Week 3 - B - Urinary incontinence

Question 1

What is any involuntary leakage of urine known as?

Answer 1

This is urinary incontinence

Question 2

Urinary incontinence is often a difficult subject to approach as patients can feel nervous What can they often complain of emotionally?

Answer 2

Feeling embarrassed or distressed

Question 3

What prevalence of men and women have urinary incontinence?

Answer 3

1in3 women have urinary incontinence

1in10men have urinary incontinence

Question 4

What are the 4 different types of urinary incontinence?

Answer 4

Urge incontinence

Stress incontinence

Mixed incontinence

Overflow incontinence

Question 5

What is the most common type of incontinence and is usually in women?

Answer 5

This is stress incontinence

Question 6

Urine may leak by an extraurethral route such as a ectopic ureter or fistula How do these cause incontinence?

Answer 6

Ectopic ureter is a ureter that connects usually to the urethra

Fistula causes an opening between urethra and vagina causing drippage of urine

Question 7

What are the two stages of the micturition cycle?

Answer 7

The filling (storage) phase and The voiding phase

Question 8

Describe the filling phase of micturition? (only intravesical and urethral pressure for now)

Answer 8

During this phase the intravesical pressure slowly rises as the urine volume rises

The urethral pressure will begin to increase as the urethral sphincter has to tighten to prevent flow of urine

Question 9

What happens to the detrusor and abdominal pressure during the filling phase?

Answer 9

As the volume of urine increases the detrusor pressure increases as the detrusor muscle enlarges to hold more urine

The abdominal pressure should not change here

Question 10

What is compliance of the bladder?

Answer 10

This is the ability for the bladder to keep the intravesical pressure relatively stable due to the detrusor muscle expanding

Question 11

The second phase of micturition is the voiding phase What happens here?

Answer 11

The detrusor pressure increases as it contracts to push urine out causing the intravesical pressure to therefore decrease

Abdominal pressure should remain the same

Question 12

What happens during urodynamics to measure the different pressures?

Answer 12

A thin flexible tube is passed into the urethra - this measures intravesical pressure

Another is passed into the back passage - this measure abdominal pressure

The urethral tube fills the bladder with fluid and then the patient is asked to urinate

Question 13

How is the detrusor pressure calculated?

Answer 13

The detrusor muscle is calculated by the difference between the intravesical and abdominal pressures

Question 14

During urodynamics due to thin flexible tube, what is the X-ray test that takes pictures of your bladder and urethra while your bladder is full and while you are urinating?

Answer 14

The cystourethrogram allows pictures to be taken whilst you are urinating and filling

(cysto - bladder, urethro - urethra)

Question 15

What are the 3 different components of the micturition reflex?

Answer 15

Bladders and sphincters

Spinal bladder control centre

Micturition centre in the brain

Question 16

WHat nerves are the spinal to bladder control centre? Where is the micturition centre in the brain?

Answer 16

S2-4 is the spinal to bladder control centre

Micturition centre in the brain is located in the pons

Question 17

Is the storage phase of micturition under sympathetic or parasympathetic control?

Answer 17

Storage phase is under sympathetic control as it cause the internal urethral sphincter to keep closed

Question 18

sympathetic control to the bladder is via the hypogastric nerves What level is this?

Answer 18

This is T10-L2

Question 19

The voiding phase is under parasympathetic control Which nerves cause the internal urethral sphincter to open and the detrusor muscle to contract?

Answer 19

S2-S4 parasympathetic nerves from the sacral plexus cause the detrusor to contract and the internal urethral sphincter to open

Question 20

What is the sphincter under voluntary control in micturition and why? What is its nerve supply?

Answer 20

External urethral sphincter - under volunary control as it lies in the perineum and therefore is a body wall structure

Supplied by the pudendal nerve (S2-S4)

Question 21

Often old male patients can present with a large palpable bladder and chronic urinary retention What is this type of incontinence?

Answer 21

This is overflow incontinence

Question 22

When will patients often complain of incontinency in overflow incontinence?

