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Elderly Years > Urinary Incontinence & Erectile Dysfunction > Flashcards

Urinary Incontinence & Erectile Dysfunction Flashcards

1
Q

State the innervation of the urinary bladder.

A
  • Somatic to external urethral sphincter:
    • S2-S4 pudendal
  • Sympathetic:
    • L1-L3 hypogastric
  • Parasympathetic
    • S2-S4 pelvic
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2
Q

Describe the filling phase of the micturition cycle.

A
  • Stretch receptors stimulated
  • Bladder relaxes
  • Sphincter contracts (sympathetic alpha receptors)
  • Desire to void at 75% capacity → voluntary control to maintain continence (capacity 400-500mL)
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3
Q

Describe the voiding phase of the micturition cycle.

A
  • Voluntary and reflex (parasympathetic) relaxation of sphincter and pelvic floor
  • Reflex detrusor contraction (parasympathetic)
  • Intravesical pressure > urethral pressure
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4
Q

Why does urinary incontinence occur?

A
  • Detrusor dysfunction - urge urinary incontinence.
  • Sphincter dysfunction - stress urinary incontinence.
  • Bladder overdistension with chronic retention of urine - overflow urinary incontinence.
    • Mixed urinary incontinence.
    • Anatomical abnormalities.
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5
Q

What is stress urinary incontinence?

Describe the pathophysiology.

A
  • Definition - involuntary leakge of urine on effort, exertion, sneezing, laughing or coughing.
  • Caused by dysfunction of the urethral sphincter.
  • Caused by:
    • Bladder neck / urethral hypermobility
      • Pelvic floor weakness
      • Rotational descent of bladder neck / urethra
    • Intrinsic sphincter deficiency
      • Internal and external sphincters
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6
Q

What are the risk factors for SUI in women?

A
  • Factors which reduce urethral closure pressure:
    • Childbirth: vaginal delivery, particularly assisted.
    • Ageing
    • Oestrogen withdrawl
    • Pelvic surgery
    • Neurological disorders e.g. MS, SC injury
  • Factors which increase intra-abdominal pressure:
    • Obesity
    • Chronic cough (e.g. smokers)
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7
Q

What should you ask in the history of a woman presenting with ?SUI?

A
  • Involuntary leakage of urine upon:
    • Coughing?
    • Sneezing?
    • Laughing?
    • Exertion?
  • Wearing pads?
    • Must ask this explicitly because this information may not be volunteered.
    • How many are they going through?
  • Parity
  • PMHx - any risk factors
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8
Q

Describe the examination and investigation of ?SUI in a woman.

A
  • Pelvic examination
  • Stress test
  • Pad test
    • Go away and wear pads for 24 hours then the pads are weighed to assess how much urine they are leaking.
  • Bladder diary
  • ICIQ-UI
    • Questionnaire - different ones for different types of incontinence.
  • Urine dip +/- MSU
    • To rule out infection.
  • Urodynamics (only if considering surgical management)
  • Cystoscopy if indicated (e.g. haematuria)
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9
Q

What are the management options for SUI in women?

A
  • Conservative
    • Pelvic floor muscle training
      • Supervised
      • 30% of women with mild SUI improve
    • Lifestyle modification
      • Weight loss
      • Smoking cessation
      • Modify fluid intake
    • Medication
      • Duloxetine (second line, only as an alternative to surgery)
    • Surgical - pelvic floor
      • Urethral bulking agent
      • Burch colposuspension
      • Suburethral sling
      • Artificial urinary sphincter
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10
Q

What are the risk factors for SUI in men?

A
  • Main cause post-prostatectomy due to sphincter incompetence.
    • Removal of internal sphincter in RP
    • Damage to sphincter innervation in RP
    • Damage to external urethral sphincter at TURP (<1%)
  • ↑ age
  • Pre-existing bladder dysfunction
  • Radiotherapy
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11
Q

Describe the examination and investigation of SUI in a male.

A
  • Stress test
  • Pad test
  • Questionnaires e.g. ICIQ-MLUTS
  • Post void residual (exclude overflow)
  • Videourodynamics
  • Cystoscopy
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12
Q

What are the management options for SUI in males?

A
  • Conservative
    • Pelvic floor muscle training pre- and post- operatively
      • Speeds recovery
      • Does not cure SUI
    • Pads
    • Penile sheath e.g. Conveen
    • Urethral catheter
  • Surgical
    • Slings
    • Artificial sphincter
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13
Q

What is urge urinary incontinence?

A
  • Urge incontinence is a sudden and strong need to urinate.
  • A symptom of overactive bladder syndrome.
  • Caused by dysfunction of detrusor smooth muscle.
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14
Q

What questions should you ask in the hx of a patient with ?UUI?

A
  • Frequency
  • Urgency?
  • Urge incontinence
  • Nocturia?
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15
Q

Describe the examination and investigation of a patient with UUI.

