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MBBS VI - SpC - Family Medicine > URO - Urinary incontinence > Flashcards

URO - Urinary incontinence Flashcards

1
Q

Differentiate urinary incontinences and enuresis

A

Urinary incontinence: condition where involuntary loss of urine is a social/hygienic problem and is objectively demonstrable

Enuresis: any involuntary loss of urine
Nocturnal enuresis is normal in babies/ kids

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2
Q

Describe the physiological mechanisms for urinary continence

A

Anatomical support by
→ Intact pelvic floor holding bladder neck + urethra in place (esp in F)

Intrinsic urethral mechanism by
→ Coaptation of mucosa
→ Compression by submucosa and internal/external sphincters

Prostate as continence device in M → above factors less important

Neurological control by CNS and spinal cord

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3
Q

Somatic neural control of micturition

Anatomical structures involved in coordination and control
Parasympathetic, sympathetic and reflex control

A
  1. Pudendal nerve: from S2-S4 Onuf’s nucleus (anterior horn)
    » Innervates striated sphincter, anterior levators, superficial perineal muscles
    » Close external sphincter muscle in urethra
  2. Pontine micturition center
    Inputs (3):
    » Corticol input from frontal lobes to inhibit micturition
    » Afferent sensory input from stretch receptors in bladder Detrussor muscles
    » Cerebellar input for coordinated voiding
    Output (1):
    » Sympathetic output from T10-L2 to Hypogastric nerve, merge with parasympathetic fibers to form pelvic plexus
    » Contracts internal sphincter muscle in urethra
  3. Sacral micturition center
    » Communicates with pontine center for micturition reflex
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4
Q

Define normal void volume, residual volume

Define urinary frequency and nocturia

A

Normal void: 200-400mL
Normal residual: <150mL

Frequency: >8 voids during daytime, >Q2H

Nocturia: >2 voids during sleep, each void preceded and followed by sleep

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5
Q

Physiology of urine storage and voiding

Anatomical structures involved
High pressure or low pressure?

A

Urine storage:

  • Bladder expands for low-pressure storage
  • Bladder outlet closed at rest and even at high intra-abdominal pressure
  • No involuntary bladder contraction

Urine voiding:

  • Periodic voluntary urine expulsion at low pressure
  • Coordinated contraction of bladder smooth muscles + relax sphincter muscles to remove anatomical obstruction at outlet
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6
Q

Anatomical abnormalities that lead to urinary incontinence?

A

Bladder:

  • Detrussor overactivity (idiopathic, neurogenic)
  • Low bladder compliance (SCI, cystitis, hysterectomy)

Sphincter abnormalities

  • Extrinsic sphincter = Urethral HJypermobility due to weak pelvic floor muscle support
  • Intrinsic sphincter deficiency (ISD) = abnormal urethral muscle, blood flow, innervation
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7
Q

Physiological pathway for micturition reflex and voluntary inhibition of micturition

A

Involuntary micturition/ micturition reflex:
- Intravesical pressure in bladder&raquo_space; sensory input into pontine micturition center&raquo_space; relaxation of sphincter muscles and THEN detrusor contraction&raquo_space; induce involuntary emptying

Voluntary micturition: block somatic neural efferent activities

Stop micturition:
- Cortical input from frontal lobe into pontine micturition center&raquo_space; inhibit micturition

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8
Q

Prevalence of urinary incontinence
Demographics
Most prevalent type

A

F&raquo_space; M Mostly post-menopausal women
50-70 years old

Stress incontinence at 50%, Mix incontinence at 36%

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9
Q

5 major types of incontinence

A

Urge incontinence (UUI)

Stress incontinence (SUI)

Overflow incontinence

Functional incontinence

Mixed incontinence: urge + stress incontinence

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10
Q

Define Urge incontinence and underlying mechanism

A 
Urge incontinence (UUI): strong desire to void that is difficult to defer and a/w leakage
→ Often mixed with SUI (mixed incontinence) and may be worsened by anxiety/stress
→ Mechanism: detrusor overactivity leading to inappropriate bladder contraction
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11
Q

