Urinary Incontinence

Question 0

What are some examples of lower urinary tract symptoms?

Answer 0

STORAGE:

• frequency
• urgency
• nocturia (excessive need to urinate at night)
• incontinence

VOIDING:

• slow stream
• splitting/spraying
• intermittency
• hesitancy
• straining
• terminal dribble

POST-MICTURITION:

• post-micturition dribble
• feeling of incomplete emptying

Question 1

Define urinary incontinence. What are the different types of urinary incontinence?

Answer 1

Complaint of any involuntary leakage of urine

Stress urinary incontinence: on effort/exertion or on sneezing/coughing

Urge urinary incontinence: accompanied by or immediately proceeded by urgency

Mixed urinary incontinence: stress + urge urinary incontinence

Overflow urinary incontinence: lower motor neurone lesion causes low detrusor pressure, reduced perianal sensation, and lax anal tone —> large residual urine (which leaks out)

Question 2

What is overactive bladder syndrome? What are some of the risk factors?

Answer 2

Frequent and strong desire to urinate, with or without incontinence, which adversely affects quality of life

Risk factors: 
PREDISPOSING: 
- race
- family presentation 
- anatomical/neurological abnormalities 

PROMOTING:

• co-morbidities
• obesity
• age
• increased intra-abdominal pressure
• cognitive impairment
• UTI
• drugs
• menopause (oestrogen preserves strength and flexibility of bladder/pelvic floor)

OBS&GYNAE:

• pregnancy (increased intra-abdominal pressure) & childbirth (damage to nerve of pelvic floor; possibly due to episiotomy)
• pelvic surgery
• pelvic prolapse

Question 3

What examinations and investigations should be performed for overactive bladder syndrome?

Answer 3

Examinations:

• abdominal exam (to exclude palpable bladder)
• digital rectal exam (prostate)
• external genitalia stress test (ask to cough)
• vaginal exam

Investigations:

• URINE DIPSTICK
• frequency/volume chart (volume ingested & eliminated)
• bladder diary
• post-micturition residual volume
• pressure/flow studies: put transducer in bladder (measures total pressure) & anal canal (measures abdominal pressure) to calculate detrusor pressure (total - abdominal)
• pad tests
• cystoscopy

Question 4

What is the management for overactive bladder syndrome?

Answer 4

LIFESTYLE:

• modify fluid intake
• weight loss
• stop smoking
• reduce caffeine intake
• avoid constipation (causes overflow incontinence via increased abdominal pressure)
• fixed schedule of voiding (when not already used e.g. due to time constraints of working day)

CONTAINED (patients unsuitable for surgery):

• indwelling catheter (urethral or supra-pubic)
• sheath device (adhesive condom + catheter tubing & bag)
• incontinence pads

Question 5

What is the specific management for stress incontinence?

Answer 5

• pelvic floor muscle training (Kegel exercises) = muscles used when ceasing urination voluntarily
• duloxetine (NA & serotonin reuptake inhibitor = increases activity of external urethral sphincter during continence phase)

Female:

• low-tension vaginal tapes (polypropylene mesh which supports mid-urethra)
• retropubic suspension procedures (corrects anatomical position of proximal urethra & improves urethral support)
• classical fascial sling procedures (supports urethra & augments bladder outflow resistance)
• intramural bulking agents (inject substance to improve ability of urethra to resist abdominal pressure)

Male:
- male artificial urinary sphincter (mechanical device; cuff stimulates action of normal sphincter to close urethra)

Question 6

What is the specific management for urge urinary incontinence?

Answer 6

• bladder training (void every hour, slowly increase interval over time)
• anticholinergics e.g. oxybutynin (M2, M3)
• beta-3-adrenoceptor agonist mirabegron (increases storage capacity)
• surgery

Question 7

Why can women become incontinent after giving birth?

Answer 7

Weakened pelvic floor muscles (levator ani muscles) which help make up the urogenital diaphragm - functional external urethral sphincter (sphincter urethrae)

—> pelvic contents fall (bladder neck drops), sphincter stretched, nerves damaged

Increased abdominal pressure e.g. coughing can surpass the control of the external urethral sphincter (stress incontinence)

+ ?damaged pelvic/hypogastric nerve

Question 8

What is the normal capacity of the human bladder? At approximately what volume do we feel the urge to urinate?

Answer 8

Normal capacity = ~350ml-750ml (550ml)

Urge to urinate = ~150ml-200ml