Incontinence

Question 1

What stimulates voiding

Answer 1

Parasympathetic S2-S4
Muscarinic receptors
Contract detrusor muscle
Pelvic nerves

Question 2

What causes detrusor muscle relaxation (storage)

Answer 2

Sympathetic B-adrenoreceptor have constant inhibitory affect on bladder contraction allowing storage
Hypogastric - T10-L2

Question 3

What causes internal sphincter contraction (storage)

Answer 3

Sympathetic a-adrenoreceptor

Hypogastric - T10-L2

Question 4

What allows voluntary motor control over urination

Answer 4

Pudendal S2-S4 control external sphincter contraction and pelvic floor

Question 5

How does urination occur

Answer 5

Stretch receptors detect filling
Go to spinal cord
Stimulate para and detrusor contracts

Question 6

How do you have voluntary control over urination

Answer 6

Pontine micturition centre can block para until voluntary switch to voiding occurs
Frontal cortex has overall control

Question 7

What are age related causes of incontinence

Answer 7

Increased residual volume + decreased capacity
Vaginal atrophy
Prostate hypertrophy

Question 8

What co-morbidities cause incontinence

Answer 8

Bladder outlet obstruction
Stroke
Spinal cord pathology
Cognitive

Question 9

What are environmental causes

Answer 9

Assistance
Mobility
Toilet on different level
Home / social 
Increased water intake

Question 10

What are reversible causes of incontinence

Answer 10

Polydipsia
Medication - diuretics 
Delerium
Prolapse
UTI 
Constipation

Question 11

What are the types of incontinence

Answer 11

Stress
Urge / overactive bladder
Retention with overflow
Underactive

Question 12

What is stress incontinence

Answer 12

Leakage on increased intra-abdominal pressure
Pressure > urethral pressure holding sphincter
Weak outlet

Question 13

What causes SUI

Answer 13

Intra abdominal > urethral pressure
Weak external sphincter / pelvic floor
Hammox laxity stimulating stretch receptors

RF
Women with children 
Post-menopause
Obesity
Smoking
Chronic cough 
Prostate or pelvic surgery

Question 14

What causes urge incontinence / overactive bladder (incontinence immediately proceeded by urgency)

Answer 14

Detrusor instability / overactivity
Overactive bladder even if low volume
Bladder stones / cancer
Stroke / neuro

Question 15

What are the symptoms of urge incontinence / overactive bladder

Answer 15

Frequency
Nocturnal incontinence
Urgency
Patient knows every toilet or never leaves house

Question 16

What causes retention with overflow

Answer 16

Obstruction - tumour / BPH / urethral stricture / anti-cholinergic

Question 17

What are the symptoms of overflow

Answer 17

Hesitancy
Reduced stream
Dribbling 
Double void
Palpable bladder 
Blockage at urethra

Question 18

How do you investigate incontinence

Answer 18

History inc social + extrinsic factors
Urine dipstick / MSSU = 1st line to exclude infection
Bladder diary - intake and outtake
Examination - abdominal / PV / PR
Post void residual assessment if can’t void / overflow - bladder scan
Urodynamics if surgery contemplated
Refer to specialist

Question 19

What do you look for in examination

Answer 19

Anal tone - neuropathic
Strength of pelvic floor 
Constipation as RF for incontinence 
Prolapse 
Vaginal atrophy - oestrogen cream may help

Question 20

When do you refer to a specialist

Answer 20

Failure of initial management

Faecal incontinence

Question 21

When do you refer at onset

Answer 21

Vesico-vaginal fistula 
Palpable bladder after micturition 
CNS disease 
Severe BPH 
Previous Rx 
Fibroids
Prolapse - rectocele / cystocele

Question 22

What is general management of incontinence

Answer 22

Weight control
Fluid control 
Stop unnecessary drugs 
Reduce irritants - caffeine / alcohol / drugs 
Make toilet accessible

Question 23

What do you do if all management fails

Answer 23

Incontinence pads
Urosheath
Catherisation

Question 24

What is 1st line in SUI

Answer 24

PFMT

Biofeedback to tell if working

Question 25

What are other Rx for SUI

Answer 25

Duloxitine / Yentreve Oestrogen cream Surgery - TVT 1st line or colposuspension Risk of bladder perforation, vascular injury, erosion of TVT leading to UTI

Question 26

How is 1st line for urge

Answer 26

Bladder retraining programme + prompted regular toilet

Question 27

What is drug treatment for urge

Answer 27

``` Anticholinergics / anti-muscarinics to relax detrusor - Oxybutynin - Mirebegron if >75 Botulinum toxin Sacral nerve stimulation TCA ```

Question 28

What are SE of anti-cholinergic

Answer 28

Cognitive Postural hypo as cholinergic cause dilatation Retention Constipation Eye issues as receptors in eyes cause constriction Dry mouth CI - BPH - Narrow angle glaucoma - Myasthenia grans

Question 29

How do you treat overflow

Answer 29

Relieve obstruction - anti-androgen / TURP for prostate | A-blocker - relax sphincter

Question 30

When do you use a catheter

Answer 30

Last resort Symptomatic urinary retention Bladder obstruction that cannot be cleared Undue stress

Question 31

What are main drugs used to treat incontinece

Answer 31

Anti-muscarinic - relax detrusor B-adrenoreceptor agonist - relax detrusor Alpha blocker - relax sphincter Anti-androgen

Question 32

What causes an underactive bladder

Answer 32

Neurological disease - MS / stroke | Prolonged catheter as muscle atrophy

Question 33

What are the symptoms of underactive bladder

Answer 33

No awareness of filling | Results in overflow incontinence

Question 34

How do you treat underactive bladder

Answer 34

Parasympa mimetic might help | Only treatment is catheter

Question 35

What are the RF for SUI

Answer 35

``` Age Parity = main RF Menopause Smoking Increase in intra abdominal pressure Pelvic floor trauma Connective tissue disease Nerve problems Pelvic Surgery Obesity ```

Question 36

What are other causes of SUI / Ddx that should be looked for

Answer 36

``` Anxiety Excess fluid UTI Stone Atrophy ```

Question 37

What is important in the Hx

Answer 37

Obstetric Gynae Medical Previous PFMT / surgery