WEEK 1: INCONTINENCE AND URINARY RETENTION

Question 1

What is urinary retention?

Who is it commonly found in?

Answer 1

Urinary retention (UR) can be defined as inability to achieve complete bladder emptying by voluntary micturition, and categorized as acute UR, chronic UR or incomplete bladder emptying. UR is common in elderly men.

Question 2

For male patients, particularly in older age groups, what is comparatively common, usually as a consequence of benign prostate enlargement (BPE)?

Answer 2

For male patients, particularly in older age groups, bladder outlet obstruction (BOO) is comparatively common, usually as a consequence of benign prostate enlargement (BPE).

Question 3

Most common in men in their fifties and sixties because of __________.

A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called ________.

The bladder can also sag or be pulled out of position by a sagging of the lower part of the colon, in a condition called_________.

People of all ages and both sexes can have nerve disease or nerve damage that interferes with bladder function.

Answer 3

Most common in men in their fifties and sixties because of prostate enlargement.

A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele.

The bladder can also sag or be pulled out of position by a sagging of the lower part of the colon, a condition called rectocele.

Question 4

Outline causes of urinary retention.

Answer 4

-vaginal childbirth
-infections of the brain or spinal cord
-diabetes
-stroke
-accidents that injure the brain or spinal cord
-multiple sclerosis
-heavy metal poisoning
-pelvic injury or trauma

There are numerous causes now recognized in women, broadly categorized as infective, pharmacological, neurological, anatomical, myopathic and functional.

Question 5

What are the symptoms of urinary retention?

Acute
Chronic

Answer 5

Acute urinary retention causes great discomfort, a pain, urgent need to urinate, the lower belly is bloated.

Chronic urinary retention, by comparison, causes mild but constant discomfort. Difficulty starting a stream of urine. Once started, the flow is weak dribbling of urine urge to urinate a condition called overflow incontinence.

Question 6

Describe the diagnosis of urinary retention.

Answer 6

Urine Sample
A urine sample will be examined for signs of infection, which may be a cause or a result of urinary retention.

Bladder Scan
A bladder scan uses an ultrasound device that can determine how much urine is in the bladder.

Patient is asked to urinate, and then doctor or nurse will use the bladder scan to determine the post-void residual (PVR).

The word residual refers to the amount of urine left in the bladder after urinating.

Question 7

How is urinary retention diagnosed?

Answer 7

How is urinary retention diagnosed?

History of Complaints and Physical Examination
A physician will suspect urinary retention by asking about the symptoms and will attempt to confirm the diagnosis with a physical examination of the lower abdomen.

The physician may be able to feel the distended bladder by lightly tapping on your lower belly. Tapping or striking for diagnostic purposes is called percussing.

Question 8

State the diagnostic methods for urinary retention.

Answer 8

Rectal examination
PSA
CT abdomen pelvis
Prostate biopsy
Urodynamic tests

Rectal Examination:

Purpose: A rectal examination involves the insertion of a gloved, lubricated finger into the rectum to feel for abnormalities in the prostate gland. It is commonly performed as part of a routine physical examination or to assess the prostate’s size, texture, and any signs of irregularities, especially in the context of prostate cancer screening.
PSA (Prostate-Specific Antigen) Test:

Purpose: The PSA test measures the levels of a protein produced by the prostate gland in the blood. Elevated PSA levels can indicate various prostate conditions, including benign prostatic hyperplasia (BPH) or prostate cancer. However, an elevated PSA level does not necessarily confirm cancer, and further diagnostic tests may be needed.
CT (Computed Tomography) Abdomen and Pelvis:

Purpose: A CT scan of the abdomen and pelvis is a diagnostic imaging test that uses X-rays to create detailed cross-sectional images of the abdominal and pelvic regions. It is often used to evaluate the anatomy and detect abnormalities in organs such as the prostate, bladder, kidneys, and surrounding structures.
Prostate Biopsy:

Purpose: A prostate biopsy involves the removal of small tissue samples from the prostate gland for microscopic examination. It is typically performed when there are suspicions of prostate cancer based on elevated PSA levels or abnormal findings on a rectal examination. The samples are analyzed to determine whether cancer cells are present.
Urodynamic Tests:

Purpose: Urodynamic tests assess how well the bladder and urethra are storing and releasing urine. These tests are used to evaluate urinary incontinence, difficulties with urination, or other bladder-related issues. Urodynamic tests may include measuring bladder pressure, urine flow rate, and other parameters to diagnose and plan treatment for various urological conditions.

