Incontinence

Question 1

What 2 factors usually ensure continence between voiding? (2)

Answer 1

1. Intravesical pressure remains low due to stretching of the bladder and stability of detrusor muscle which does not contract involuntarily.
2. Sphincter mechanisms of the bladder neck and urethral muscles.

Question 2

Describe the process of voiding. (2)

Answer 2

Onset:
sphincters relax (decreased sympathetic activity)
detrusor muscle relaxes (increased parasympathetic activity)
Overall control by cerebral cortex and pons.

Question 3

Name the 5 types of incontinence. (5)

Clue FOCUS

Answer 3

Functional
Overflow
Continuous (fistula)
Urge
Stress

Question 4

Name 2 causes of stress incontinence. (2)

Answer 4

Men: post-prostatectomy
Women: after vaginal delivery; forceps delivery; obesity, increased age.

Question 5

What is stress incontinence? (2)

Answer 5

Raised intra-abdominal pressure is transmitted to bladder but not to urethral sphincter as a result of sphincter weakness (bladder neck slipped below pelvic floor); there is a small leak of urine when intra-abdominal pressure rises.

Question 6

What is the treatment of stress incontinence? (2)

Answer 6

Conservative: Pelvic floor exercises for at least 3 months.
Medical: Duloxetine
Surgical: “mid-urethral sling” eg tension-free vaginal tape (TVT)

Question 7

What investigations should be performed when considering a diagnosis of stress incontinence? (2)

Answer 7

Dipstick (rule out UTI)

Cystometry (rule out overactive bladder)

Question 8

What is overactive bladder? (2)

Answer 8

Defined as urgency with or without urge incontinence, usually with frequency or nocturia in the absence of infection.

Question 9

How can overactive bladder and stress incontinence be confused? (2)

Answer 9

Stress incontinence results in leakage of urine on raising intra-abdominal pressure eg coughing.
Coughing can also stimulate detrusor contraction as seen in overactive bladder.

Question 10

Name a trigger for urge incontinence. (1)

Answer 10

Excessive caffeine.

Question 11

What is the management for overactive bladder/urge incontinence? (3)

Answer 11

Conservative:
Urinary diary- reduce fluid intake or caffeine intake
Med review- reduce diuretics or anti-psychotics
Bladder training.

Medical:
Anticholinergics eg oxybutynin relax detrusor muscle.
Vaginal oestrogens after menopause
Botulinum toxin A

Question 12

What volume can the bladder hold when you feel the first urge to void? (1)
How much can it store? (1)

Answer 12

200ml

500ml

Question 13

What information is kept in a urinary diary? (2)

Answer 13

Record over 1 week of time and volume of fluid intake and micturition.

Question 14

What is cystometry? (1)

Answer 14

Direct measure (via a catheter) of pressure in the bladder whilst bladder is filled and provoked with coughing.
A pressure transducer is also placed in the rectum or vagina to measure abdominal pressure.

The detrusor pressure can then be calculated by the intra-abdominal pressure - the urethral pressure.

Question 15

How can cystometry distinguish between stress and urge incontinence? (2)

Answer 15

There is involuntary leakage of urine on raising intra-abdominal pressure e.g. coughing then if there is a contraction of detrusor muscle the diagnosis is overactive bladder/urge incontinence.
If the detrusor does not contract then it is likely to be stress incontinence.

Question 16

Which type of incontinence is associated with vaginal prolapse? (1)

Answer 16

Stress