Urinary Incontinence

Question 1

Define urinary incontinence?

Answer 1

Complaint of any involuntary leakage of urine

It is common and socially stigmatising

Question 2

Types of urinary incontinence?

Answer 2

Urethal:
• Urge incontinence - involuntary leakage accompanied, or immediately preceded, by urgency
• Stress incontinence - involuntary leakage on effort/exertion, sneezing or coughing
• Mixed incontinence - involuntary leakage assoc. with urgency and also with exertion (effort, sneezing, coughing)
• Overflow incontinence

Urine leaking via an extra-urethral route:
• Ectopic ureter
• Fistula

Question 3

Phases of micturition cycle?

Answer 3

Filling (storage) phase

Voiding phase

Question 4

Describe how the filling phase proceeds

Answer 4

Increased intravesical pressure (due to increased volume of urine)

Abdominal pressure remains the same

Urethral pressure increases as the urethral sphincter must remain closed; in order to hold the urine, the detrusor muscle expands (compliant)

Question 5

Define compliance?

Answer 5

Ability of the bladder to keep its pressure unchanged irrespective of bladder volume and afferent stimulation

Question 6

Describe how the voiding phase proceeds

Answer 6

Detrusor muscle contract to void and the urethral sphincter relaxes; as voiding occurs, the intravesical pressure decreases

Abdominal pressure should remain the same (straining or pressing on the abdomen is not normal)

Question 7

Ix for urinary incontinence?

Answer 7

Cystomethogram - urodynamics

Can be used to determine the type of incontinence and, if mixed, which type is most predominant

Question 8

What will the urodynamics Ix show if there is obstruction?

Answer 8

The detrusor pressure will be very high as there is an attempt to compensate

Question 9

Components of micturition reflex (filling phase)?

Answer 9

Filling (storage) phase - sympathetic nervous system is engaged

Allows bladder relaxation and external sphincter to contract (prevents incontinence)

Occurs via the hypogastric nerve (T10-L2)

Question 10

Components of the micturition reflex (voiding phase)?

Answer 10

Voiding phase - parasympathetic nervous system is engaged

Allows bladder contraction and relaxation of the external sphincter (allows micturition)

Occurs via the pudendal nerve (S2, 3, 4)

Question 11

Causes of overflow incontinence?

Answer 11

Usually bladder outflow obstruction, e.g: enlarged prostate

With chronic retention, the bladder fills with more urine and the detrusor stretches so much that it does not work; this increases the intravesiclar pressure as the detrusor has lost its compliance pressure increases at the renal pelvis and this leads to renal dysfunction

Question 12

Symptoms and signs of overflow incontinence?

Answer 12

Huge palpable bladder

Chronic retention

Insensible incontinence

Often they are wet at night (nocturia and enuresis)

Renal impairment

Question 13

Describe urge incontinence

Answer 13

Is part of the urge syndrome, i.e:

Daytime frequency with only small voided volumes

Urgency:
• Provocation - key in the door, sound of running water, standing up, coughing/laughing

Enuresis

Urge urinary incontinence

Question 14

Potential cause of urge incontinence?

Answer 14

May be due to detrusor overactivity incontinence

Bladder dysfunction characterised by involuntary contractions occurring during inhibition of voiding

Question 15

Ix of detrusor overactivity?

Answer 15

Urodynamics - the detrusor contracts when it should not; the rise in detrusor P causing an increase in intravesical P but abdominal pressure remains the same

Question 16

How does afferent over-stimulation occur?

Answer 16

Source of irritation in the bladder, e.g: bladder stone

Paraplegia (loss of central inhibition)

Destruction of S2-3 centre - bladder becomes an inert bag

Pelvic surgery or fracture - parasympathetic nerves damaged

Idiopathic detrusor overactivity

Question 17

Describe (urodynamic) stress incontinence

Answer 17

Urine leaks during increased intra-abdominal pressure, without a detrusor contraction

Due to damage to the pelvic floor or urethral function, e.g: childbirth

They require catheterisation

Question 18

Ix for stress incontinence?

Answer 18

Urodynamics - detrusor pressure is normal;

Question 19

Describe spectrum of overactive bladder

Answer 19

Mixed, OAB wet, OAB dry

Question 20

Symptoms and signs of urinary incontinence?

Answer 20

Painless, palpable mass arising from the pelvis

Cannot “get below it”

Dull to percussion

This is the “full” bladder

Question 21

Treatment of overflow urinary incontinence?

Answer 21

Assess renal function

Catheterise

Treat the obstruction and rehabilitate the bladder

If necessary, teach intermittent self-catheterisation OR insert long-term catheter

Question 22

Treatment of urge urinary incontinence?

Answer 22

Dietary discretion (avoid caffeine)

Biofeedback

Bladder retraining, time bladder emptying

Pharmacotherapy:
• Anti-muscarinics, e.g: oxybutynin, tolterodine
• β3-adrenergics (mirabegron)

Botulinum toxin injection (botox for the bladder)

Neuromodulation (pacemaker for the bladder)

Enterocystoplasty surgery - increases the volume of the bladder

Question 23

Treatment of stress incontinence?

Answer 23

Weight loss and smoking cessation

Pelvic floor exercises (physiotherapy)

Pharmacotherapy (role is not big):
• Duloxetine (serotonin 5-HT) and norepinephrine (NE) reuptake inhibitor

Surgical correction:
• Open procedures - colposuspension
• Tape procedures (minimally invasive)

Question 24

Treatment of mixed incontinence?

Answer 24

Must confirm which type of incontinence is the most dominant

Combination of urge and stress incontinence therapies are used

Question 25

Causes of urinary incontinence in the elderly?

Answer 25

Multifactorial:
• Immobility
• Dementia
• Drugs, e.g: diuretics and sedatives
• Obstruction and overflow
• Neuropathy
• Pelvic flood weakness

Question 26

Describe ectopic ureter

Answer 26

Rare congenital cause of urinary incontinence

Question 27

Describe vesico-vaginal fistula

Answer 27

Can be caused by prolonged obstructed labour, which is common in developing countries

Question 28

Define urgency?

Answer 28

Complaint of a sudden compelling desire to pass urine, which is difficult to defer

Urgency, with/without urge incontinence and usually with frequency and nocturia, can be described as overactive bladder syndrome (AKA urge syndrome, urgency-frequency syndrome)

Question 29

What are voiding symptoms?

Answer 29

Experienced during the voiding phase and inc:
• Slow stream
• Splitting
• Spraying of the urinary stream
• Hesitancy
• Straining

Question 30

What is a frequency volume chart (FVC)?

Answer 30

Records the volumes voided as well as the time of each micturition, day and night, for at least 24 hours, e.g: a bladder diary for 3 days