Question 9

State 3 complications of urinary retention.

Answer 9

UTI
CKD
BLADDER DAMAGE

Question 10

STATE 3 TREATMENT OF URINARY RETENTION METHODS

Answer 10

*CATHETERIZATION
*TREATMENT TO RELIEVE PROSTATE ENLARGEMENT
*WOMEN – TREATMENT OF RECTOCELE AND CYSTOCELE

Question 11

What is urinary incontinence?

Answer 11

Urinary incontinence (UI), involuntary urination, is leakage of urine.

Impacts quality of life

Results from treatable underlying conditions often underreported.

Question 12

State the causes of urinary incontinence in women.

Answer 12

Women:

1. Stress urinary incontinence:

loss of support of the urethra which is usually a consequence of damage to pelvic support structures as a result of childbirth.

It is characterized by leaking of small amounts of urine with activities which increase abdominal pressure such as coughing, sneezing and lifting.

2. Urge urinary incontinence is caused by uninhibited contractions of the detrusor muscle. It is characterized by leaking of large amounts of urine in association with insufficient warning to get to the bathroom in time.
3. Polyuria (excessive urine production) of which, in turn, the most frequent causes are uncontrolled diabetes mellitus, primary polydipsia (excessive fluid drinking), central diabetes insipidus and nephrogenic diabetes insipidus. [Polyuria generally causes urinary urgency and frequency but doesn’t necessarily lead to incontinence.

Question 13

Describe the pathophysiology of urinary incontinence.

Answer 13

Continence and micturition involve a balance between urethral closure and detrusor muscle activity.

Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls, and bladder pressure rises.

During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra.

At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body.

Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding the urethra suddenly relax (sphincter muscles).

Question 14

Describe urinary incontinence in children.

Answer 14

Urination, or voiding, is a complex activity. The bladder is a balloon like muscle that lies in the lowest part of the abdomen.

The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body.

Controlling this activity involves nerves, muscles, the spinal cord and the brain.

The bladder is made of two types of muscles:
The detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra.
A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby’s bladder fills to a set point, then automatically contracts and empties.

As the child gets older, the nervous system develops. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.

Question 15

Describe the diagnostic tests for urinary incontinence.

Answer 15

Stress test– the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.

Urinalysis– urine is tested for evidence of infection, urinary stones, or other contributing causes.

Blood tests– blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.

Ultrasound– sound waves are used to visualize the kidneys, ureters, bladder, and urethra.

Cystoscopy– a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.

Question 16

Describe the 3 types of urinary incontinence.

Answer 16

`1. Transient incontinence is a temporary version of incontinence.

It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.

2. Giggle incontinence is an involuntary response to laughter. It usually affects children.
3. Double incontinence. There is also a related condition for defecation known as fecal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to have fecal incontinence in addition.] This is sometimes termed “double incontinence”.

Question 17

Describe the treatment of urinary incontinence.

Answer 17

Treatment
Treatment options range from conservative treatment, behavior management, bladder retraining, pelvic floor therapy, collecting devices (for men), fixer-occluder devices for incontinence (in men), medications and surgery. The success of treatment depends on the correct diagnoses. Weight loss is recommended in those who are obese.

1. Exercising the muscles of the pelvis such as with Kegel exercises are a first line treatment for women with stress incontinence.

Efforts to increase the time between urination, known as bladder training, is recommended in those with urge incontinence.

Both these may be used in those with mixed incontinence.

