Urinary Incontinence & Erectile Dysfunction Flashcards
State the innervation of the urinary bladder.
- Somatic to external urethral sphincter:
- S2-S4 pudendal
- Sympathetic:
- L1-L3 hypogastric
- Parasympathetic
- S2-S4 pelvic
Describe the filling phase of the micturition cycle.
- Stretch receptors stimulated
- Bladder relaxes
- Sphincter contracts (sympathetic alpha receptors)
- Desire to void at 75% capacity → voluntary control to maintain continence (capacity 400-500mL)
Describe the voiding phase of the micturition cycle.
- Voluntary and reflex (parasympathetic) relaxation of sphincter and pelvic floor
- Reflex detrusor contraction (parasympathetic)
- Intravesical pressure > urethral pressure
Why does urinary incontinence occur?
- 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.
What is stress urinary incontinence?
Describe the pathophysiology.
- 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
- Bladder neck / urethral hypermobility

What are the risk factors for SUI in women?
- 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)

What should you ask in the history of a woman presenting with ?SUI?
- 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
Describe the examination and investigation of ?SUI in a woman.
- 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)
What are the management options for SUI in women?
- 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
- Pelvic floor muscle training
What are the risk factors for SUI in men?
- 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
Describe the examination and investigation of SUI in a male.
- Stress test
- Pad test
- Questionnaires e.g. ICIQ-MLUTS
- Post void residual (exclude overflow)
- Videourodynamics
- Cystoscopy
What are the management options for SUI in males?
- Conservative
- Pelvic floor muscle training pre- and post- operatively
- Speeds recovery
- Does not cure SUI
- Pads
- Penile sheath e.g. Conveen
- Urethral catheter
- Pelvic floor muscle training pre- and post- operatively
- Surgical
- Slings
- Artificial sphincter
What is urge urinary incontinence?
- Urge incontinence is a sudden and strong need to urinate.
- A symptom of overactive bladder syndrome.
- Caused by dysfunction of detrusor smooth muscle.
What questions should you ask in the hx of a patient with ?UUI?
- Frequency
- Urgency?
- Urge incontinence
- Nocturia?
Describe the examination and investigation of a patient with UUI.
- Abdo + pelvic exam +/- DRE
- Neuro examination
- Questionnaires
- ICIQ-OAB
- Bladder diary
- Urinalysis +/- MSU
- Flow + residual
- Pad test
- USS
- Urodynamics
What are the management options for UUI?
- 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
What is mixed urinary incontinence and how is it treated?
- A combination of SUI and UUI.
- Treat predominant symptoms first.
What is overflow urinary incontinence?
What causes it?
- 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
What questions should you ask in the hx of a patient with ?overflow urinary incontinence?
- 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?
Describe investigation and treatment of overflow urinary incontinence.
- U&E
- USS
- Treat the cause
What are the other causes of urinary incontinence?
- Vesicovaginal fistula
- Urethral diverticulum
- Ectopic ureter
Define erectile dysfunction.
The consistent or recurrent inability to attain and / or maintain a penile erection sufficient for sexual intercourse.
Why does incidence of ED increase with increasing age?
Increased atherosclerosis in penile arteries: corporeal ischaemia + fibrosis.
What is the nervous innervation responsible for erections?
Pelvic splanchnic nerves S2-S4
What are the causes of ED?
- 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.
Describe a comprehensive history for ED.
- 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
Which examinations would be relevant in a patient with ED?
- 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
Which investigations would be relevant in ED?
- 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
What are the management options for ED?
- Psychosexual therapy
- Counselling
- Sex education
- Partner communication skills
- CBT
- Drug therapy
- PDES inhibitors
- Testosterone replacement
- Intraurethral therapy
- Intracavernosal injection
- Vacuum device
- Penile implant