7 - urinary incontinence

Question 1

what is the incidence of urinary incontinence?

Answer 1

SUI - 47%

UUI - 21%

Question 2

what is the prevalence with age of incontinence?

Answer 2

increased from 20 years up to 50 years where there is a dip. most prevalent in over 90 year olds

Question 3

what happens to the bladder if there is a upper motor neurone lesion

Answer 3

high pressure detrusor contractions. poor coordination with sphincters

Question 4

what is stress incontinence?

Answer 4

Involuntary leakage on effort or exertion, or on sneezing or coughing

Question 5

what is urge incontinence?

Answer 5

involuntary leakage accompanied by or immediately proceeded by urgency

Question 6

what is the difference between stress and urge incontinence?

Answer 6

stress occurs on effort or exertion or on sneezing or coughing.

Question 7

what is the difference between stress and urge incontinence?

Answer 7

stress occurs on effort or exertion or on sneezing or coughing. urge is involuntary leakage accompanied by or immediately proceeded by urgency

Question 8

what are the risk factors associated with urinary incontinence?

Answer 8

pregnancy and childbirth
pelvic prolapse 
race 
family predisposition
obesity 
co-morbidities 
age 
UTI 
drugs 
menopause

Question 9

what are the initial investigations to be done on a patient with suspected UI?

Answer 9

urine dipstick - mandatory
- UTI, haematuria, proteinuria, glucosuria

basic non-invasive urodynamics

• frequency volume chart
• bladder diary (> 3 days)
• post micturition residual volume - if have voiding dysfunction

optional

• invasive urodynamics
• pad tests
• cystoscopy

Question 10

what are the initial investigations to be done on a patient with suspected UI?

Answer 10

urine dipstick
- UTI, haematuria, proteinuria, glucosuria

basic non-invasive urodynamics

• frequency volume chart
• bladder diary (> 3 days)
• post micturition residual volume - if have voiding dysfunction

optional

• invasive urodynamics (pressure - flow studies)
• pad tests
• cystoscopy

Question 11

what is the initial management of a patient with UI?

Answer 11

general lifestyle interventions - modify fluid intake, weight loss, stop smoking, decrease caffeine intake (UUI), avoid constipation, timed voiding - fixed schedule

Question 12

what is contained incontinence?

Answer 12

management for patients unsuitable for surgery who have failed conservative or medical management.

• indwelling catheter
• sheath device (condom catheter)
• incontinence pads

Question 13

what is the initial management of SUI?

Answer 13

pelvic floor training
8 contractions x3/day
at least 3 months

Question 14

what is the initial management of UUI?

Answer 14

bladder training
schedule of voiding: void every hour during the day, not void in between, intervals increased by 15-30 mins a week until interval of 2-3 hours reached
at least 6 weeks

Question 15

what is the pharmacological management of SUI?

Answer 15

duloxetine (noradrenaline + serotonin uptake inhibitor) - increases activity in the striated sphincter during filling phase

Question 16

what is the pharmacological management of UUI?

Answer 16

anti-cholinergics e.g. oxybutynin
acts on muscarinic receptors M2 M3

B3 agonist e.g. mirabegron (increases bladders capacity to store urine)

intravesical injection of botulinum toxin (inhibits release of Ach at pre-synaptic nmj causing targeted flaccid paralysis) 3-6 months duration of actions

Question 17

what are the side effects of drugs (anti-cholinergics acting on M receptors)

Answer 17

M1 - CNS, salivary glands
M2 - heart SM
M3 - SM, salivary glands
M4 - CNS

Question 18

what is the surgical management of patients with SUI?

Answer 18

FEMALES: 
permanent intention:
low tension vaginal tapes 
retropubic suspension procedures
classical sling procedures 

temporary intention: (further pregnancies planned)
intramural bulking agents

MALES:
artificial urinary sphincter
male sling procedure

Question 19

what is a low tension vaginal tape? SUI

Answer 19

it supports the mid urethra, polypropylene mesh. >90% success rates.

Question 20

what is retropubic suspension procedures? SUI

Answer 20

when you correct the anatomical position of proximal urethra and improve urethral support

Question 21

what is classical fascial sling procedures? SUI

Answer 21

supports the urethra and augments bladder outflow resistance

Question 22

what are intramural bulking agents? SUI

Answer 22

improves the ability of urethra to resist abdominal pressure by improving urethral coaptation

Question 23

what is a male artificial urinary sphincter? SUI

Answer 23

gold standard
urethral sphincter deficiency
cuff stimulates the action of a normal sphincter to circumferentially close the urethra

Question 24

what is the surgical management of a patient with UUI?

Answer 24

sacral nerve neuromodulation
autoaugmentation
augmentation cystoplasty
urinary diversion