Urinary Incontinence Flashcards
Is incontinence a natural part of the aging process?
No
Is most incontinence multifactorial or single cause?
Multifactorial
What are the different types of incontinence?
Stress Urge Overflow Mixed Functional Abnormal communications of the urinary tract - fistulae
What is stress incontinence?
Urine leakage when intra abdominal pressure exceeds urethral pressure.
Due to weakened pelvic floor muscles - not supporting urethra
What can cause the leakage in stress incontinence?
Sneezing, coughing, laughing, straining, lifting, exercise
Does stress incontinence usually occur in men or women?
Women
What are some risk factors for stress incontinence?
Pregnancy (vaginal delivery) - damage to pelvic floor muscles and weakening of urethral sphincter Constipation - recurrent strain Obesity Pelvic surgery e.g TURP Conditions that cause chronic cough
After menopause muscles become weaker
What is urge incontinence?
Frequent voiding, often cannot hold urine. Due to overactive bladder as a result of detrusor hyperactivity (can also occur in obstruction).
Nocturnal incontinence is common
What can cause urge incontinence?
Idiopathic Infection Malignancy Neurological - stroke, PD, Alzheimer’s disease, MS, spinal cord injury Bladder outlet obstruction Diabetes Diuretics
What are the symptoms of urge incontinence?
Frequent voiding
The urge to empty the bladder is soon followed by uncontrollable emptying
Can be sudden and without warning
Enuresis (bed wetting)
What is overflow incontinence?
Involuntary release of urine from an over full bladder. Often due to bladder outlet obstruction. Can also be due to detrusor underactivity.
What can cause overflow incontinence?
Prostate enlargement - BPH, malignancy
Kidney and bladder stones
Strictures due to inflammation / infection
Malignancy
Autonomic neuropathy e.g DM, MS
Anticholinergics
Alpha agonists - sphincter contraction
Calcium channel blockers - reduced smooth muscle contraction
What is functional incontinence?
Physical (e.g poor mobility), cognitive or behavioural disability that impairs ability to use toilet
In mixed urinary incontinence, which types are often seen together?
Stress and urge
When taking a continence history, what should be included?
Symptoms - storage, voiding, pain, dysuria, haematuria
Oral intake and types of drinks - caffeine
Bowel habits - type and frequency
PMH - diabetes, neurological conditions
Drug history
Collateral history
Past surgery
Obstetric and gynaecological history in women
What investigations should be done?
Review bladder and bowel diary - frequency and volume chart
Urine dipstick and MSU
Post micturition bladder scan
DRE - prostate and stool
Bloods - FBC, PSA, CRP, U&E (kidney damage), LFT, Alkaline phos (malignancy), HbA1c
Urodynamic studies
What physical examinations should be done?
Abdominal examination - feel and percuss for palpable bladder, palpate for masses or enlarged kidneys, DRE
External genitalia review - atrophic vaginitis in females
Vaginal examination - prolapse
Neurological examination - assess gait, check dorsiflexion of toes (S3) and perianal sensation (L1-2), sensation of sole (S1)
Cognition - AMT for cognitive decline
CVS
In terms of management, what should be addressed first?
Lifestyle factors
- weight loss
- switch to decaf drinks
- smoking cessation (nicotine can irritate bladder and coughing can increase pressure)
- regular toileting
- good bowel habit
- improve oral intake
How should stress incontinence be managed?
Pelvic floor retraining - 8 contractions at least 3 times per day for at least 3 months
Weight loss if appropriate
Duloxetine (urethral contracture) - not likely to be a cure, it can help in making it less of a problem
Surgery - tension free vaginal tape (like a sling to support urethra and bladder neck)
What type of muscle is the detrusor muscle?
Smooth muscle - fibres running in all different directions
Controlled by the autonomic nervous system
Describe the internal urethral sphincter
A thickening of the bladder wall, proximal part of the urethra
Primary function in men: prevent retrograde ejaculation of semen
Is the IUS well developed in men or women?
