Neuropathic bladder/urinary incontinence

Question 1

why are women more likely to have incontinence than men?

Answer 1

they have a weak bladder neck mechanism
bladder does not contract very strongly
the urethral sphincter is supported by pelvic floor muscles which are not very strong

Question 2

why are men more likely to have obstructive causes of LUTS than women?

Answer 2

there is both a bladder neck sphincter and a distal urethral sphincter
bladder can contract quite strongly and develop high pressures
urethra is much longer
the distal urethral sphincter is also supported by the pelvic floor
it is the bladder neck mechanism that contributes a lot to obstruction and retention

Question 3

why is there a bladder neck mechanism in males?

Answer 3

to prevent retrograde ejaculation

Question 4

where does the ejaculatory duct joint the urethra?

Answer 4

prostatic urethra

Question 5

is the bladder neck mechanism in males a urinary sphincter?

Answer 5

no it is a gential sphincter to prevent retrograde ejaculation

Question 6

what does the cortex do in micturition?

Answer 6

senses whether the bladder is full

allows voluntary initiation of voiding

Question 7

what does the PMC/PAG allow you to do?

Answer 7

co-ordination of bladder contraction and sphincter relaxation

Question 8

what are the spinal reflexes of micturition?

Answer 8

• reflex bladder contraction when the bladder is full (but overridden by higher centres) - contrplled by the sacral micturition centre
• guarding reflex - controlled by Onuf’s nucleus
• sympathetic - receptive relaxation

Question 9

from what spinal levels are the sympathetic fibres to the bladder?

Answer 9

T10-L2

Question 10

what does the sympathetic NS do in micturition?

Answer 10

inhibits detrusor contraction - ie bladder relaxation

SMOOTH muscle sphincter contraction

Question 11

what does the parasympathetic NS do in micturition?

Answer 11

detrusor contraction

SMOOTH muscle sphincter relaxation

Question 12

what does the somatic pudendal nerve do?

Answer 12

contraction and relaxation of the STRIATED muscle sphincter - you don’t usually use this, but only when you are desperate and trying not to go

Question 13

what are the storage symptoms of LUTS?

Answer 13

frequency
nocturia
incontinence
urgency

Question 14

what are the voiding symptoms of LUTS?

Answer 14

slow stream
splitting or spraying 
hesitancy 
straining 
terminal dribble 
intermittency

Question 15

what are the post micturition symptoms?

Answer 15

post micturition dribble

feeling of incomplete emptying

Question 16

what is the definition of frequency?

Answer 16

passing water more often

Question 17

what is the definition of urgency?

Answer 17

a sudden, compelling desire to void which is difficult to defer

Question 18

nocturia definition?

Answer 18

going to the toilet 2 or more times per night - nocturia is going to the toilet in the middle of the night with the intention of going back to sleep

Question 19

incontinence definition?

Answer 19

involuntary loss of urine

Question 20

intermittency definition?

Answer 20

urinating in a stop-start fashion

Question 21

Hesitancy defintion?

Answer 21

delay in initiation of micturition

Question 22

What parameters can you get from a bladder diary?

Answer 22

• 24 hour urine volume
• volume produced /day
• volume produced/night - if you know what time they went to sleep and woke up
• frequency of urination/day
• frequency of urination/night
• frequency of incontinence
• frequency of nocturia
• nocturnal volume ÷ 24 hour volume
• functional capacity - the maximum value in the bladder diary that the bladder has held

Question 23

what is the normal urinary frequency per day?

Answer 23

2-8

Question 24

what is the normal urinary frequency at night?

Answer 24

0-1

Question 25

what is the normal volume per day produced for a 70kg male?

Answer 25

2L, should be less than 2.7 L

Question 26

what is the normal volume of urine produced per night?

Answer 26

900mL

Question 27

what is the normal nocturnal volume ÷ 24 hour volume?

Answer 27

1/3 = 33%

Question 28

what is the functional capacity of the bladder?

Answer 28

>400ml

Question 29

what os the normal incontinence/day?

Answer 29

0

Question 30

what is urgency/urge incontinence?

Answer 30

incontinence associated with an urgent desire to void which is difficult to defer, usually the result of overactivity of the detrusor muscles

Question 31

what is stress incontinence?

Answer 31

occurs when there is an increase in intra-abdominal pressure eg after a cough or sneeze with weak pelvic floor muscles

Question 32

what is mixed incontinence?

Answer 32

a combination of both stress and urge incontinence

Question 33

what is continuous incontinence?

Answer 33

due to a fistula, eg communication between the badder and the vagina, just keep leaking urine from the vagina

Question 34

what is overflow incontinence?