Answer 22

Often complain of incontinence at night whilst sleeping or terminal dribbling

Question 23

The reason fro the retention mostly is due to the enlargement of the prostate (with age it grows in size, benign prostatic hyperplasia)
The BPH puts pressure on the urethra which means overtime if there is a chronic retention it will start t fill up more and more What will eventually happen to the detrusor muscle?

Answer 23

Eventually the detrusor muscle continue to stretch causing hypertrophy and eventually it can stop functioning

Question 24

Why can renal impairment happen with overflow incontinence?

Answer 24

The intravesicular pressure build up can bactrack into the ureter and into the renal pelvis leading to dilatation of the renal pelvis which can cause acute kidney injury

Question 25

Apart from BPH, what are potential other causes of overflow incontinence?

Answer 25

Bladder stones in the ureter

Detrusor muscle impairment preventing contraction

Anticholinergics stopping parasympthatetics - important to know if on any

Tumours

Question 26

What is the non pharmacological treatment in overflow urinary retention? (voiding difficulty)

Answer 26

Conservative management, which involves: Pelvic floor muscle training and bladder training.

Avoid constipation

Potentially catheterisation if acute retention - usually suprapubic

Question 27

What is the pharmacological management given to treat overflow urinary retention? How long do they take to work and how do they work?

Answer 27

If the man has moderate-to-severe voiding symptoms

Give an alpha blocker - tamsulosin - takes up to 6 weeks to have clear effects (results in relaxation of bladder smooth muscle)

Second line Offer a 5-alpha reductase inhibitor - eg finasteride - can take up to 6 months to show effects

(anti-andorgen preventing dihydrotesterone formation therefore preventing prostate enlergement)

Question 28

What are main side effects of both alpha blockers (tamsulosin) and 5-alpha reductase inhibitors (eg finasteride)?

Answer 28

Tamsulosin - can cause hypotension

Alpha reductase inhibitor - can cause sexual dysfunction / gynaecomostia

Question 29

What can be given to treat the overflow urinary incontinence in men if the drugs dont work? If the man has a mixed picture of storage symptoms and voiding symptoms that arent responding to alpha blocker, what can be added?

Answer 29

If pharmacological treatment does not work - can try urinary catheterisation or TURP (trans-urethral resection of prostate)

If the man has a mixed picture with storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, consider adding an antimuscarinic (anticholinergic) drug eg Oxybutynin (immediate release), tolterodine (immediate release),

Question 30

daytime frequency (go to the toilet so much eg every 30 minutes), voids very little volumes of urine and has a sense of urgency What is this?

Answer 30

This is urge urinary incontinence

Question 31

What can the urge to go to the toilet typically be provocated by?

Answer 31

Turning key to open door, running water, standing up

Question 32

What is believed to be a cause of urge incontinence?

Answer 32

Detrusor overactivity causing impulse to pee

Question 33

Detrusor over-activity is diagnosed by urodynamic What does it show on urodynamics?

Answer 33

Shows an increase in detrusor activity intermittently causing small amounts of urine production in the filling phase

The abdominal pressure is risen due to asking the patient to cough

Question 34

What can cause the overstimulation of the bladder leading to afferent signals suggesting a full bladder and therefore efferent response to cause detrusor contraction?

Answer 34

Can be caused due to bladder, stones, intravesicle tumours

Question 35

Urge incontinecne can also be caused by health conditions which interfere with the brain’s ability to send messages to the bladder via the spinal cord. Give examples of these conditions?

Answer 35

Parkinson’s, stroke, MS

Question 36

Urine leaks during increased intra abdominal pressure, without a detrusor contraction Which type of incontinence and what can cause it?

Answer 36

This is stress incontinence and it can be caused by coughing, laughing, sneezing

Question 37

Why is the increased intraabdominal pressure able to pass the sphincters causing leakage?

Answer 37

Due to damage to pelvic floor or urethral function eg - childbirth

Question 38

Are stress and urge urinary incontinence able to be diagnosed through a history?

Answer 38

Yes they are able to be diagnosed through a good clinical history

Question 39

Both urge and stress can also be diagnosed through urodynamics however What is seen on stress incontinence?