Define stress incontinence and underlying mechanisms

A 
Stress incontinence (SUI): leakage a/w Increase abdominal pressure
→ Mechanism: due to poor urethral sphincter function
→ Triggers: cough, sneeze, laughing, heavy lifting
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12
Q

Define overflow incontinence and underlying mechanism

A

Overflow incontinence: constant dribbling (esp at night) with associated retention of urine
→ Mechanism: BOO/DUA leads to abnormally distended bladder with large residual volume→ bladder over-distension with continuous dribbling
→ Signs: significant post-void residual, palpable bladder
→ Complications: UTI, bladder stones, obstructive uropathy

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13
Q

Define functional incontinence and underlying mechanism

A

Functional incontinence: urine leakage due to inability to get to toilet
→ Causes: impaired mobility (eg. elderly), dementia, lack of carer
→ Usually dx of exclusion as other types also present in functionally limited individuals

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14
Q

List general modifiable and unmodifiable risk factors of urinary incontinence (not specific to type)

A

Unmodifiable:

  1. White ethnicity
  2. Age > 50, post-menopausal
  3. Female sex

Modifiable:

  1. Smoking, Caffeine
  2. Obesity, Poor mobility
  3. Fluid intake level
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15
Q

Diseases/ Conditions associated with Urinary incontinence

A

Urogenital tract damage:

  • Vaginal childbirth
  • Anatomical disorders - VVF, ectopic ureter, urethral diverticulum
  • Iatrogenic: pelvic, perineal and prostate surgery
  • Radiation therapy

Neurological damage:

  • CVA
  • Parkinsons
  • MS, SCI

UTI
DM
Medications

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16
Q

Ddx structural causes of urinary incontinence

A

Congenital duplex ureter

Infection

Iatrogenic - e.g. post-postatectomy sphincteric injury

Birth injury: vesico-vaginal fistula, stress incontinence

Neoplastic

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17
Q

Mechanisms of poor bladder compliance

A
  1. Increase viscoelasticity of bladder wall
  2. Filing rate exceeds rate of stress relaxation
  3. Over-filling beyond distensibility
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18
Q

Reversible, transient causes of urinary incontinence

A 
D – delirium
I – infection
A – atrophic vaginitis or urethritis
P – pharmaceuticals (see RHS)
P – psychological disorders
E – endocrine disorders
R – restricted mobility
S – stool impaction
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19
Q

Drug and food causes of urinary incontinence

A 
Diuretics – urge
Caffeine – urge
Alcohol – urge
Anticholinergics – overflow
Alpha-agonists – overflow
Beta-agonists – overflow
Sedatives/antidepressants – overflow
ACEI (cough) – stress
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20
Q

Ketamine cystitis

  • Cause
  • Physiological defect
  • Presentation
A

Cause: Chronic ketamine abuse

Defect: Small, poor compliance bladder

Presentation: Urge incontinence, urinary frequency, obstructive uropathy

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21
Q

Urge incontinence

  • Common causes
A
  1. Idiopathic overactive bladder (OAB)**
    a) Neurogenic OAB:
    - Brain: CVA, PD, Tumor, MS …etc
    - Spine: injury, tumor, myelodysplasia …etc

b) Non-neurogenic OAB:
- Chronic BOO: BPH, urethral strictures, Pelvic mass
- Cystitis, bladder cancer
- Bladder stones

  1. Drugs: Diuretics, Caffeine, Alcohol
22
Q

Stress incontinence

  • Most common causes in male and female
A

Male:

  • Prostate surgery**
  • Spinal cord injury
  • Drugs: a-blockers, ACEi

Female:

  • Urethral hypermobility - poor pelvic floor support to urethra/ bladder neck, caused by birth trauma, increase IAP
  • Intrinsic sphincteric deficiency: neuromuscular damage after pelvic surgeries
23
Q

