Urinary Incontinence

Question 1

What are the three types of incontinence?

Answer 1

Overflow incontinence
Stress incontinence
Urge incontinence- Also overactive bladder

Question 2

What are the features of overflow incontinence?

Answer 2

Occurs when there is urinary outlflow obstruction which causes urinary retention. Increasing volumes in the bladder cause triggering of the stretch reflex which results in voiding.

Question 3

What cause overflow incontinence?

Answer 3

Bladder outflow obstruction

E.g. BPH, Strictures, Malignancy, Prostate cancer

Question 4

What are the features of stress incontinence?

Answer 4

Stress incontinence is when there is urination when there are increases in intra-abdominal pressure such as with coughing or laughing. This occurs due to incompetent sphincter and pelvic floor weakness

Question 5

When is stress incontinence common?

Answer 5

After childbirth due to disruption of the pelvic floor musculature
Also occurs with increasing age and obesity

Question 6

What are the features of urge incontinence?

Answer 6

Urge to urinate is quickly followed by uncontrollable and sometimes complete bladder emptying. Due to detrusor overactivity- also called overactive bladder.

Question 7

What causes urge incontinence?

Answer 7

Issues with central pathways or peripheral afferents
Infection
Diabetes

Question 8

What investigations should be done for urinary incontinence?

Answer 8

Depends upon the cause

Patient Assessment
IPSS in men
QoL Assessment in women

Examination
Palpate/Percuss Bladder
DRE in men
Sensation in saddle area
Check anal tone
Vaginal examination- Check pelvic floor contraction
Neurological examination- MS

Urine-
Dipstick
MSU
Urodynamic studies
Post micturition volume assessment (via bladder scan or catheter)
Bladder diary- record fluid intake and urine output

Blood-
FBC, Infective markers
PSA in men (BPH can cause prostatic hypertrophy)

Question 9

What lifestyle changes can you recommend to patients with urge and stress incontinence?

Answer 9

Decrease alcohol and caffeine intake

Lose weight if appropriate

Question 10

What conservative methods may be used to manage urge and stress incontinence?

Answer 10

Less caffeine and alcohol, weight loss

Pelvic floor training
Behavioural therapies
Pads
Bladder retraining

Question 11

What medical options may be used in the treatment of urge incontinence?

Answer 11

Antimuscarinics e.g. Oxybutynin, Tolterodine
Beta 3 Agonist- Mirabegron (If antimuscarinics not suitable or not working)
Desmopressin- for nocturia, it is an ADH analogue

Question 12

Give an example of a beta 3 agonist?

Answer 12

Mirabegron

Question 13

Give an example of antimuscarinic used in the management of urge incontinence?

Answer 13

Oxybutynin
Tolterodine

Note- Immediate release oxybutynin should be avoided in frail older women

Question 14

What invasive procedures might be used in the management of urge incontinence?

Answer 14

Botox injection into bladder wall- if not responded to pharmacological treatment. Must be able to perform intermittent self catheterisation.

Percutaneous posterior tibial nerve stimulation- if botox injections not wanted or self catheterisation not possible

Question 15

What surgical procedures may be considered for the management of urge incontinence?

Answer 15

Synthetic tapes to support the urethra to increase resistance to flow
Bulking agents around the urethra,

Question 16

What is the treatment for overflow incontinence?

Answer 16

Relieve the cause of the obstruction

Question 17

What is the gold standard investigation for urinary incontinence?

Answer 17

Urodynamic studies

Question 18

What antidepressant drug may be used to treat stress incontinence in women?

Answer 18

Duloxetine