Answer 39

Ask the patient to cough to test stress dynamics

The rise in abdominal pressure is seen linked to the leakage of urine in the filling phase

Question 40

Often patients can have stress incontinence with an overactive bladder (urge incontinence) With severe detrusor overactivity in urge incontinence, what can sometimes happen?

Answer 40

It can sometimes be brought on by coughing

Question 41

Painless palpable mass arising from pelvis •Cannot “get below” it •Dull to percussion What is the mass? What gender is it usually in? What is the usual type of incontinence associated with it?

Answer 41

Mass is the bladder

Usually seen in males

Associated with overflow incontinence

Question 42

Treatment of overflow incontinence, what function tests are assessed? Also treat the cause of obstruction How can the urine pressure be relieved from the bladder?

Answer 42

Test renal function

Catheritisation often relieves the pressure

Question 43

If there is a backflow of pressure from the vesicle causing renal pelvis dilatation, what is this and how can it be diagnosed?

Answer 43

This is hydronephrosis and can be diagnosed using ultrasound

Question 44

When urge urinary incontinence, what should be avoided from the diet as it can cause irritation from the diet?

Answer 44

Caffeine

Question 45

The patient can also be taught how to pee regularly with urge urinary incontinence The next step after lifestyle is pharmacotherapy, what is the first and second line treatment?

Answer 45

First line drug - Antimuscarinic - such as oxybutynin

(dont give in older 65s due to high anti-cholinergic burden) or tolterodine

Second line - Beta 3 adrenoceptor agonist - such as mirabegon

(By stimulation of β3-AR the contraction of the smooth muscles of the bladder is decreased and the bladder can store more volume of urine at a given time)

Question 46

Why are antimuscarinics good in urge urinary incontinence? What are their side effects?

Answer 46

They act by blocking muscarinic receptors on the detrusor muscle, which are stimulated by acetylcholine.

Therefore decreasing the detrusor overactivity

Due to anti-cholinergic effect it can cause sedation, nausea, delirium

Question 47

What is a main side effect of mirabegron?

Answer 47

Can worsen high blood pressure - usually only in people with very high BP

Question 48

What are the three main non-pharmacological treatments in stress incontinence?

Answer 48

Weight loss

Stop smoking

Pelvic floor exercises - physiotherapy

Question 49

Which drug is useful in the management of urinary stress incontinence? (weak pelvic floor)

Answer 49

Duloxetine (an SNRI) works to help

Question 50

For stress incontinence surgery is mainstay of treatment, what is the type of suspension known as?

Answer 50

Tension free vaginal tape - where there is a mid-urethral sling to stabilise the urethra - usually 1st line now

Colosuspension - stabilises the anterior vaginal wall, bladder neck, and proximal urethra in a retropubic position (older surgery)

Question 51

What are the two extraurethral routes again?

Answer 51

Ectopic ureter - kidney to urethra

Fistula - usually vesico-vaginal fistula

Question 52

Definitions the complaint of any involuntary leakage of urine?
involuntary leakage on effort or exertion, or on sneezing or coughing.?
involuntary leakage accompanied by, or immediately preceded by urgency. ?

Answer 52

the complaint of any involuntary leakage of urine - Urinary incontinence

involuntary leakage on effort or exertion, or on sneezing or coughing.? - Stress urinary incontinence

involuntary leakage accompanied by, or immediately preceded by urgency. - Urgency urinary incontinence

Question 53

Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as what syndrome? What is nocturia?

Answer 53

This can be described as overactive detrusor syndrome or urge syndrome

Nocturia can be defined as the need to wake and pass urine at night, in contrast to enuresis, where urine is passed unintentionally during sleep

Question 54

is involuntary leakage associated with urgency and also with exertion- effort, sneezing or coughing, what is this?

Answer 54

This is mixed urinary incontinence

Question 55

Post micturition means at the end of micturition does any more come out – what is this?

Answer 55

This is terminal dribbling

Question 56

What is terminal dribbling and hesitancy seen in classically?
What is urnary hesitancy?

Answer 56

Seen in benign prostate hyperplasia - need a PR exam to decide if benign or malignant

Urinary hesitancy - Difficulty starting or maintaining a urine stream is called urinary hesitancy.