Urinary Incontinence Flashcards
Which nerves control storage, voiding, and somatic control respectively?
Storage - hypogastric (Sympathetics)
Voiding - Pelvic (Parasympathetic)
Somatic control - Pudendal
What two things must occur for voiding to occur?
Urethral sphincter relaxation (NO)
Bladder contraction via the detrusor muscle contraction (pelvic nerve and ACh)
What are some types of incontinence and common causes?
Urge - UTI,
Stress - reduced sphincter function
Overflow - outflow obstruction, detrusor weakness
Continuous - fistula
Functional - impaired cognition, psychiatric
What is the DIAPPERS mnemonic for causes of treatable incontinence?
D - Delirium I - Infection A - Atrophy urethritis, vaginitis P - Pharmaceuticals P - Psychological E - Excessive urine output R - Restricted mobility S - Stool impaction
How do you treat incontinence due to detrusor overactivity?
- Behavioural techniques - bladder training, posture
- Pelvic floor muscle strengthening
- Anti-cholinergics - Oxybutynin on PBS, mirobagron (alpha 3 agonist)
- Intradetrusion botulinum toxin A
- Surgery
How do you treat outflow track obstruction?
Treat cause
- Prostate - alpha blockage, 5 alpha reductase inhibitors
- TURP
- Women - gyne repair
How do you treat stress incontinence?
Pelvic floor exercises
Electrosimulation and biofeedback
Avoid triggers
Intravaginal devices
What are the storage symptoms?
Frequency (>8 during the day), urgency, Nocturia
What are the voiding symptoms?
Hesitancy, poor stream, intermittency, straining, drilling
What causes stress incontinence?
Sphincter weakness
Which part of the CNS controls micturition?
Pons micturition centre
Sacral micturition centre
How does caffeine affect the bladder?
Causes detrusor hyperactivity
Coffee also has a diuretic effect
Does does diabetes affect continence?
Osmotic diuresis with glucose
Autonomic neuropathy
Glucosuria = increase risk of UTIs
How does autonomic neuropathy affect the bladder?
Starts out causing hyperactivity
This is followed by bladder enlargement, then underactivity and acontractility > residual volume
What is a normal residual volume? What about in the elderly?
less than 50ml
less than 100ml unless symptomatic
How does constipation affect continence?
Stool puts pressure on the bladder
Straining affects the pelvic floor
What is constipation?
Infrequent passage of stool
Hardness of stools
How do benzodiazepines affect continence?
They reduce arousal and cause people to wake later causing a functional incontinence
How does peripheral oedema effect continence?
Nocturnal polyuria as fluid returns to the intravascular space causing polyuria
What is the definition of nocturnal polyuria?
1/3 of daily urine output during the night (including first urination in the morning)
How do calcium channel blockers relate to continence?
Constipation and urinary retention due to smooth muscle affect
Particularly verapamil
What is atrophic vaginitis? Mx?
Age related reduction in vaginal secretions causes excoriation, rash > dysuria, nappy rash
Topical vaginal oestrogen or pessary
When don’t you use topical oestrogen?
Recent hx of breast cancer because of slight systemic absorption
How do you Mx constipation?
Lifestyle - 1.5L water - Fibre - Exercise Pharmacological - Coloxyl and senna - Silium - Movicol (bulking agent) - Fibrogel - Lactulose
How does coloxyl and senna work?
Coloxyl is a softer
Senna is a stimulant
How is the mx of bowels in spinal cord patients different?
Coloxyl with every meal
5 Senna at night, alternant days
So a bowel day every second day
Which anti-cholinergics are used? What are their SE’s?
Oxybutynin
Solifenacin
Darifenacin
Anti-SLUD, confusion in the elderly
Which other medications have anti-cholinergic affects?
Anti-depressants
Anti-psychotics
What is Mirobagron? What is the advantage of its use?
B3 agonist - synergic with the sympathetic action to help storage
Little SEs except increase bioavailability of metoprolol and dig
Increases metoprolol and digoxin levels when used
What are second line therapies for detrusor overactivity?
Intradetrusor botox - paralyses bladder to reduce bladder pressures
100units to reduce urgency but maintaining voiding capacity
200unit for total acontractility therefore requiring self-catheterisation
Wears off after 8-9months
+/- Self-catheterisation
When is desmopressin used?
In nocturnal polyuria - used mainly in children
Which drugs can adversely affect continence?
Opioids - constipation Diuretics Ca2+ channel blockers - impaired external sphincter contraction, and constipation EtOH Caffeine SGLT2s BZD