Answer 34

occurs in the presence of a FULL bladder

Question 35

what is social incontinence?

Answer 35

occurs in those with dementia

Question 36

How is overactive bladder defined?

Answer 36

urgency with frequency, with or without nocturia, when appearing in the absence of local pathology

Question 37

How is detrusor overactivity diagnosed?

Answer 37

urodynamics

Question 38

How is an overactive bladder managed?

Answer 38

``` behavioural therapy antimuscarinic drugs B3 agonists botox sacral neuromodulation surgery ```

Question 39

what behavioural therapy is offered to those with overactive bladder?

Answer 39

* cut out alcohol and caffeine from diet * going to the toilet less often to train the bladder to hold more urine = bladder drill * fluid volume chart helps with this

Question 40

how do anti-muscarinic agents work?

Answer 40

competitive inhibitors of Ach this blpocks the parasympathetic NS and causes the detrusor muscle to relax, increasing bladder capacity the reduces urinary frequency, urgency and urge incontinence in those with OAB they tend to be specific for the M3 receptor, which is present in the bladder

Question 41

Give examples of anti-muscarinic agents for OAB

Answer 41

oxybutynin tolterodine solifenacin they are used as first line pharmacological treatment when bladder training is ineffective

Question 42

Give an example of a beta 3 agonist and explain how it works for OAB

Answer 42

mirabegron beta-3 adrenergic receptor agonist that causes relaxation of the detrusor smooth muscle of the urinary bladder and increases bladder capacity, by increasing sympathetic activity.

Question 43

Hoe does botox work for OA?

Answer 43

it is a neurotoxin and blocks the neuromuscular junction for Ach release, so the bladder relaxes

Question 44

what is a common side effect of anti-muscarinic agents?

Answer 44

dry mouth (remember secretions are parasympathetic and this drugs are anticholinergics)

Question 45

what is a side effect of botox?

Answer 45

paralysis of the bladder requiring catheterisation due to incomplete bladder emptying

Question 46

what is sacral modulation?

Answer 46

insertion of an electrode into the S3 nerve root to modulate afferent signals from the bladder to the brain, as these are the signals that cause urgency

Question 47

what is the surgical option for OAB?

Answer 47

augmentation cystoplasty

Question 48

what are the causes of stress incontinence in females?

Answer 48

• secondary to birth trauma - causes denervation of the pelvic floor and urethral sphincter weakening of fascial support of bladder and urethra • neurogenic • congenital

Question 49

How is stress urinary incontinence managed in women?

Answer 49

pelvic floor physio mainstay is surgery: sling, colposuspension, bulking agents, artificial sphincter (duloxetine is an SSRI that strengthens the female sphincter)

Question 50

what are the causes stress incontinence in males?

Answer 50

neurogenic | iatrogenic eg radical prostatectomy

Question 51

How is stress incontinence in males treated?

Answer 51

artificial sphincter or male sling

Question 52

What are the different causes of urinary obstruction that cause voiding problems?

Answer 52

BPE -men urethral stricture prolapse/mass - mainly in women

Question 53

what is the treatment of voiding symptoms that are not caused by obstruction?

Answer 53

it is likely they have detrusor underactivity so use long-term catheter to empty their bladder or sacral neuromodulation

Question 54

what is the management of men with BPO with no ED?

Answer 54

1st line: alpha antagonist 2nd: 5 alpha reductase inhibitor specialist: TURP

Question 55

what is the management of men with BPO and ED?

Answer 55

1st: PDE5 inhibitor 2nd: alpha agonist specialist: TURP/ intracavernosal injections/ penile implant

Question 56

What are the treatments from 1st to specialist for men with OAB?

Answer 56

1st: antimuscarinic 2nd: b3 agonist/alpha antagonist specialist: botox

Question 57

what are the treatments for mixed stress and urge incontinence in men?

Answer 57

1st antimuscarinic 2nd: B3 agonist specialist: TURP/botox

Question 58

what are the treatments for women with OAB?

Answer 58

1st: antimuscarinic 2nd: B3 agonist specialist: botox

Question 59

What are the treatments for women who have stress urinary incontinence?

Answer 59

1st: physiotherapy specialist: surgery

Question 60

What is an unsafe bladder?

Answer 60

one that puts the kidneys at risk of damage

Question 61

what are the risk factors for an unsafe bladder?

Answer 61

raised bladder pressure vesico-ureteric reflux chronic infection due to residual urine and stones

Question 62

What are the causes of raised bladder pressure?

Answer 62

prolonged detrusor contraction | loss of bladder compliance (eg loss of receptive relaxation due to loss of symp NS)