Urinary Incontinence

Question 1

Which nerves control storage, voiding, and somatic control respectively?

Answer 1

Storage - hypogastric (Sympathetics)
Voiding - Pelvic (Parasympathetic)
Somatic control - Pudendal

Question 2

What two things must occur for voiding to occur?

Answer 2

Urethral sphincter relaxation (NO)

Bladder contraction via the detrusor muscle contraction (pelvic nerve and ACh)

Question 3

What are some types of incontinence and common causes?

Answer 3

Urge - UTI,
Stress - reduced sphincter function
Overflow - outflow obstruction, detrusor weakness
Continuous - fistula
Functional - impaired cognition, psychiatric

Question 4

What is the DIAPPERS mnemonic for causes of treatable incontinence?

Answer 4

D - Delirium
I - Infection
A - Atrophy urethritis, vaginitis
P - Pharmaceuticals
P - Psychological 
E - Excessive urine output
R - Restricted mobility
S - Stool impaction

Question 5

How do you treat incontinence due to detrusor overactivity?

Answer 5

• Behavioural techniques - bladder training, posture
• Pelvic floor muscle strengthening
• Anti-cholinergics - Oxybutynin on PBS, mirobagron (alpha 3 agonist)
• Intradetrusion botulinum toxin A
• Surgery

Question 6

How do you treat outflow track obstruction?

Answer 6

Treat cause

• Prostate - alpha blockage, 5 alpha reductase inhibitors
• TURP
• Women - gyne repair

Question 7

How do you treat stress incontinence?

Answer 7

Pelvic floor exercises
Electrosimulation and biofeedback
Avoid triggers
Intravaginal devices

Question 8

What are the storage symptoms?

Answer 8

Frequency (>8 during the day), urgency, Nocturia

Question 9

What are the voiding symptoms?

Answer 9

Hesitancy, poor stream, intermittency, straining, drilling

Question 10

What causes stress incontinence?

Answer 10

Sphincter weakness

Question 11

Which part of the CNS controls micturition?

Answer 11

Pons micturition centre

Sacral micturition centre

Question 12

How does caffeine affect the bladder?

Answer 12

Causes detrusor hyperactivity

Coffee also has a diuretic effect

Question 13

Does does diabetes affect continence?

Answer 13

Osmotic diuresis with glucose
Autonomic neuropathy
Glucosuria = increase risk of UTIs

Question 14

How does autonomic neuropathy affect the bladder?

Answer 14

Starts out causing hyperactivity

This is followed by bladder enlargement, then underactivity and acontractility > residual volume

Question 15

What is a normal residual volume? What about in the elderly?

Answer 15

less than 50ml

less than 100ml unless symptomatic

Question 16

How does constipation affect continence?

Answer 16

Stool puts pressure on the bladder

Straining affects the pelvic floor

Question 17

What is constipation?

Answer 17

Infrequent passage of stool

Hardness of stools

Question 18

How do benzodiazepines affect continence?

Answer 18

They reduce arousal and cause people to wake later causing a functional incontinence

Question 19

How does peripheral oedema effect continence?

Answer 19

Nocturnal polyuria as fluid returns to the intravascular space causing polyuria

Question 20

What is the definition of nocturnal polyuria?

Answer 20

1/3 of daily urine output during the night (including first urination in the morning)

Question 21

How do calcium channel blockers relate to continence?

Answer 21

Constipation and urinary retention due to smooth muscle affect
Particularly verapamil

Question 22

What is atrophic vaginitis? Mx?

Answer 22

Age related reduction in vaginal secretions causes excoriation, rash > dysuria, nappy rash

Topical vaginal oestrogen or pessary

Question 23

When don’t you use topical oestrogen?

Answer 23

Recent hx of breast cancer because of slight systemic absorption

Question 24

How do you Mx constipation?

Answer 24

Lifestyle
- 1.5L water
- Fibre 
- Exercise
Pharmacological
- Coloxyl and senna
- Silium 
- Movicol (bulking agent)
- Fibrogel 
- Lactulose

Question 25

How does coloxyl and senna work?

Answer 25

Coloxyl is a softer

Senna is a stimulant

Question 26

How is the mx of bowels in spinal cord patients different?

Answer 26

Coloxyl with every meal
5 Senna at night, alternant days
So a bowel day every second day

Question 27

Which anti-cholinergics are used? What are their SE’s?

Answer 27

Oxybutynin
Solifenacin
Darifenacin

Anti-SLUD, confusion in the elderly

Question 28

Which other medications have anti-cholinergic affects?

Answer 28

Anti-depressants

Anti-psychotics

Question 29

What is Mirobagron? What is the advantage of its use?

Answer 29

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

Question 30

What are second line therapies for detrusor overactivity?

Answer 30

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

Question 31

When is desmopressin used?

Answer 31

In nocturnal polyuria - used mainly in children

Question 32

Which drugs can adversely affect continence?

Answer 32

Opioids - constipation
Diuretics
Ca2+  channel blockers - impaired external sphincter contraction, and constipation
EtOH
Caffeine
SGLT2s
BZD