Urinary Incontinence

Question 1

Nerve function in urinary continence

Answer 1

CNS inhibits; parasympathetic → pelvic nerve from S2-S4 helps urinate, as does somatic → pudendal nerve.

Question 2

Work up of urinary incontinence

Answer 2

Voiding diary (when are you leaking?)
Do U/A and UCx to r/o infection
Can get urodynamics, PVR, etc.
Standing stress test: stand over towel & cough.

Question 3

Stress incontinence symptoms

Answer 3

Sx on exertion or straining (cough / laugh / exercise)

Question 4

Stress incontinence physical exam findings

Answer 4

Cotton swab test for hypermobile urethra

Question 5

Stress incontinence etiology

Answer 5

Pelvic relaxation & urethral hypermobility, can also be due to intrinsic
sphincter deficiency

Question 6

Stress incontinence treatment

Answer 6

Start with behavior /biofeedback / training / Kegels /pessaries / etc, but may need to go to surgery:
Use sling if hypermobile & intrinsic sphincteric deficiency combined
Use retropubic urethropexy if stress incontinence for hypermobility alone (sling can be obstructive as well - higher rate of retention, voiding dysfunction).
Use urethral bulking if stress incontinence for intrinsic sphincteric deficiency alone

Question 7

Urge incontinence

Answer 7

Involuntary urine loss with sudden urgency whether or not bladder is full; frequency & nocturia

Question 8

Etiology of urge incontinence

Answer 8

Detrusor overactivity
Most is idiopathic; also with CNS injury
Alz dz, stroke, Parkinson’s, MS, diabetes → no central inhibition of detrusor contraction

Question 9

Treatment of urge incontinence

Answer 9

Start tx with bladder training, Kegels, behavior
Med tx: anticholinergics (oxybutynin), smooth muscle relaxants (detrol / tolterodine).
No role for surgery in urge incontinence

Question 10

Mixed urinary incontinence

Answer 10

Mixed symptoms of urge and stress incontinence

Question 11

Mixed urinary incontinence etiology

Answer 11

Both stress & detrusor activity

Question 12

Mixed urinary incontinence treatment

Answer 12

Imipramine (TCA) especially good if mixed incontinence (both anticholinergic & alpha-adrenergic)

Question 13

Overflow incontinence

Answer 13

Frequent / constant dribbling, also stress / urge incontinence.

Question 14

Overflow incontinence etiology

Answer 14

Poor / absent bladder contractions (or more

rarely obstruction) → retention → overflow

Question 15

Overflow incontinence treatment

Answer 15

Reduce urethral closing pressure (prazosin,
terazosin, phenoxybenzamine)
Striated muscle relaxants (diazepam, dantrolene)
Cholinergic agents (bethanecol) to increase contractility
Intermittent self-cathing used too.

Question 16

Bypass incontinence Dx

Answer 16

Dx with indigo carmine instilled into bladder, then tampon.

Can use IVP / cystogram / etc too

Question 17

Bypass incontinence

Answer 17

Urinary fistula after pelvic surgery or radiation, esp TAH

Question 18

Bypass incontinence treatment

Answer 18

Fix fistula (surgery)
Use abx for UTI / estrogen if postmenopausal / etc

Question 19

Functional incontinence

Answer 19

Nursing home, geriatrics, poor mobility

Can’t get to bathroom

Question 20

Functional incontinence treatment

Answer 20

Fix social situation, psych consult, SW, etc.

Question 21

Stress incontinence surgery

Answer 21

Use sling if hypermobile & intrinsic sphincteric deficiency combined
Use retropubic urethropexy if stress incontinence for hypermobility alone (sling can be obstructive as well - higher rate of retention, voiding dysfunction).
Use urethral bulking if stress incontinence for intrinsic sphincteric deficiency alone