Small vaginal cones of increasing weight may be used to help with exercise

2. A number of medications exist to treat incontinence including: fesoterodine, tolterodine and oxybutynin. While a number appear to have a small benefit, the risk of side effects is a concern.

For every ten or so people treated only one will become able to control their urine and all medication are of similar benefit.

Medications are not recommended for those with stress incontinence and are only recommended in those who have urge incontinence who do not improve with bladder training.

3. Surgery may be used to alleviate incontinence after other treatments have been tried and found not to be effective.

Urodynamic testing seems to confirm that surgical restoration of vault prolapse can cure motor urge incontinence. In those with problems following prostate surgery there is little evidence regarding the use of surgery.

4. The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine or porcine) or the patients own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a backboard of support under the urethra.

Tension-free transvaginal tape
The tension-free transvaginal tape(TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra. The 20-minute outpatient procedure involves two miniature incisions and has an 86-95% cure rate. Complications, such as bladder perforation, can occur in the retropubic space if the procedure is not done correctly. This minimally invasive procedure is a common treatment for stress urinary incontinence.

Transobturator tape
The transobturator tape (TOT) sling procedure aims to eliminate stress urinary incontinence by providing support under the urethra. This minimally invasive procedure eliminates retropubic needle passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area. While the procedure has shown risks during its infancy, recent developments have increased the cure rate to 90%.

Mini-sling
The mini-sling procedure has reported short term cure rates of 67% to 83%.
Needleless sling
The needleless sling is a single incision TOT. It is implanted via one unique incision. The needleless has approximately 136% more surface area than the mini sling, which may better support the pelvic floor and urethra, and no sharp instruments are required to implant the sling besides the scalpel used to make the incision, which may enhance patient comfort.

Readjustable sling
The re-adjustable sling consists of a standard synthetic mesh sling combined with sutures that attach to an implantable tensioning device that resides permanently under the skin in the abdominal wall. Once implanted, this Readjustable Mechanical External (REMEEX) device can be re-accessed under local anesthesia to fine tune the sling should incontinence reappear months or years after the initial surgery

5. Bladder repositioning
   Most stress incontinence in women results from the bladder dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament or bone. For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder but also compresses the bottom if the bladder and the top of the urethra, further preventing leakage.
6. Marshall-Marchetti-Krantz
   The Marshall-Marchetti-Krantz (MMK) procedure, also known as retropubic suspension or bladder neck suspension surgery, is performed by a surgeon in a hospital setting. Developed in 1949 by doctors Victor F. Marshall (1913–2001), a urologist, Andrew Anthony Marchetti (1901–1970), an OB/GYN, and Kermit E. Krantz (OB/GYN) is the standard by which new procedures are measured.
7. Devices
   Individuals who continue to experience urinary incontinence need to find a management solution that matches their individual situation. The use of devices has not been well studied in women as of 2014.

Collecting systems (for men) – consists of a sheath worn over the penis funneling the urine into a urine bag worn on the leg. These products come in a variety of materials and sizes for individual fit. Studies show that urisheaths and urine bags are preferred over absorbent products – in particular when it comes to ‘limitations to daily activities’. Solutions exist for all levels of incontinence. Advantages with collecting systems are that they are discreet, the skin stays dry all the time, and they are convenient to use both day and night. Disadvantages are that it is necessary to get measured to ensure proper fit and you need a health care professional to write a prescription for them.

Fixer-occluder devices (for men) are strapped around the penis, softly pressing the urethra and stopping the flow of urine. This management solution is only suitable for light or moderate incontinence.

Indwelling catheters (also known as foleys) are very often used in hospital settings or if the user is not able to handle any of the above solutions himself. The indwelling catheter is typically connected to a urine bag that can be worn on the leg or hang on the side of the bed. Indwelling catheters need to be changed on a regular basis by a health care professional. The advantage of indwelling catheters are, that the urine gets funneled away from the body keeping the skin dry. The disadvantage, however, is that it is very common to get urinary tract infections when using indwelling catheters.[23]

Intermittent catheters are single use catheters t