Urinary Incontinence

Question 1

Continence in women is maintained in the urethra by…

Answer 1

The external sphincter and pelvic floor muscles maintaining urethral pressure higher than bladder pressure

Question 2

What is incontinence?

Answer 2

Involuntary leakage of urine

Question 3

Incontinence is divided into what different types?

Answer 3

Urge
Stress
Mixed

Question 4

Continuous urinary leakage is associated most commonly with…

Answer 4

A vesicovaginal fistula or congenital abnormality e.g ectopic ureter

Question 5

What should be asked when taking a history?

Answer 5

Daytime voids (normal = 4-7)
Nocturia (up to 70y/o > 1 night time voiding is abnormal)
Nocturnal enuresis
Urgency - most frequently due to detrusor overactivity
Voiding difficulties - hesitancy, straining, slow or intermittent stream
Feeling of incomplete emptying
Dysuria
Haematuria
Recurrent UTI
Any symptoms of prolapse or bowel symptoms
Check PMH and DH

Question 6

What is a simple way of obtaining info about fluid intake and voiding problems?

Answer 6

Frequency/volume charts - fill in for 72 hour period

Question 7

What should be done on examination?

Answer 7

Check weight, BMI, BP and signs of systemic disease
Note manual dexterity and mobility - can affect treatment options
Neurological exam if suspect neurological cause
Exclude an abdominal or pelvic mass
Presence of prolapse
Leakage on coughing?

Question 8

What risk factors are there for UI?

Answer 8

Advancing age 
Previous pregnancy and childbirth
High BMI
Hysterectomy 
FH

Question 9

Describe stress incontinence

Answer 9

Involuntary leakage on effort or exertion, coughing or laughing
Commonly due to urethral sphincter weakness

Question 10

Describe urge incontinence/ overactive bladder

Answer 10

Detrusor overactivity

Commonly coexists with frequency and nocturia

Question 11

What is overflow incontinence?

Answer 11

Leakage due to bladder outlet obstruction

Usually due to injury of insult e.g post partum

Question 12

What investigations are there?

Answer 12

Urinalysis - dipstick and culture to exclude UTI
Imaging - not done routinely, but may be done to exclude incomplete bladder emptying and if pelvic mass suspected
Bladder diaries
Vaginal examination - exclude prolapse
Cystoscopy - visualise the urethra, bladder mucosa, trigone
USS if suspecting retention
Urodynamics

Question 13

Describe urodynamic tests

Answer 13

Tests to look at ability of bladder to store and void urine
Flow meter - measures volume and flow
Cystometry = more invasive, measures pressure in bladder on voiding and filling, bladder filled with saline via a catheter and an intravesical and rectal probe measure the differences in pressure to give detrusor pressure. Patient asked: first desire to void, strong desire to void and to cough

Question 14

How is stress incontinence managed?

Answer 14

Pelvic floor muscle training
NICE recommends at least 8 contractions performed 3 times per day for minimum of 3 months
Medication usually not an option, in some rare cases duloxetine used
Surgery:
- colposuspension (lifting the neck of bladder)
- sling surgery
- vaginal mesh surgery not done due to complications

Question 15

How is urge incontinence managed?

Answer 15

Bladder retraining - last minimum 6 weeks, gradually increasing intervals between voiding
Bladder stabilising drugs
- antimuscarinics are first line
- oxybutynin (immediate release) but avoid in frail older women, tolterodine (immediate release), darifenacin (once daily)
- mirabegron (beta 3 agonist) useful if concerns about anticholinergic side effects in frail elderly patients
Surgery and procedures:
- Botulinum toxin A injections to side of bladder, last several months and can be repeated, may find it difficult to completely empty bladder, not currently licensed
- Sacral nerve stimulation

Question 16

What side effects are associated with antimuscarinics?

Answer 16

Can’t pee, can’t see, can’t spit, can’t shit

Also:
Mad as a hatter
Hot as a hare
Red as a beet 
Dry as a bone
Blind as a bat

Question 17

When is oxybutynin contraindicated?

Answer 17

Glaucoma

Question 18

When is mirabegron contraindicated?

Answer 18

HTN

Question 19

Explain urodynamics

Answer 19

Measuring flow - patient sits on a commode and a urinary flow meter measures voided volume over time and plotted on a graph

Cystometry - mor invasive and involves the bladder being filled with saline via a catheter and an intravesical and rectal probe measure differences in pressure to give the detrusor pressure. The patient is asked for first desire to void, strong desire to void and to cough - results printed on a graph and detrusor contraction or leakage noted