incontinence

May be mixed urinary incontinence

Question 5

What is meant by stress incontinence?

Answer 5

Occurs when urain leaks as pressure is put on the bladder (during exercise or laughing)
Most common type in younger and middle-aged women

Question 6

What is urge incontinence?

Answer 6

Occurs when people get a sudden need to urinate and cannot make it to the toiler in time
More common in elderly patients who have co-morbidities

Question 7

What are the common causes of stress incontinence?

Answer 7

Due to weakened pelvic floor muscles and/or urinary sphincter
Childbirth and prostate surgery can cause this
Often triggered to relaxed pelvic floor with an increased abdominal pressure

Question 8

What is the common cause of urge incontinence?

Answer 8

Caused by the bladder contracting inappropriately (oversensitivity)
Bladder infection, cancer, stroke or spinal cord injury (other neurological disorders) can cause this
More medical management options that for stress incontinence.

Question 9

What investigations should be done for urinary incontinence?

Answer 9

Urine dip to rule out UTI - signs of UTI should have midstream sample for culture.
Post-void scan to assess quality of bladder emptying
Bladder diaries for a minimum of 3 days
Urodynamic studies

Question 10

What is urodynamic testing?

Answer 10

Any procedure that looks at how well parts of the lower urinary tract (Bladder, sphincters and urethra) work to stroke and release urine.
Often focused on bladder contraction - appropriate timing, strength, retention

Question 11

When might urodynamic testing by recommended?

Answer 11

Leak urine
Go to the bathroom frequently
Feel pain when urinating
Feel a sudden, strong urge to use the bathroom
Have trouble starting to urinate
Have problems emptying your bladder completely
Have repeated urinary tract infections

Question 12

What different investigations are included within urodynamic tests?

Answer 12

Uroflowmetry - volume of and speed that urine comes out of bladder.
Postvoid residual urine - US or cathter to measure urine left after urination
Cystometric test
Leak point pressure measurement - press in bladder when leak occurs
Pressure flow study
Electromyography
Video urodynamic tests.

Question 13

What is a cystometric test?

Answer 13

Measures how much urine bladder can hild, pressure in bladder, and how full bladder is when you feel the need to urinate.
A catheter is used to empty your bladder completely.
Then slowly filled with warm water - patient asked to describe how feel and at what point feel they need to urinate - can record volume of water and pressure in bladder at this point
May also detect pressure rises if bladder contracts when not meant to.

Question 14

What is the function of a pressure flow study for urinary incontinence?

Answer 14

Measures how much pressure your bladder needs to urinate and how quickly urine flows at that pressure.

Question 15

What is a electromyography related to urinary incontinence?

Answer 15

Uses special sensors to measure the electrical activity of the muscles and nerves in and around your bladder and sphincters

Question 16

What is a video urodynamic test for urinary incontinence?

Answer 16

Uses x-rays or ultrasound to take pictures/videos of bladder as it fills and empties
A trained technician may use a catheter to fill bladder with contrast for a better picture.

Question 17

What is the non-surgical management for urinary incontinence?

Answer 17

Lifestyle advice - reduce caffeine, and weight loss.
Pelvic floor muscle training
For urge - oxybutynin (not in older women with high risk of sudden deterioration in mental or physical health), tolterodine (anticholinergic)

Question 18

What is the surgical management for incontinence?

Answer 18

Botox injection (urge)
Colposuspension (for stress)
Autologous rectus fascial sling (stress)
Retropubic mid-urethral mesh sling (stress)

Question 19

When might women with urianry incontinence require referral to a specialist?

Answer 19

Persisting bladder or urethral pain
Palpable bladder on bimanual or abdominal examination after voiding
Clinically benign pelvic massess
Associated faecal incontinence
Suspected neurological disease
Symptom of voiding difficulty
Suspected urogenital fistulae
Previous continencne surgery
Previous pelvic cancer surgery
Previous pelvic radiation therapy.

Question 20

What is meant by Anticholinergic Burden?

Answer 20

A patients cumulative anticholinergic effect from their regular medications.

Question 21

What are some common side effects of anticholinergic medications?

Answer 21

Confusion (increased risk of dementia)
Dry mouth
Hallucinations
Drowsiness

Question 22

What is meant by an autonomic bladder?

Answer 22

Spinal cord injury above the level of the sacrum - loss of conscious control over micrturition
Initially - urine retention requiring a catheter
An alternative micturition reflex is then established locally - this reflex enables emptying but is unconscious
Loss of bladder sensation.

Question 23

What is an atonic bladder?

Answer 23

Spinal cord injury at the level fo the sacrum
Loss of sensory input
Loss of micturition relfex leads to overflow incontinence.

Question 24

What is the guarding reflex of the bladder?

Answer 24

Spinal level reflex, unconscious, low level afferent firing increases pudendal and hypogastric output - helps store urine and prevent micturition at low level bladder fullness.
In adults can be aided by conscious control influencing the pontine storage centre.

Question 25

What is the spinobulbospinal reflex?

Answer 25

The voluntary micrturition reflex
High level firing of afferents makes aware of fullness sensation.
Efferents increase parasympathetic output, decrease sympathetic and pudendal ouput.

Question 26

Describe the basic innervation of the bladder.

Answer 26

NOTE pudendal goes to nicotinic not Muscarininc.

Question 27

What is the basic mechanism of action of oxybutynin/tolterodine?

Answer 27

Class: Anti-muscarinic
MOA: Competitive antagonist for ACh at muscarininc receptors in the bladder wall, leads to relaxation of the smooth muscles of the bladder.
Indications: urinary incontinence, frequency, leaking, nocturnal enuresis, overactive bladder (Urge incontinence)
Contraindications: urinary retention, should be cautions in patients with acute MI, arrhythmias and caridiac insufficiency.