Urology::Urinary Incontinence

Question 1

What is the difference between urge, stress & overflow incontinence? [3]

Answer 1

overactive bladder (OAB)/urge incontinence:
- due to detrusor overactivity

stress incontinence:
* due to weakness of the pelvic floor and sphincter muscles
* This allows urine to leak at times of increased pressure on the bladder

Overflow Incontinence
* chronic urinary retention due to an obstruction to the outflow of urine

Question 2

How do you manage urge incontinence with drugs? [3]

Answer 2

bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)

bladder stabilising drugs: antimuscarinics
are first-line. NICE recommend
- oxybutynin (immediate release),
- tolterodine (immediate release)
- darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’

mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Question 3

How do you treat stress incontinence? [3]

Answer 3

If stress incontinence is predominant:

• pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
• surgical procedures: e.g. retropubic mid-urethral tape procedures
• Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Question 4

How do you manage urge incontinence that has failed to respond to retraining and medical management include? [4]

Answer 4

• Botulinum toxin type A injection into the bladder wall
• Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
• Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
• Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

Question 5

Surgical options to treat stress incontinence include? [4]

Answer 5

Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.

Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape

Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra

Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support

Question 6

What would indicate that urinary retention is chronic? [2]

Answer 6

Not painful
more than 1L in the bladder

Question 7

What would indicate that urinary retention is high pressure? [2]

Answer 7

Hydronephresis and impaired renal function occurs (creatinine increased)