Urinary Incontinence

Question 1

What is urinary incontinence?

Answer 1

Involuntary leakage of urine.

Question 2

How could a lower motor neurone lesion cause urinary incontinence

Answer 2

Low detrusor muscle pressure
Large residual urine +/- overflow incontinence.
Sphincter is relaxed and there is no feeling that your bladder is full.

Question 3

How could an upper motor neurone lesion cause urinary incontinence

Answer 3

High pressure detrusor contraction
Poor coordination with sphincters
Urine flows back up ureter to the kidneys

Question 4

What kind of symptoms occur within the lower urinary tract that constitute urinary incontinence?

Answer 4

Storage- frequency, urgency, nocturia and incontinence.

Voiding – slow stream, splitting, spraying, intermittency, hesitancy, straining and dribble.

Post-micturition – post micturition dribble and feeling of incomplete emptying.

Question 5

Describe the 4 types of incontinence.

Answer 5

1. (SUI) Stress urinary incontinence – involuntary leakage on effort or exertion or on sneezing/coughing. This occurs because of faults with the sphincter.
2. (UUI) Urge urinary incontinence – involuntary leakage accompanied by or immediately proceeded by urgency. This occurs because of issues with the detrusor muscles or stretch receptors.
3. (MUI) Mixed urinary incontinence – mixture of both
4. Overflow incontinence – bladder accepts more and more urine without voiding.

Question 6

What is OABS?

Answer 6

Overactive bladder syndrome – prevalence of OABS is much higher than the prevalence of UUI – wet and dry OABS. OABS can occur with or without urinary incontinence and its symptoms are Urgency, frequency and nocturia.

Question 7

Do SUI and OABS ever occur together?

Answer 7

SUI by itself doesn’t occur with OABS they only occur together when it is MUI and OABS.

Question 8

How does age relate to urinary incontinence?

Answer 8

Urinary incontinence increases in prevalence with age. Two peaks – one at early 50s and another post 90.

Question 9

Which are the most common types of urinary incontinence?

Answer 9

SUI – 47%, MUI – 28%, UUI – 21%

Question 10

What risk factors are there for UI?

Answer 10

Pregnancy and childbirth, pelvic surgery and DXT (deep x-ray therapy) and Pelvic prolapse

Question 11

What promoting factors are there for UI?

Answer 11

Promoting factors include: Co-morbidities, obesity, age, cognitive impairment, UTI, Drugs and menopause

Question 12

What predisposing factors are there for UI?

Answer 12

Predisposing factors include: Race, family predisoposition, anatomical abnormaltities and neurological abnormalities.

Question 13

What examinations are important in UI?

Answer 13

BMI, abdominal exam to exclude palpable bladder, digital rectal examination (DRE) to look at the prostate in males (Limited neurological examination). In females, we look at external genitalia – stress test and do a Vaginal exam.

Question 14

What investigations should be done?

Answer 14

Urine dipstick – UTI, haematuria, proteinuria and glucosuria
Frequency volume charts
Bladder diary > 3 days
Post micturition residual volume - in patients with voiding dysfunction done using ultrasound
Optional – invasive urodynamics (pressure-flow studies)
Pad tests – quantifies how much urine is being lost
Cystoscopy – inspection of bladder and urethra using a camera.

Question 15

How do we manage UIs conservatively?

Answer 15

Modify fluid intake
Weight loss
Stop smoking
Decrease caffeine intake (UUI)
Avoid constipation
Timed voiding – fixed schedule

Question 16

What more drastic options are available for managing UIs?

Answer 16

Contained Incontinence
Sheath Device (Condo catheter) that then collects urine in a bag
Indwelling catheter – the exits form the bladder either through the abdominal wall or the urethra, patient opens valve to empty bladder when they require to.
Incontinence pads

Management of SUI
Pelvic floor training – 8 contractions 3x a day for at least 3 months duration

Question 17

What pharmacological interventions can we give?

Answer 17

Duloxetine – combined noradrenaline and serotonin uptake inhibitor (so higher concentrations in the junction). Increases activity in the strained sphincter during filing phase. Not recommended by NICE as first line or routine second lines treatment but may be offered as alternative to surgery – has lots of side effects

Question 18

What permanent surgery options are there for women?

Answer 18

• Low tension vaginal tapes (most common) – supports the mid urethra with a polypropylenes mesh. Most common as is >90% successful.
• Open retropubic suspensions procedures – correct anatomical position of proximal urethra and improve urethral support
• Classical sling procedures – supports urethra and augments bladder outflow resistance

Question 19

What temporary surgery options are there for women?

Answer 19

e.g. if further pregnancies are planned – Intramural bulking agents – improve ability of urethra to resist abdominal pressure by improving urethral accommodation. Injections are usually autologous fat, silicone, collagen or certain polymers.

Question 20

What is the main aim of all these operations?

Answer 20

All these procedures add more resistance to the urine passing through the sphincter

Question 21

What surgery options are there for men?

Answer 21

• Artificial sphincter – most common – mechanical hydraulic device that stimulates the action of a normal sphincter using a small ball the inflates or deflates in urethral opening of bladder to close the urethra, problems include infection, erosion and device failure.
• Male sling procedure – treats SUI – developing/experimental treatment

Question 22

How are UUIs managed

Answer 22

Bladder training – schedule voiding, void every hour during the day, must not void in between – wait or leak. Intervals increased by 15-30mins a week until interval of 2-3 hours reached. At least 6 weeks of training.

Question 23

How are UUIs managed pharmacologicaly?

Answer 23

Pharmacological – anticholinergics acting of M2 and M3 receptors – side effects are systemic on all M receptors such as CNS, salivary glands, Heart muscles, Smooth muscle and eyes. Oxybutynin – NICE price i.e. cheap.

Beta – 3 adrenoreceptor agonists helping bladder to relax more. Mirabegron – increases bladder’s capacity to store urine.

Botulinum toxin – potent biological neurotoxin, inhibits release of ACh at pre-sympathetic neuromuscular junction causing targeted flaccid paralysis. Only works for about 3-6 months.

Question 24

What are the surgical options for UUIs?

Answer 24

Sacral nerve neuromodulation – implanting probes and battery disturbing signals from and to the brain. Urinary diversion, and if patients wishes them removal of the bladder completely.