Urinary incontinence

Question 1

Define urinary incontinence?

Answer 1

Any involuntary leakage of urine

Question 2

Why is important you ask specifically about incontinence?

Answer 2

Some people will be embarrassed and so hide it.

Question 3

What ratio of women are affected? What ratio of men are affected?

Answer 3

Women: 1:3
Men: 1:10

Question 4

With regard to urethral urinary incontinence, what are the four major causes?

Answer 4

Overflow incontinence
Urge incontinence
Stress incontinence
Mixed incontinence

Question 5

In the storage phase of micturition, intravesicular pressure is less/more than urethral pressure

Answer 5

Less than; urine is therefore retained.

Question 6

Abdominal pressure affects intravesicular pressure - true/false

Answer 6

True - increase intra-abdominal pressure (e.g. cough) and the intravesicular pressure goes up.

Question 7

Detrusor pressure in the storage phase should be approximately __

Answer 7

0

Question 8

Detrusor contracts during the voiding to increase intravesicular pressure and intra-abdominal pressure above the urethral and atmospheric pressure - true/false

Answer 8

False - only affects intravesicular pressure. No effect on intra-abdominal; anterolateral control this and can be consciously contracted but do not contract during the reflex.

Question 9

When intravesicular pressure is higher than atmospheric, what will happen

Answer 9

Urine is much more likely to flow

Question 10

What are the components of the micturition reflex?

Answer 10

Brain
Spinal cord (S2-4)
Bladder/sphincters

Question 11

Describe the micturition reflex

Answer 11

Afferent fibres would sense stretch and relay it to the spinal system and the efferent fibres will stimulate contraction and relaxation of the sphincters.

Question 12

How do we control micturition?

Answer 12

Cortical centre of the brain sends inhibitory signals to override the reflex.

Question 13

What nerves are involved in micturition?

Answer 13

Parasympathetic (pelvic) and pudendal nerves - all from S2-S4

Question 14

What is overflow incontinence?

Answer 14

Bladder outflow obstruction, huge palpable bladder, chronic urine retention. Insensible incontinence with no warning.

Question 15

How is overflow incontinence often noticed?

Answer 15

it is often noticed because of wet beds?

Question 16

urge incontinence is part of _____ syndrome.

Answer 16

Urge syndrome.

Question 17

What is urge incontinence?

Answer 17

Frequent, small voided volumes. Can be provoked by many things e.g. key in door, running water, standing up, coughing, laughing etc.

Question 18

Urge incontinence doesn’t get wet at night - true/false

Answer 18

False - it can

Question 19

Some patients will reach the toilet on time almost everytime with urge incontinence - true/false

Answer 19

True

Question 20

What characterises urge incontinence?

Answer 20

Overactivity of detrusor; contractions while trying to inhibit detrusor either consciously or subconsciously.

Question 21

New onset urge incontinence is a red flag - true/false

Answer 21

true; could be bladder irritation.

Question 22

Give a few causes of urge incontinence

Answer 22

Excess central facilitation brought on by anxiety
paraplegia giving loss of inhibitory control
S2-S4 very vulnerable to spinal injury
Pelvic surgery or fracture cause parasympathetic nerves
idiopathic

Question 23

Stress incontinence is due to anxiety and emotional stress - true/false

Answer 23

false - abdominal pressure stress

Question 24

Define stress incontinence

Answer 24

Incontinence due to increased abdominal pressure without detrusor contraction.

Question 25

What causes stress incontinence?

Answer 25

Damage to pelvic floor or urethra - commonly thanks to childbirth.

Question 26

What is a good test of stress incontinence?

Answer 26

When the patient coughs, do they leak? If yes, they probably have stress incontinence

Question 27

What should make you think that an abdominal mass is a full bladder?

Answer 27

Painless, palpable, midline suprapubic region, arising from the pelvis, you can’t get below it and it is dull to percussion

Question 28

if they are female and appear to have a full bladder, what else should you think?

Answer 28

Pregnancy - ask about missed periods.

Question 29

How should you treat an overflow incontinence?

Answer 29

Assess renal function and relieve the obstruction using a catheter. Rehabilitate bladder and teach them intermittent self-catherisation to help relieve the bladder entirely each time.

Question 30

Why is caffeine important in urge incontinence?

Answer 30

Causes diuresis and makes urge incontinence much worse; (Decaf anyone?)

Question 31

What non-pharmacological treatment can you use for urge incontinence?

Answer 31

teach them to understand the volumes they’re passing and retrain their bladders
Surgery (absolutely the last option!)

Question 32

What pharmacological therapy is there for urge incontinence?

Answer 32

Antimuscarinics (oxybutynin and tolteridine)
Beta-three adrenerics (mirabegron)
Botox (unlicensed but can be used)
Neuromodulation

Question 33

Stress incontinence first line treatment is…

Answer 33

Weight loss
Smoking cessation
Pelvic floor exercises physiotherapy

Question 34

What drug has a slight pharmacological action in stress incontinence?

Answer 34

Duloxetine - Serotonin 5HT inhibitor and noradrenaline reuptake inhibitor.

Question 35

What non-pharmacological treatment might you consider for stress incontinence?

Answer 35

Surgical procedures such as colposuspension - replaced largely by minimally invasive tape procedures

Question 36

Mixed incontinence is treated as ….

Answer 36

A mixture of treatments for stress and urge incontinence

Question 37

Incontinence in the elderly has many factors - true/false

Answer 37

True

Question 38

name some of the factors contributing to incontinence in the elderly

Answer 38

Immobility
Dementia 
Drugs (e.g. diuretics and sedatives) 
Obstruction and overflow
Neuropathy 
Pelvic floor weakness

Question 39

Ectopic ureter is a common cause of incontinence - true/false

Answer 39

False - very rare congenital issue

Question 40

How does ectopic ureter cause incontinence?

Answer 40

Attaches below the bladder to urethra and so causes continuous incontinence.

Question 41

Fistula as a cause of incontinence is very important in what scenario?

Answer 41

Developing countries where access to gynaecology is not readily available. Very uncommon in now in developed countries.