Urinary Incontinence

Question 1

define incontinence

Answer 1

involuntary micturition

Question 2

define compliance of the bladder

Answer 2

normally the vesico-elastic proeprties of teh bladder allow it to store increasing volumes of urine with little change in bladder pressure until capacity is reached

Question 3

what does a cysometrogram measure

Answer 3

• cystometry measures the contractile force of the bladder when voiding
• generates a cystometrogram which plots volume of liquid emptied from the bladder agaisnt intravesical pressure

Question 4

describe what happens during normal voiding

Answer 4

• emptying of bladder results in a bell shaped curve on uroflowmetry with a rise to peak amplitude
• following voiding, bladder pressure decreases rapidly, pelvic floor muscles contract and the bladder neck closes

Question 5

how may compliance lead to incontinence

Answer 5

poor compliance means significant increase in bladder pressure with small increases in bladder volume - may lead to incontinence

Question 6

what happens to bladder compliance with dialysis

Answer 6

• bladder compliance decreases the longer the duration fo dialysis continues

Question 7

how would bladder outlet obstruction be indicated on a cystometrogram

Answer 7

high voiding detrusor pressure with a low flow rate

Question 8

define urge incontinence

Answer 8

• involuntary leakage accompanied by, or immediately preceding urgency
• often described as the complaint of a sudden compelling desire to pass urine, which is difficult to defer

Question 9

how does urge incontinence present

Answer 9

daytime frequncy, small voided volumes, urgency (may be triggered), enuresis

Question 10

causes of urge incontinence

Answer 10

phasic increases in detrusor muscle (over activity):

• This can be due to central inhibitory pathway malfunction (e.g. paraplegia) or sensitisation of the peripheral afferent terminals in the bladder
• Destruction of sacral nerves
• Pelvic surgery/fracture can damage sacral nerves
• Can be a bladder muscle problem
• Neurological: DM, MS and Parkinson’s damage nerves involved in the micturition reflex
• Infection/stones/cancer can irritate the bladder and stimulate afferent nerves
• Constipation can stimulate the nerves
• Idiopathic

Question 11

what diseases can damage the nerves involved in the micturition reflex and cause urge incontinence

Answer 11

DM, MS, Parkinsons

Question 12

what is bladder dysfunction characterised by

Answer 12

asynchronous detrusor contractions and inhibition of voiding

Question 13

treatment of urge incontinence

Answer 13

• dietary discretion
• biofeedback
• drugs
• botulinum toxin
• neuromodulation (bladder pacemaker)
• surgery

Question 14

what does biofeedback involve

Answer 14

learning to control the urge to urinate

Question 15

what drugs are used for urge incontinence

Answer 15

• anti-muscarinics eg oxybutynin and tolterodine
  
  • bladder voiding involves stimulation of the muscarinic receptors of the detrusor muscle by ACh
  • there is some negative effect on detrusor contraction
  • but improve frequency and urgency
• beta 3 adrenergics (eg mirabegron) are 2nd line

Question 16

what surgery is indicated for urge incontinence

Answer 16

enterocystoplasty

Question 17

stress incontinence

Answer 17

• increased abdominal pressure that overwhelms sphincter muscles without detrusor contraction
• eg cough, sneeze, laugh

Question 18

causes of stress incontinence

Answer 18

• damage to pelvic floro or urethral function eg childbirth
• incompetent sphincter eg old age and obesity

Question 19

typical history of stress incontinence

Answer 19

loss of small but infrequent amounts of urine on coughing etc

Question 20

how does pregnancy cause stress incontinence

Answer 20

child puts pressure on bladder

Question 21

treatment of stress incontinence

Answer 21

• weight loss and smoking cessation
• pelvic floor exercises strengthen external sphincter muscles - Kegel exercises
• drugs - limited role
• surgical correction

Question 22

what drugs are used for the management of stress incontinence

Answer 22

duloxetine and norephinephrine

Question 23

surgical correction of stress incontinence

Answer 23

tension free vaginal tape to support the urethra

Question 24

name 2 ways to record urine at home

Answer 24

• frequency volume chart records the volume voided as wll as the time of each micturition for at least 24 hours
• bladder diary

Question 25

overflow incontinence

Answer 25

• there is a problem with emptying
• eg due to blockage in urine flow or ineffective detrusor muscle

Question 26

how does overflow incontinence present

Answer 26

• urine leaks from the bladder, often at night
• weak/intermittent flow
• hesitancy
• large palpable bladder due to chronic retention

Question 27

treatment of overflow incontinence

Answer 27

remove blockage or alpha blocker

Question 28

treatment of mixed incontinence

Answer 28

treat based on the dominant cause

Question 29

alpha blocker mechanism

Answer 29

relax striated and smooth muscle

Question 30

mixed incontinence

Answer 30

combination of urge and stress - leakage associated with increased abdominal pressure and urgency

Question 31

define overactive bladder syndrome

Answer 31

urgency with/out urge incontinence, often with frequency and nocturia

Question 32

cause of urinary incontinence in the elderly

Answer 32

• multifactorial: immobility, dementia, drugs (eg sedatives, diuretics), obstruction, overflow, neuropathy, pelvic floor weakness

Question 33

ectopic ureter

Answer 33

• rare and congenital
• can cause urinary incontinence

Question 34

vesico-vaginal fistula

Answer 34

• important in developing countries due to prolonged obstructed labour