urinary incontinence

Question 1

what is incontinence

Answer 1

involunatry loss of urine/stool in suffiecient amount or frequency to constitute a social/health problem

Question 2

urinary incontinence epidemiology

Answer 2

1. more prevelent in women
2. bimodal age distrubition with peaks at 50-55yro (menopaurse) and then 75+

Question 3

what are the 7 types of incontinence

Answer 3

1. stress
2. urge
3. mixed
4. overflow/nocturnal enuresis
5. functional
6. continuous
7. post micturition dribbling

Question 4

what is urge incontinence

Answer 4

the involuntary leakage of urine accompanied by urgency -> sudden compelling desire to void which is difficult to defer

Question 5

what is stress incontinence

Answer 5

involuntary leakage on effort, exertion, sneezing etc. -> caused by weakness of the pelvic floor

Question 6

what are the 2 phases of the bladder

Answer 6

1. storage phase -> requires compliant bladder, competent bladder outlet and neurological sensory input
2. voiding phase -> requires contractile detrusor and competent bladder outlet

Question 7

5 neurological areas involved in bladder functions + what they do

Answer 7

1. cerebral cortex - detection of need to void and initiation of voiding at appropriate time
2. pontine micturition centre - brainstem, relay centre between brain and spinal chord
3. sympathetic systhem (T10-L2) -> inhibition of the parasymp., contractino of outflow tract, low pressure storage vessel
4. parasymathetic systme (S2-S4) -> excitatory to bladder smooth muscle - DETRUCTOR contraction, voiding phase
5. somatic (S2-4) -> external urethral sphincter contraction, pelvic floor contraction, continence and co-ordinating voiding

Question 8

what are the 4 parts of the urethra in males

Answer 8

1. prostatic urtehtra
2. membranous urethra
3. bulbular urethra
4. penile urethra

Question 9

during storage what features does the bladder display (2)

Answer 9

1. compliant (can expand and allow filling)
2. sensate

Question 10

during emptying what feature does the bladder display

Answer 10

contractile

Question 11

during storage what feature does the bladder outlet display

Answer 11

competent

Question 12

during emptying what feature does the bladder outlet display

Answer 12

relaxation

Question 13

3 conditions associated with urge incontinence

Answer 13

1. detrusor overactivity
2. sensory urgency
3. bladder outlet obstruction

Question 14

what can cause stress incontience in men (3)

Answer 14

1. TURP
2. radical retropubic prostatectomy (RRP)
3. trauma

Question 15

what can cause stress incontinece in women

Answer 15

1. fascia laxity
2. ligament weakness

Question 16

which sex is stress incontinence seen more in

Answer 16

women

Question 17

what is overflow incontinence

Answer 17

chronic, painless retention that leads to leaking when relaxed e.g. at night

Question 18

what might a pt w outflow incontinence complain of

Answer 18

having to loosen their belt as they feel like their abdomen is enlarging (due to retention of urine)

Question 19

what is continuous incontinence

Answer 19

continuous leakage of urine like a dripping tap -> may be iatrogenic cause

Question 20

what is post-void dribbling usually due to

Answer 20

retention in the bulbous urethra -> its like a ‘u bend’ where urine can pool sometimes

Question 21

risk factors for urinary incontinecne (9)

Answer 21

1. women
2. age
3. route of baby delivery
4. pregnancy
5. obestiy
6. menopause
7. smoking
8. pelvic surgery
9. bladder outlet obstruction (men)

Question 22

red flags for incontinence (8)

Answer 22

1. Hx of UTI
2. haematuria
3. pain
4. pelvic mass
5. pelvic radiation
6. previous surgery
7. symptomatic prolapse
8. suspected fistula

Question 23

investigations for urinary incontinence (4)

Answer 23

1. dipstick
2. voiding diary
3. flow rate and post void residual
4. questionnaires

Question 24

what are urodynamics

Answer 24

pressure study tests that give info about pressures in the bladder to determine detrusor activity

Question 25

4 levels of continence

Answer 25

1. independent continence (dry without ongoing treatment) 2. dependednt contrinence (dry with toileting therapy or medication) 3. contained continence (pads or appliances) 4. incontinent

Question 26

what causes urge incontinecne

Answer 26

detrusor overactivity

Question 27

urge incontinence mgx

Answer 27

1. conservative -> fluid and dietary advice (more water, less caffeine and fizzy drinks), bladder retraining 2. antimuscarinics 3. S3 neuromodulation 4. surgery -> botox, S3 implant, clam cystoplasty

Question 28

how do anti muscarinic agents reduce incontience

Answer 28

bind to muscarininc receptors to decrease involuntary detrusor contractions and increase bladder capacity

Question 29

contraindications to anticholinergic drugs (3)

Answer 29

1.uncontrolled narrow angle glaucoma 2. myasthenia gravis 3. bowel disorders

Question 30

side effects of antimuscarinic drugs (6)

Answer 30

1. dry mouth 2. constipation 3. ophthalamic -> raised IOC, blurred vision, paralysis of accommodation 4. drowsiness 5. confusion 6. tachycardia

Question 31

mirabegron MOA

Answer 31

potent and selective agonist of beta-3 adrenergic receptors -> activation of B3Rs leads to relaxation of the smooth muscle of the detrusor muscle during the storage phase -> improved storage capacity and decreases voiding frequency

Question 32

what must be done prior to surgery for incontinence

Answer 32

urodynamics to confirm diagnosis

Question 33

what is percutaneous tibial nerve stimulation

Answer 33

stimulation of the tibial neve at the medial malleolus -> this is the same nerve root as that which controls the bladder

Question 34

what is sacroneuromodulaton

Answer 34

insertion of permanent stimulator in the S3 foramen to control the stimulation of the bladder -> signals bladder to relax the detrusor muscle

Question 35

what is the risk of botox for incontinence treatments and what are patients taught to avoid this

Answer 35

risk of complete paralysis of the detrusor muscle leading to complete urinary retention -> pts taught to self catheterise in case

Question 36

female stress incontinence mgx (3)

Answer 36

1. conservative - weight loss, muscle strengthening exercises 2. duloxetine (not used much anymore) 3. surgery

Question 37

what surgeries can be done for stress incontinence (3)

Answer 37

1. Injectables (e.g. urethral bulking agent) 2. Sling Surgery 3. Colposuspension

Question 38

to whom might injectables (urethral bulking agents) be offered to

Answer 38

1. youngs pts who are yet to have a family 2. elderly pts who cannot tolerate invasive surgery

Question 39

risks of uritary sling surgery (4)

Answer 39

1. haemorrhage 2. Retention 3. Denovo Detrusor overactivity 4. Erosion of tape

Question 40

what is colposuspension surgery

Answer 40

Endopelvic hammock retentioned by sutures between fascia and ligament -> purpose is to suspend the prolapsed urethra so that the urethrovesical junction and proximal urethra are replaced in the abdominal cavity

Question 41

complications of colposuspension surgery (4)

Answer 41

1. Open surgery 2. Retention 3. Posterior prolapse 4. Detrusor overactivity

Question 42

male stress incontinence mgx

Answer 42

1. pelvic floor exercises (taught to men pre-prostate surgery due to significant risk of iatrogenic stress incontinence) 2. injectables (urethral bulking agents) 3. male urinary sling 4. artificial urinary sphincter

Question 43

what must be checked for before catheterisation

Answer 43

whether there is an artificial sphincter -> if present the cuff must be deflated prior to catheterisation