Overflow incontinence

Common causes in Male and female

A

Male:
1. Bladder outlet obstruction: BPH**, Spinal cord lesions

  1. Detrussor underactivity:
    - Neuropathies and lower spinal cord disease
    - Acute overdistension (e.g. post-op)
    - Drugs: a-agonist, anticholinergics, antidepressants

Female:

  1. Detrussor underactivity: (more common)
    - post-menopausal UG atrophy
    - neuropathies and lower SC diseases
    - Acute overdistension, eg. post-operative
    - Drugs: α-agonists, anticholinergics, antidepressants
  2. Bladder outlet obstruction
    - External compression: fibroids, pelvic tumours
    - Others: advanced POP, over-correction from prev OT
24
Q

Patient presents with Incontinence a/w sense of urgency, triggered by running water, hand-washing, cold exposure

Most likely cause of incontinence?
Relevant history/ risk factors/ etiologies

A

Urge incontinence

Relevant history:

  • Other LUTS, esp storage symptoms
  • Hx of bladder pathologies, eg. UTI, stones, BPH
  • Hx of neurological conditions, eg. stroke, SCI, and DM
  • Drug Hx, eg. diuretics, and fluid intake incl caffeine/alcohol
25
Patient presents with Incontinence a/w physical exertion, coughing, laughing, lifting, rising from bed Most likely type Relevant history/ risk factors/ etiologies
Stress incontinence - Chronic ↑abd pressure: chronic cough, obesity - Obstetric history: multiparity, perineal tears - Hx of prostate surgery: radical prostatectomy, TURP (usu not)
26
Patient presents with feeling of incomplete emptying, suprapubic discomfort, dribbling without any warning/ triggers Most likely type of incontinence Relevant history/ risk factors/ etiologies
Overflow incontinence Relevant history: - Other LUTS, esp voiding symptoms - LL neurological symptoms and Hx of spinal cord diseases - Hx of BPH or any other prostate pathology - Gynaecological history, eg. fibroids, pelvic organ prolapse - Drug history, eg. α-agonists, anticholinergics, antidepressants
27
Idiopathic overactive bladder - Cause of which type of urinary incontinence - Presentation - Triggers - Etiologies
Urge incontinence*** Presentation: - Strong sense to void, then involuntary loss of urine Triggers: - worsened by anxiety/stress - Etiologies: Neurogenic OAB: Brain: CVA, NPH, PD, brain tumour, TBI, MS SC: injury, tumour, transverse myelitis, myelodysplasia Non-neurogenic OAB due to bladder pathology Chronic BOO: BPH, urethral stricture Cystitis (infection/inflammation) and tumour Bladder stones and bladder foreign body Drugs: diuretics, caffeine, alcohol
28
Complications of overflow incontinence
1. UTI 2. Bladder stone formation 3. Obstructive uropathy, worsen renal function
29
Patient presents with leaking of urine before reaching toilet, old-age Most likely type of incontinence, causes
Functional incontinence: urine leakage due to inability to get to toilet Causes: impaired mobility (eg. elderly), dementia, lack of carer
30
Outline history taking for urinary incontinence
Patient: Old age? Post-menopausal? HPI: Incontinence: Duration, type, frequency, volume/ number of pads, triggers and constant vs intermittent Associated symptoms: Obstructive symptoms Voiding/drinking habit: voiding diary if possible PMH: Neurological and mental health history Gynaecological and Obstetic, Menstrual history Urological history: UTI, surgeries ...etc Medication and social history: drug abuse, chronic drug use, caffeine/ smoking/ alcohol Impact on quality of life
31
Outline list of P/E for urinary incontinence
1. Post-void abdominal examination: → Palpable bladder indicates urinary retention - overflow incontinence → Abdominal mass compress on bladder 2. Pelvic examination in women → pelvic masses, organ prolapse, atrophic changes 3. Rectal examination: → Feel for: anal tone (± faecal soiling), faecal impaction, rectal mass, BPH → Test reflexes: anal reflex, bulbocavernous reflex (BCR, S2-4) 4. Genital examination: - Atrophy, cystocele, rectocele, skin excoriations, pelvic masses 5. Neurological examination if any suspicion of spinal cord/brain pathologies
