Incontinence

Question 1

Bladder nerve supply for storage, voiding and voluntary?

Answer 1

Storage = Sympathetic (T10-L2)

Voiding = parasympathetic (S2-4)

Voluntary = somatic pudendal nerve (S2-4)

Question 2

What are normal bladder volumes?

Answer 2

120mls = feeling something is there
200mls = desire to urinate
500mls = urgency to urinate

Question 3

What is the bladder emptying process?

Answer 3

Detrusor contraction
Urethral relaxation
Sphincter co-ordination
Absence of obstruction or anatomical shunts

Cortical influence (Pontine centre)
--> activation of para and inhibition of symp pathway

Question 4

What is urinary incontinence?

Answer 4

ANY involuntary leakage of urine

Question 5

What is stress urinary incontinence?

Answer 5

Involuntary leakage on effort or exertion, on sneezing or coughing

Question 6

What is urge urinary incontinence?

Answer 6

Involuntary leakage accompanied by or immediately preceded by urgency

Question 7

What is mixed urinary incontinence?

Answer 7

Involuntary leakage accompanied by or immediately preceded by urgency on effort or exertion, on sneezing or coughing

Question 8

What are the risk factors for UI?

Answer 8

Age
Parity
Menopause
Smoking
Medical problems
-Diabetes 
Increased intra abdo pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery

Question 9

How to assess patients with UI?

Answer 9

History
Examination
-General, abdominal, neurological, gynecological and pelvic floor assessment
-Prolapse, stress incontinence, uro-genital atrophy changes, pelvic mass, pelvic floor tone
Investigations
Management

Question 10

What is the patient assessment for UI?

Answer 10

3 day urinary diary

• Fluid intake
• Urine output
• Daytime frequency
• Nocturia
• Average voided volume

Urine dipstick - MSSU

Question 11

What are the investigations for incontinence ?

Answer 11

Urinalysis
Post voiding residual volume assessment - scanning
Urodynamics - only indicated if surgical treatment is contemplated

Question 12

What is the management for UI?

Answer 12

Lifestyle changes
-Smoking, weight, diet, alcohol and caffeine
Medial treatments
-Duloxetine (nausea)
Physiotherapy
-Pelvic floor muscle training
Surgery
-BMI <35

Question 13

What is the management for overactive bladder?

Answer 13

Treat symptoms
No immediate cure
MDT approach
Requires dedicated team

Lifestyle

• Normalise fluid
• Reduce caffeine
• Stop smoking
• Weight loss
• Bladder training programme

Question 14

What is the pharmacological treatment for UI?

Answer 14

Antimuscarinic oral drugs / transdermal patches
Anyicholinergic agents
Tri-cyclic antidepressants
Beta adrenoceptor agonist = Betmiga

Botox
Neuromodulation (needle stimulation at S2-4 = reflex inhibition to the detrusor muscle)