Urinary Incontinence Flashcards
What is urinary incontinence
The complaint of any involuntary leakage of urine
What are the 4 different types of urinary incontinence
Overflow
Urge
Stress
Mixed
In what 2 ways could urine leak by an extraurethral route
Ectopic ureter
Fistula
In normal physiology, describe the difference in pressure between the intravesical pressure and the urethral pressure during the storage phase
The intravesical pressure is less than the urethral pressure so urine stays in the bladder during the storage phase
In normal physiology, describe the difference in pressure between the intravesical pressure and the urethral pressure during the voiding phase
Increased intravesical pressure exceeds the urethral pressure allowing flow to occur
Why do we not use urodynamics unless we absolutely have to
Invasive test
What does urodynamics allow us to do
Understand the changing pressures around the bladder
What do we ask the patient to do during urodynamics
Cough 3 times with increasing pressure levels
Why do we get the patient to cough in urodynamics
To increase the abdominal pressure
What are the 4 main components of the micturition reflex
Brain
S2,S3
Spinal Bladder Centre
Bladder and Sphincters
Why do reflexes happen without you thinking about them
Because the afferent fibre in the spinal cord is allowed to fire off the reflex
What happens in the spinal reflex arc in terms of over riding the micturition reflex
There is an inhibitory signal that goes to down to the reflex centre and switches off the reflex
What is the underlying cause of overflow incontinence
An overflowing bladder due to an obstruction
Describe some symptoms and signs of a patient with overflow incontinence
Huge palpable bladder
Chronic retention
Insensible incontinence
Often wet at night
What is urge incontinence part of
Urge syndrome
Describe the signs and symptoms of urge syndrome
Frequency Small voided volumes Urgency Provocation e.g. key in the door, sound of running water, standing up, coughing, laughing Enuresis Urge urinary incontinence
How is detrusor overactivity diagnosed
by urodynamics
What happens to the detrusor muscle that causes bladder dysfunction
It contracts during inhibition of voiding
Describe the findings of detrusor overactivity on urodynamics
The bladder will not fill as much as a normal patient before getting an urge.
When the patient coughs, on coughing, (i.e. increasing the intra-abdominal pressure) the intravesical pressure will increase and remain at a higher pressure compared to a normal person on the final cough
Some patients cannot hold on and will leak urine
Involuntary contraction of the detrusor muscle
What might be the underlying problem for patients with urge incontinence
Irrotation in the bladder
(Irritation in the sensory organ of the reflex arc)
such as bladder stone, bladder tumour or an excess stimulation of the afferent arc of the reflex
What is meant by paraplegia and how does this affect the bladder
Loss of central inhibition e.g. spinal injury
The bladder will fill and kick off and empty itself in paraplegia
Where is the commonest site of a spinal injury
Down at the lumbar level - i.e. close to S2,S3
What happens if there is destruction of S2-3 centre
Bladder becomes an inert bag
How does the detrusor muscle become an inert bag when there is a spinal cord injury
The reflex is turned off and so no muscle activity occurs. Therefore the bladder fills up and flows freely
What population may be affected by idiopathic detrusor overactivity
Middle aged women
What are the symptoms of idiopathic detrusor overactivity
Frequency and urgent incontinence
What happens in stress incontinence
urine leaks during increased intra-abdominal pressure without a detrusor contraction
Cough, sneeze etc.
What often causes stress incontinence
Damage to pelvic floor or urethral function - childbirth
How is a diagnosis of stress incontinence made
Urodynamics
Describe what is seen in urodynamics in stress incontinence
As the bladder volume increases, leakages become bigger
Destrusor has normal activity
Cough causes a leak without a detrusor contraction
Why do patients with stress incontinence go to the toilet more frequently
They know that they will get less leakage if they void more often
On examination, how can we tell that we are examining the bladder
It is a painless palpable mass that arises from the bladder
We cannot “get below” it
Dull to percuss
What is the treatment for overflow urinary retention
Catheterise the patient and then try to rehabilitate the bladder
Some patients will self catheterise
What happens to the bladder in overflow urinary incontinence
It is chronically stretched leaving a bigger and bigger residual flow every time they go tot eh toilet
What is some advice you can give a patient with urge urinary incontinence
Dietary discretion (avoid caffeine) Bladder retraining - time bladder emptying
What drugs can be given for urge urinary incontinence
Antimuscarinics e.g. oxybutynin, tolterodine
Beta 3 adrenergic e.g. mirabegron
What surgical procedure can be done for urge urinary incontinence
Enterocystoplasty
Open up the bladder and add a patch of bowel to it - this drastically helps the incontinence
What is a side effect of an antimuscarinic
Makes the mouth dry - patients want to drink more - more urine output
What are the conservative management options for stress incontinence
Weight loss
stop smoking
pelvic floor exercises (physio)
What drug can be used occasionally for stress incontinence
Duloxetine
What surgical procedures can be performed for stress incontinence
Open procedure - colposuspension but now more often it is the minimally invasive “tape” procedure
What is meant by mixed incontinence
A combination of urge and stress therapies
What is the treatment for mixed incontinence
Lose weight
stop smoking
less caffeine
Surgery
What factors can result in urinary incontinence in the elderly
Immobility Dementia Drugs - diuretics, sedatives obstruction (prostate benign hyperplasia) and overflow neuropathy pelvic floor weakness
In what other ways may urine be lost from the bladder
Ectopic ureter
Fistula
How does an ectopic ureter arise and how does it cause incontinence
It is congenital
It bypasses the sphincter meaning that urine can flow freely
Why is a vesico-vaginal fistula more common in developing countries
Prolonged obstructed labour causing holes in the bladder
What is the definition of urgency
The complaint of a sudden compelling desire to pass urine which is difficult to deter
What are some voiding symptoms that a patient may complain of
Slow stram splitting spraying of the urinary stream hesitancy straining
What does a frequency volume chart (FVC) do
record the volumes voided as well as the time of each micturition, day and night for at least 24 hours