32
First-line investigations for urinary incontinence
1. Voiding diary: Frequency/ Volume charts 2. Urinalysis, C/ST to r/o UTI 3. RFT, Fasting glucose - obstructive uropathy, diabetic nephropathy 4. Uroflowmetry - flow rate and post-void residual volume 5. Urodynamic studies - Gold standard, for complicated incontinence:
33
Outline the recorded metrics and estimated metrics in Voiding Diary
Recorded: 24-72h - Fluid intake, physical activity - Frequency - Void volume - Incontinence episodes and triggers Estimations: - 24h urine volume - Frequency - Nocturia - Functional bladder capacity
34
Urodynamic studies - Indications - Functions
Indication: Gold standard, for complicated incontinence - Detrusor overactivity - Voiding dysfunction - Unclear clinical diagnosis - Previous surgery for stress incontinence - Any neurological deficits Functions: - Find etiology of incontinence - Assess Detrusor function - Assess pelvic floor prolapse - Find urodynamic risk factors for urinary tract deterioration
35
List all metrics measured in Urodynamic studies + advantage of video UDS
1. Flowmetry - Flow rate and residual urine 2. Filling phase - Instability or hypotonia 3. Voiding phase - Obstruction 4. Video: shape of bladder, bladder neck, any reflux - Better evaluation of bladder neck descent and urethra, clearly quantify anterior wall prolapse 5. Electromyography - striated sphincter function: → Leak point pressure (LPP): Pabd or Pdet required to overcome outlet resistance and produce incontinence → Urethral pressure profilometry (UPP): measures urethral pressure along its length
36
General lifestyle management for all types of urinary incontinence
Lifestyle modifications: 1. Weight-reduction 2. Less caffeine, alcohol intake, don't reduce fluid intake 3. Use incontinence pads
37
List non-pharmacological/ physiotherapy for urinary incontinence
Pelvic floor (Kegel) exercises Biofeedback: placement of vaginal pressure sensor → live feedback of strength of pelvic floor contractions Bladder training: timed voiding with controlling of urgency by distraction or mental relaxation techniques
38
List medical treatment options for urinary incontinence
Medical therapy: check for C/I to anticholinergics, usually require ~4w to see full benefit - Anticholinergics, eg. oxybutynin, tolterodine, solifenacin - Beta-3 agonist: Mirabegrone - Vaginal oestrogen: suitable for postmenopausal women with vaginal atrophy - Desmopressin: suitable for persistent nocturia
39
List surgical treatment options for urinary incontinence (excluding stress incontinence)
Surgical therapy: - Sacral Nerve neuromodulation - Posterior Tibial Nerve Stimulation (PTNS) - botox injection - augmentation cystoplasty - urinary diversion
40
Surgical treatment options specific to stress incontinence
For stress incontinence only: - Transurethral injection: bulking agents (eg. silicon, collagen) - Mid-urethral sling (MUS): tension-free vaginal tape (TVT) in F, trans-obturator tape (TOT) in M - Burch coloposuspension: suture lateral vaginal walls to iliopectineal ligaments - Artificial urinary sphincter: most effective Tx for M, pump to deflate sphincter
41
Describe bladder training for urinary incontinence
Train Central control of voiding: timed voiding according to a schedule, stop voiding under urgency controlling urgency by distraction or mental relaxation techniques
42
Antimuscarinic therapy for urinary incontinence MoA Effective time
MoA: Bladder contraction involves M3 receptors Antimuscarinic drug acts as competitive antagonist against muscarinic receptros >> Inhibits post-synaptic M3 receptors, stop Phospholipase3/IP3 pathway and Calcium influx >> Reduce smooth muscle contaction Time: 3-4 weeks before effect
