Week 3 - B - Urinary incontinence Flashcards
What is any involuntary leakage of urine known as?
This is urinary incontinence
Urinary incontinence is often a difficult subject to approach as patients can feel nervous What can they often complain of emotionally?
Feeling embarrassed or distressed
What prevalence of men and women have urinary incontinence?
1in3 women have urinary incontinence
1in10men have urinary incontinence
What are the 4 different types of urinary incontinence?
Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
What is the most common type of incontinence and is usually in women?
This is stress incontinence
Urine may leak by an extraurethral route such as a ectopic ureter or fistula How do these cause incontinence?
Ectopic ureter is a ureter that connects usually to the urethra
Fistula causes an opening between urethra and vagina causing drippage of urine
What are the two stages of the micturition cycle?
The filling (storage) phase and The voiding phase
Describe the filling phase of micturition? (only intravesical and urethral pressure for now)
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
What happens to the detrusor and abdominal pressure during the filling phase?
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
What is compliance of the bladder?
This is the ability for the bladder to keep the intravesical pressure relatively stable due to the detrusor muscle expanding
The second phase of micturition is the voiding phase What happens here?
The detrusor pressure increases as it contracts to push urine out causing the intravesical pressure to therefore decrease
Abdominal pressure should remain the same
What happens during urodynamics to measure the different pressures?
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
How is the detrusor pressure calculated?
The detrusor muscle is calculated by the difference between the intravesical and abdominal pressures
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?
The cystourethrogram allows pictures to be taken whilst you are urinating and filling
(cysto - bladder, urethro - urethra)
What are the 3 different components of the micturition reflex?
Bladders and sphincters
Spinal bladder control centre
Micturition centre in the brain
WHat nerves are the spinal to bladder control centre? Where is the micturition centre in the brain?
S2-4 is the spinal to bladder control centre
Micturition centre in the brain is located in the pons
Is the storage phase of micturition under sympathetic or parasympathetic control?
Storage phase is under sympathetic control as it cause the internal urethral sphincter to keep closed
sympathetic control to the bladder is via the hypogastric nerves What level is this?
This is T10-L2
The voiding phase is under parasympathetic control Which nerves cause the internal urethral sphincter to open and the detrusor muscle to contract?
S2-S4 parasympathetic nerves from the sacral plexus cause the detrusor to contract and the internal urethral sphincter to open
What is the sphincter under voluntary control in micturition and why? What is its nerve supply?
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)
Often old male patients can present with a large palpable bladder and chronic urinary retention What is this type of incontinence?
This is overflow incontinence
When will patients often complain of incontinency in overflow incontinence?
Often complain of incontinence at night whilst sleeping or terminal dribbling
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?
Eventually the detrusor muscle continue to stretch causing hypertrophy and eventually it can stop functioning
Why can renal impairment happen with overflow incontinence?
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
Apart from BPH, what are potential other causes of overflow incontinence?
Bladder stones in the ureter
Detrusor muscle impairment preventing contraction
Anticholinergics stopping parasympthatetics - important to know if on any
Tumours
What is the non pharmacological treatment in overflow urinary retention? (voiding difficulty)
Conservative management, which involves: Pelvic floor muscle training and bladder training.
Avoid constipation
Potentially catheterisation if acute retention - usually suprapubic
What is the pharmacological management given to treat overflow urinary retention? How long do they take to work and how do they work?
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)
What are main side effects of both alpha blockers (tamsulosin) and 5-alpha reductase inhibitors (eg finasteride)?
Tamsulosin - can cause hypotension
Alpha reductase inhibitor - can cause sexual dysfunction / gynaecomostia
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?
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),
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?
This is urge urinary incontinence
What can the urge to go to the toilet typically be provocated by?
Turning key to open door, running water, standing up
What is believed to be a cause of urge incontinence?
Detrusor overactivity causing impulse to pee
Detrusor over-activity is diagnosed by urodynamic What does it show on urodynamics?
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
What can cause the overstimulation of the bladder leading to afferent signals suggesting a full bladder and therefore efferent response to cause detrusor contraction?
Can be caused due to bladder, stones, intravesicle tumours
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?
Parkinson’s, stroke, MS
Urine leaks during increased intra abdominal pressure, without a detrusor contraction Which type of incontinence and what can cause it?
This is stress incontinence and it can be caused by coughing, laughing, sneezing
Why is the increased intraabdominal pressure able to pass the sphincters causing leakage?
Due to damage to pelvic floor or urethral function eg - childbirth
Are stress and urge urinary incontinence able to be diagnosed through a history?
Yes they are able to be diagnosed through a good clinical history
Both urge and stress can also be diagnosed through urodynamics however What is seen on stress incontinence?
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
Often patients can have stress incontinence with an overactive bladder (urge incontinence) With severe detrusor overactivity in urge incontinence, what can sometimes happen?
It can sometimes be brought on by coughing
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?
Mass is the bladder
Usually seen in males
Associated with overflow incontinence
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?
Test renal function
Catheritisation often relieves the pressure
If there is a backflow of pressure from the vesicle causing renal pelvis dilatation, what is this and how can it be diagnosed?
This is hydronephrosis and can be diagnosed using ultrasound
When urge urinary incontinence, what should be avoided from the diet as it can cause irritation from the diet?
Caffeine
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?
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)
Why are antimuscarinics good in urge urinary incontinence? What are their side effects?
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
What is a main side effect of mirabegron?
Can worsen high blood pressure - usually only in people with very high BP
What are the three main non-pharmacological treatments in stress incontinence?
Weight loss
Stop smoking
Pelvic floor exercises - physiotherapy
Which drug is useful in the management of urinary stress incontinence? (weak pelvic floor)
Duloxetine (an SNRI) works to help
For stress incontinence surgery is mainstay of treatment, what is the type of suspension known as?
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)
What are the two extraurethral routes again?
Ectopic ureter - kidney to urethra
Fistula - usually vesico-vaginal fistula
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. ?
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
Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as what syndrome? What is nocturia?
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
is involuntary leakage associated with urgency and also with exertion- effort, sneezing or coughing, what is this?
This is mixed urinary incontinence
Post micturition means at the end of micturition does any more come out – what is this?
This is terminal dribbling
What is terminal dribbling and hesitancy seen in classically?
What is urnary hesitancy?
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.