Men
Describe the external urethral sphincter
It is part of the pelvic floor
Skeletal muscle - under voluntary control, so when you decide to urinate, the EUS actively relaxes
The stretch receptors in the bladder wall are innervated by a sensory neurone that projects into which part of the spinal cord?
S2,3,4 keeps the piss and shit off the floor
Area of micturition and defication
Describe the storage reflex arc
The sensory neurones attached to stretch receptors in the bladder wall ascend up to T10- L2 segment (known to contain sympathetic neurones) synapses with sympathetic preganglionic neurones, which project onto post-ganglionics. These post ganglionics project onto 2 sites - detrusor itself and IUS.
Sympathetics inhibit contraction of detrusor (beta 3 receptor) and stimulate internal sphincter (alpha 1 receptor)
= STORAGE
As volume increasing, pressure not spiking (as muscle stretching)
What supplies the EUS?
Somatic motor fibres that run along the pudendal nerve.
These fibres at S2,3,4 excite skeletal muscle at EUS, causing it to contract (nAChr receptor)
What is the name of the centre within the pons that controls the somatic fibres that close the EUS?
L centre
Is the voiding reflex primarily mediated by the sympathetic or parasympathetic system?
Parasympathetic
Describe the voiding reflex arc
The sensory neuron attached to stretch receptors enters into the spinal chord at S2,3,4 where it synapses with parasympathetic neurones.
The parasympathetic neurones project to the bladder and synapse in the bladder wall with a short post- ganglionic neuron. The effect = excitation of detrusor.
Receptor = M3
Under high levels of bladder stretch, a sensory neuron activates which area in the pons?
M centre - projects down onto parasympathetics to EXCITE them = a positive feedback loop
When the M centre is activated what is inhibited?
The L centre and sympathetics
How should urge incontinence be managed?
Lifestyle factors
Bladder retraining - minimum 6 weeks
Bladder stabilising drugs:
- antimuscarinics first line e.g oxybutynin or tolterodine
- beta 3 agonist e.g mirabegron (may be useful if concerns about anticholinergic side effects in elderly)
Botox of the bladder neck
What drug could be taken to prevent nocturia?
Loop diuretics mid afternoon
How do antimuscarinic drugs work on the bladder?
Prevent contraction
What are some antimuscarinic side effects?
Blind as a bad Dry as a bone - dry mucous membranes Red as a beet - vasodilation Mad as a hatter - delirium, confusion Full as a flask - retention and constipation Hot as a hare - lack of sweating
Also dizziness
FALLS risk in elderly
What medication is used to treat BPH?
Alpha blockers - relax prostatic smooth muscle e.g Tamsulosin, doxazocin
5 alpha reductase inhibitors - stops conversion of testosterone to more potent form (to promote cell division) e.g Finesteride (can take 6 months for symptom benefit)
What is an important side effect of alpha blockers in the elderly?
Postural hypotension
What is the most common cause of urinary incontinence in the elderly?
Infection
What are some storage symptoms?
Frequency
Urgency
Nocturia
What are some voiding symptoms?
Post micturition dribble Hesitancy Intermittent stream Terminal dribble Feeling of incomplete emptying
(Bladder outlet obstruction usually)
Is duloxetine recommended for stress incontinence as first or second line management?
No
Could be as alternative to surgery but inform about side effects
How is urge incontinence managed?
Lifestyle - reduce fluid intake especially in evening, reduce caffeine and alcohol, weight reduction, manage constipation
Medical - antimuscarinics that act on M3 receptor (use with caution in elderly) e.g oxybutynin, tolteridone, darifenacin, trospium, solifenacin, propiverine. The first 3 are NICE recommended first line agents
Oxybutynin not in older adults with frailty or PD
If contraindicated or intolerable side effects: beta 3 adrenoreceptor agonists (mirabegron)
Intravaginal oestrogens - NICE recommends their use for women who have vaginal atrophy and symptoms of overactive bladder
