Urinary incontinence

Question 1

When to screen for urinary incontinence?

Answer 1

females >65 yrs old

Question 2

what to ask about in urinary incontinence?

Answer 2

duration, severity, triggering factors (cough, sneezing) associations (frequency, urgency, dysuria), obstetric or gyencological hx, Lifestyle (ETOH use) and medications.

Question 3

Transient incontinence

Answer 3

reversible

Question 4

cause of urge incontinence

Answer 4

detrusor muscle hyperactivity or overactive bladder

can see nocturia secondary to increased detrusor contractility during bladder filling and RF are older age, neurological injury and chronic bacteriuria.

see sudden overwhelming urge to urinate

Question 5

see sudden overwhelming urge to urinate

Answer 5

urge incontinence

Question 6

stress incontinence cause

Answer 6

decreased urethral sphincter tone and urethral hypermotility

leaking with coughing, laughing, sneezing, lifting

Question 7

overflow incontinence cause

Answer 7

impaired detrusor contractility or bladder outlet obstruction

incomplete emptying or persistent involuntary dribbling

Question 8

incomplete emptying or persistent involuntary dribbling

Answer 8

overflow incontinence

Question 9

why is there detrusor hyperactivity

Answer 9

not always sure but sometimes can be due to neurological disorders or UTI’s

Question 10

initial management of urge incontinence

Answer 10

behavioral modification - bladder training and fluid mangement strategies

Question 11

if conservative measures don’t work for urge incontinence can try

Answer 11

alpha adrenergic antagonist (terazosin and tamulosin)
persistent symptoms can try antimuscarinic agents (tolterodine or oxybutynin)

0 low dose antimuscarinic drugs are safe and effective in men with underlying BPH

Question 12

what should be measured prior to starting antimuscarinic agents for treatment of urge incontinence?

Answer 12

a post void residual. If there’s any volume PVR>200 ml there should be avoided as this can cause urinary retention

Question 13

side effects of antimuscarinics in older men who have urge incontinence?

Answer 13

dizziness, dry mouth and constipation

Question 14

when do we do urodynamic studies?

Answer 14

helps provide information on bladder sensation, capacity, detrusor activity, and outlet obstruction and urine flow

only used for people with unclear or multifactorial etiology

Question 15

what is the long term surgical treatment for urinary urge incontinence?

Answer 15

sacral nerve stimulation via surgical lead placement - only used for people who have failed combined therapy.

Question 16

non pharmacological tx for urinary incontinence:

Answer 16

weight loss (in over weight pts)
dietary changes (decreased alcohol, fluid and caffeine intake - all bladder irritants)
smoking cessation
stopping offending medications (diuretics)

Question 17

behavioral therapy for urinary continence

Answer 17

bladder training (best for urge and mixed incontinence)
timed voiding
voiding diary
relaxation techniques
Pelvic floor (kegel exercises (for urge, stress, mixed incontinence)

Question 18

how to treat urge incontinence if conservative therapy (behavioral and lifestyle changes) don’t help?

Answer 18

trial antimuscarinics: oxybutynin and tolterodine. or beta 3 agonists (mirabegron)

Question 19

stress incontinence is from

Answer 19

increased intrabdominal pressure with Valsalva maneuver (coughing sneezing, laughing)

Question 20

how to diagnose with stress incontinence

Answer 20

positive cough test.

Question 21

if conservative measures don’t work with stress incontinence what is done?

Answer 21

a mid urethral sling placement is done to help with peeing.

Question 22

TCA antidepressant like amitriptyline can cause urinary incontinence how?

Answer 22

it’s a antimuscarinic medication causing urinary retention and dry mouth and constipation and antihistamine (sedation) and alpha anti adrenergic - causing hypotension and tachycardia.

This can cause overflow incontinence with constant drippling

Question 23

lower abdominal mass, continuous urinary leakage and will have elevated post void residual.

Answer 23

overflow incontinence from either detrusor underactivity (TCAs) or bladder outlet obstruction (prolapse)

Question 24

treatment of overflow incontinence is based on:

Answer 24

addressing underlying cuase: medication change, lifestyle modifications, correction of prolapse and intermittent bladder catherization

Question 25

what is interstitial cystitis?

Answer 25

increased bladder pain with filling and relief with voiding
see suprapubic tenderness (painful bladder) not enlarged bladder
no incontinence associated with thus

Question 26

urethral diverticulum (literally an outpouching in urethra) is seen

Answer 26

as a dilated urethral sac that protrudes into the anterior vagina resulting in tender palpable vaginal mass that causes dysuria and dyspareunia

see post void dripping rather than continuous dripping seen with overflow incontinence

Question 27

what causes a vesicovaginal fistula?

are are the physical exam findings for this ?

Answer 27

its’ a tract between bladder and vagina.

Occurs after pelvic surgery (hysterectomy) radiation or obstetrical complications.
See continuous urinary leakage as bladder continuously empties through vaginal vault.

will have normal post void residual volume

additionally would see urine pooling in vaginal vault.

Question 28

Treatment of overflow incontinence

Answer 28

identification and correcitn of underlying cause
cholinergic agonists
intermittent self catherization

chronic urinary retention creases risk for UTI and renal damage and so need intermittent self catherization.

Question 29

tolterodine is a

Answer 29

antimuscarinic that inhibits bladder contractions and used to treat urgency incontinence

Question 30

in MEN who have urgency and urinary incontinence that is not controlled by behavioral therapy may benefit from

Answer 30

mirabegron or anticholingerics (darifenacin, fesoterodine, oxybutynin)

These meds reduce involuntary bladder contractions by blocking the muscarininc cholinergic receptors

ok for men and women but be cautious with men who have BPH