Urinary: Incontinence

Question 1

What is the neurological supply of the bladder?

Answer 1

S234 which some from higher centres

Question 2

What nerves innervate the detrusor and sphincter muscles?

Answer 2

The detrusor muscle is under involuntary control via the parasympathetic NS - supplied by the pelvic nerves (S234)
The external sphincter is under voluntary control via the somatic NS - supplied by the pudendal nerve (S234)

Question 3

What is the maximum capacity of the bladder?

Answer 3

~500ml

Question 4

What is the consequence of a lower motor neurone lesion on the bladder?

Answer 4

The bladder is disconnected from higher centres so the detrusor muscle is always relaxed - therefore there is residual urine left over
The sphincter is always relaxed and there is no sensation of filling

Question 5

What is the consequence of an upper motor neurone lesion on the bladder?

Answer 5

The bladder loses control and is purely under reflex

The detrusor and sphincter are always contracting to urine flows back up the ureters which become dilated

Question 6

What are the 3 classifications of lower urinary tract symptoms?

Answer 6

Storage: frequency, urgency, nocturia, incontinence
Voiding (indicates obstruction): slow stream, straining, splitting, stop and start
Post micturation: feeling of incomplete emptying, post micturation dribble

Question 7

What are the different types of incontinence?

Answer 7

Stress urinary incontinence: involuntary leakage on exertion eg sneezing or coughing (problem with sphincter)
Urge urinary incontinence: leakage accompanied by urgency (sensitive bladder or problem with detrusor)
Mixed urinary incontinence: both stress and urge urinary continence at the same time
Overflow incontinence: the bladder is accepting more urine

Question 8

How prevalent is urinary incontinence?

Answer 8

Most common in men over 70 due to hypertrophic prostate
Stress urinary incontinence most common
Increases with age

Question 9

What are some risk factors for urinary incontinence?

Answer 9

Pregnancy and childbirth, pelvic prolapse, anatomical abnormalities, increased intra abdominal pressure eg obesity, UTI, menopause, drugs, age

Question 10

What examinations would you do?

Answer 10

• BMI
• abdo exam to exclude palpable bladder (rule out urinary retention)
• digital rectal examination in males
• external genitalia stress test for women (ask them to cough)

Question 11

What investigations can you do?

Answer 11

Mandatory: urine dipstick to test for infection, glucose to indicate uncontrolled diabetes, heamaturia and proteinuria
Non invasive: frequency volume chart, bladder diary, USS to measure residual volume
Invasive: pressure flow studies, cystoscopy to look inside bladder if theres any red flags

Question 12

What are some lifestyle modifications that can help manage urinary incontinence?

Answer 12

Modify fluid intake, lose weight, stop smoking, decrease caffeine intake, avoid constipation, retrain bladder

Question 13

What are the management options for pts unsuitable for surgery who have failed medical management?

Answer 13

Urethral or suprapubic catheter
Condom catheter
Incontinence pads

Question 14

What is the initial management of stress urinary incontinence?

Answer 14

Pelvic floor muscle training - 8 contractions 3x daily for 3 months
Usually pts not very compliant but good results if they are

Question 15

What is the pharmacological management of stress urinary incontinence?

Answer 15

Duloxetine - a combined noradrenaline and serotonin uptake inhibitor
Increased activity of the sphincter during the filling phase

Question 16

What are the surgical options for stress urinary incontinence?

Answer 16

Females: most common is vaginal tapes which are a mesh to support the pelvic floor and sphincter, 90% success rate
Males: artificial urinary sphincter which has a closed band around the urethra which is opened by a button in the scrotum. 92% success rate

Question 17

What is the initial management of urgency urinary incontinence?

Answer 17

Bladder training (scheduled voiding)
Void every hour then gradual increase intervals until 2-3 hours can be reached. At least 6 weeks duration

Question 18

What are the pharmacological managements of urgency urinary incontinence?

Answer 18

Anticholinergics that act on M2 and M3 receptors (but have lots of side effects due to M receptors at other sites)
B3 agonists which help bladder to relax more and therefore fill more
Botulinum toxin injected into bladder to paralyse muscles - needs repeating every 3-6 months

Question 19

What are the surgical options for urgency urinary incontinence?

Answer 19

Sacral nerve neuromodulation: alter signals from spinal chord using a probe, very effective
Divert urine from kidneys straight to outside