Urinary Incontinence

Question 1

Sympathetic nerve supply to bladder

Answer 1

-hypogastric nerve -T12-L2 -storage

Question 2

Parasympathetic nerve supply to bladder

Answer 2

-pelvic nerve -S2-S4 -voiding

Question 3

Somatic nerve supply to bladder

Answer 3

-pudendal nerve -S2-S4 -voluntary

Question 4

Bladder filling

Answer 4

-Accommodate increasing volume at constantly low pressure -Inhibition of contractions by giving rise to gradual awareness of filling

Question 5

Cortical activity during bladder filling

Answer 5

-Activating a reciprocal guarding reflex by Rhabdosphincter contraction; increase sphincter contraction & resistance -Activates Sympathetic pathway -Reciprocal inhibition of the Parasympathetic pathway -Mediates contraction of bladder base and proximal urethra

Question 6

Bladder Emptying

Answer 6

-Detrusor contraction -Urethral Relaxation -Sphincter co-ordination -Absence of Obstruction or anatomical shunts (Cystocele, Diverticulum)

Question 7

Cortical activity during bladder emptying

Answer 7

Cortical Influence (Pontine micturition centre) - Activation of parasympathetic pathway and Inhibition of Sympathetic pathway

Question 8

Urinary incontinence (UI)

Answer 8

Any involuntary leakage of urine.

Question 9

Stress urinary incontinence (SUI)

Answer 9

Involuntary leakage on effort or exertion, on sneezing or coughing.

Question 10

Urge urninary incontinence (UUI)

Answer 10

Involuntary leakage accompanied by or immediately preceded by urgency.

Question 11

Impact or uirinary incontinence

Answer 11

-UI may significantly impair the QoL -Reduce social relationships and activities -Impair emotional and psychological well- being -Impair sexual relationships -Embarrassment and diminished self- esteem

Question 12

Risk factors for unrinary incontinence

Answer 12

-pregnancy and childbirth -pelvic floor trauma -increasing age -menopause -smoking -denervation -connective tissue disorder -increased intra-abdominal pressure -surgery

Question 13

Patient assessment history

Answer 13

-age -parity -mode of deliveries -weight of heaviest baby -Smoking -HRT -Previous PFMT, Surgical treatment of SUI or POP

Question 14

Patient assessment - irritation symtoms

Answer 14

-Urgency ; Sudden compelling desire to void that is difficult to defer -Increased daytime frequency (>7) -Nocturia (>1) -Dysuria -Haematuria

Question 15

Patient assessment - incontinence symtoms

Answer 15

-Stress UI -Urgency UI -Coital Incontinence -Severity: How many pads/ day?

Question 16

Patient assessment - voiding symptoms

Answer 16

-Straining to void -Interrupted flow -Recurrent UTI

Question 17

Prolapse Symptoms

Answer 17

-Vaginal Lump/ Dragging sensation in vagina

Question 18

Bowel symptoms

Answer 18

-Faecal Incontinence -Constipation -Faecal evacuation dysfunction -IBS

Question 19

Patient assessment - tracking and tests

Answer 19

-3 days Urinary Diary : -Fluid intake: Quantity & Quality -Urine Out-Put (exclude Nocturnal Polyuria) -Daytime Frequency -Nocturia -Average voided volume -Urine dipstick

Question 20

Examination of the women with bladder/ pelvic floor problems

Answer 20

-Prolapse -Stress incontinence -Uro-genital atrophy changes -Pelvic mass (space occupying leasion) -Pelvic floor tone, strength, awareness

Question 21

Investigations for SUI

Answer 21

-Urinalysis: Multistix +/- MSSU -Post voiding residual volume assessment (usually by bladder scanning) only If symptoms of voiding difficulties -Urodynamics: ONLY indicated if surgical treatment is contemplated

Question 22

Management options for SUI

Answer 22

-Lifestyle changes -Medical treatments -Physiotherapy -Surgery

Question 23

Lifestyle changes for SUI

Answer 23

-Stop smoking -Lose weight -Eat more healthily to avoid constipation -Stop drinking alcohol and caffeine

Question 24

Pelvic floor muscle training

Answer 24

-reinforcement of cortical awareness of muscle groups -hypertrophy of existing muscle fibres -general increase in muscle tone and strength

Question 25

Pharmacological management of stress urinary incontinence

Answer 25

-Duloxetine - for moderate t severe stress urinary incontinence

Question 26

Who should receive duloxetine?

Answer 26

Primary care: -if PfMT has failed or would be enhanced by the prescribing of Duloxetine Secondary care: -does not wish surgery -not fit for surgery -after failed surgery -when the patient’s family is not complete

Question 27

Surgical treatment of SUI

Answer 27

-Retro-pubic TVT (tension free vaginal tape) -80% cure rate at 8 years

Question 28

Urgency

Answer 28

The complaint of a sudden, compelling desire to pass urine that is difficult to defer.

Question 29

Risk Factors for Urge Incontinence

Answer 29

-Advanced age -Diabetes -Urinary tract infections -Smoking

Question 30

Overactive Bladder Syndrome (OAB)

Answer 30

A symptom complex usually, but not always, related to urodynamically demonstrable detrusor overactivity (DO)

Question 31

Defining symptoms of overactive bladder syndrome

Answer 31

-urgency (with/without urgency incontinence) -usually with frequency and nocturia

Question 32

Non-pharmacological OAB interventions

Answer 32

-Life style interventions: -Normalise fluid intake -Reduce caffeine, Fizzy drinks, Chocolate -Stop Smoking -Weight loss -Bladder training programme: Timed voiding with gradually increasing intervals - Continence nurse

Question 33

Pharmacological treatment of OAB

Answer 33

-antimuscarinic -oral -transdermal -Tri-cyclic antidepressants -Imipramine

Question 34

Recent advancements in treatment of OAB

Answer 34

-Botox -Botulinum Toxin -cystoscopy/GA -effects last for 6-9 months -Neuromodulation -Needle stimulation (S2-4) -Reflex Inhibition to the Detrusor muscle -Cheap -Minimally invasive -70% improvement in Refractory OAB