43
List examples of antimuscarinic therapy for urinary incontinence and differences Options if dry mouth cannot be tolerated?
Oxybutynin***most common***: extended release, in transdermal or intravesical gel or rectal suppository, less systemic S/E Tolterodine: less salivary gland S/E Solifenacin: selective to M2, M3 Darifenacin: selective to M3 Quaternary: Less CNS S/E, e.g. Trospium chloride, Propantheline Change to Tolterodine/ Transdermal, intravesical oxybutynin
44
S/E of antimuscarinic therapy C/I
M1: Cognitive impairment M2: Tachycardia, constipation M3: Dry mouth, blurry vision, dizziness ``` C/I: Uncontrolled acute close angle glaucoma UC/ Toxic megacolon MG IO ```
45
Beta-3 agonists for urinary incontinence Example MoA S/E
Mirabegron MoA: Activate adenyl-cyclase, ATP to cAMP > PKA > lower Ca influx > Smooth muscle relaxation S/E: Hypertension, Headache, UTI, Nasopharyngitis Severe S/S: CVD, CVA
46
Botox injection for urinary incontinence MoA Onset, repeat time
Botulinum toxin A injection - Intradetrusor injection MoA: Heavy chain binds to SV2 receptor > endocytosis into presynaptic nerve terminal > Light chain cleaves SNAP-25 protein on SNARE protein complex > Stop exocytosis of Ach vesicles into NMJ > Paralyze detrusor muscle Block expression of TPRV1 and P2X3 receptors in Type C nerve > decrease urgency Onset: 1-2 weeks, repeat every 6-9 months
47
Botox injection for urinary incontinence S/E C/I
``` S/E: Urinary retention needing CISC UTI Haematuria Systemic absorption (rare) ``` ``` C/I: Active UTI Bleeding diathesis MG Pregnancy/ breast feeding Allergy ```
48
Sacral neuromodulation for urinary incontinence MoA Complications
Temporary electrode inserted percutaneously >> into S3 sacral foramen with sacral nerve Modulate local neural reflexes, inhibit bladder contraction Stimulation shows big toe dorsiflexion, anal wink, cremasteric reflex Complications: - Surgery: Bleeding, infection, pain - Implant: Mechanical failure, migration, Battery life (7y), Lower limb weakness
49
Augmentation cystoplasty for urinary incontinence MoA Complications
MoA: Open bladder down to urethral orifice, patch defect with bowel segment (distal ileum) Impair bladder contraction, lower detrusor pressure, increase bladder capacity, decrease strength of contraction Complications: Surgical: bleed, infection, leakage, ileus Long term: - CISC, mucus perforation, rupture - Hypercholremic hypokalemic metabolic acidosis - Malabsorption: fat, Vitamin B12, Bile acid >> Calcium oxalate stones, gallstones, anaemia - Malignancy: Adenocarcinoma
50
Outline specific medical and surgical treatment options for Stress incontinence
General: - Stop smoking, fluid management, lose weight - Use incontinence pad Medication: - Duloxetine: SNRI → ↑5HT/NA activity in Onuf’s nucleus → ↑urethral sphincter activity - Estrogen therapy Surgical: - Transurethral injection: bulking agents (eg. silicon, collagen) injected - Mid-urethral sling (MUS): tension-free vaginal tape (TVT) in F, trans-obturator tape (TOT) in M - Burch coloposuspension: suture lateral vaginal walls to iliopectineal ligaments - Artificial urinary sphincter: most effective Tx for M, pump to deflate sphincter
51
Transvaginal tape for stress incontinence ``` MoA Complications (intra-op and post-op) ```
Reinforce functional pubourethral ligaments Secure fixation of midurethra to pubic bone, reinforce suburethral vaginal hammock ``` Intra-op complications: - Bladder, urethral perforation - Hematoma, hemorrhage - Nerve damage Post-op complications: - Urinary retention - De novo urgency - UTI - Tape erosion ```
52
Gold standard treatment for male stress urinary incontinence
Artificial urinary sphincter: pump to deflate sphincter every time before voiding

MBBS VI - SpC - Family Medicine (42 decks)

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