A
  • Abdo + pelvic exam +/- DRE
  • Neuro examination
  • Questionnaires
    • ICIQ-OAB
  • Bladder diary
  • Urinalysis +/- MSU
  • Flow + residual
  • Pad test
  • USS
  • Urodynamics
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16
Q

What are the management options for UUI?

A
  • Conservative
    • Bladder training
    • Pelvic floow exercises
    • Modification of fluid intake
  • Medical
    • Anticholinergics e.g. tolterodine, solifenacin
    • Mirabergon - β3-adrenoceptor antagonist
    • Topical oestrogens
    • Intravesical botulinum toxin
  • Surgical
    • Sacral nerve stimulation
    • Clam ileocystoplasty
    • Urinary diversion
17
Q

What is mixed urinary incontinence and how is it treated?

A
  • A combination of SUI and UUI.
  • Treat predominant symptoms first.
18
Q

What is overflow urinary incontinence?

What causes it?

A
  • Characterised by overdistended bladder with chronic retention of urine.
  • M>F
  • Causes:
    • Detrusor failure
    • Neurological disorder
    • Bladder outflow obstruction
    • Combination
  • Post-void residul volume >800mL
19
Q

What questions should you ask in the hx of a patient with ?overflow urinary incontinence?

A
  • Bedwetting in older men
    • Must ask this explicitly because the patient probably won’t volunteer it.
    • If an elderly man admits to bedwetting this strongly suggests bladder overflow.
  • Frequency
  • Recurrent UTIs?
20
Q

Describe investigation and treatment of overflow urinary incontinence.

A
  • U&E
  • USS
  • Treat the cause
21
Q

What are the other causes of urinary incontinence?

A
  • Vesicovaginal fistula
  • Urethral diverticulum
  • Ectopic ureter
22
Q

Define erectile dysfunction.

A

The consistent or recurrent inability to attain and / or maintain a penile erection sufficient for sexual intercourse.

23
Q

Why does incidence of ED increase with increasing age?

A

Increased atherosclerosis in penile arteries: corporeal ischaemia + fibrosis.

24
Q

What is the nervous innervation responsible for erections?

A

Pelvic splanchnic nerves S2-S4

25
Q

What are the causes of ED?

A
  • Inflammatory - prostatitis.
  • Mechanical - Peyronie’s disease.
  • Psychological - depression, anxiety, relationship difficulties, stress.
  • Occlusive / vascular - HTN, smoking, ↑lipids,DM, PVD.
  • Trauma - pelvic fracture, SC injury, penile fracture / trauma.
  • Extra factors - pelvic surgery, prostatectomy, age, CKD, cirrhosis, penile carcinoma.
  • Neurogenic - MS, PD, MSA, tumour, CVA, spina bifida, SC injury, radiotherapy, peripheral neuropathy (DM/ETOH).
  • Chemical - drugs e.g. ACEi, antidepressants, antiandrogens, recreational.
  • Endocrine - DM, hypogonadism, hyperprolactinaemia, ↑/↓ thyroidism.
26
Q

Describe a comprehensive history for ED.

A
  • Sexual hx
    • Onset of problem
    • Duration of problem
    • Presence of erections e.g. nocturnal, early morning, spontaneous
      • This is reassuring and points to a psychological cause of erectile dysfunction because it proves the the mechanism still works.
    • Ability to maintain erections
    • Libido
    • Relationship issues
  • Risk factors
    • DM
    • CVD: HTN / ↑ lipids / PVD
    • Endocrine or neurological disorders
    • Surgery, trauma, radiotherapy
  • Psychological
    • Stress
    • Anxiety
    • Depression
    • Pt expectations
  • Drugs
    • Prescribed medications
    • OTC
    • Recreational
    • ED treatments tried
  • Social
    • Smoking
    • Alcohol
27
Q

Which examinations would be relevant in a patient with ED?

A
  • Secondary sexual characteristics
    • Have they reached sexual maturity?
  • External genitalia
    • Patients can have retraction which can be so painful it prevents them getting erections.
  • DRE
  • CVS examination
    • Assess CV risk - BP etc.
  • Abdominal examination
    • Masses?
    • Previous surgery?
  • Neurological
28
Q

Which investigations would be relevant in ED?

A
  • Bloods
    • Fasting glucose
    • Early morning total testosterone (8-11am)
    • Fasting lipids
    • +/- U&E, LH/FSH, prolactin, PSA
  • BP
  • IIEF - questionnaire
  • Other investigations if clinically indicated:
    • Nocturnal penile tumescence
    • Penile doppler USS
    • MRI
29
Q

What are the management options for ED?

A
  • Psychosexual therapy
    • Counselling
    • Sex education
    • Partner communication skills
    • CBT
  • Drug therapy
    • PDES inhibitors
    • Testosterone replacement
  • Intraurethral therapy
  • Intracavernosal injection
  • Vacuum device
  • Penile implant

Elderly Years (28 decks)

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