Urinary Incontinence

Question 1

what is stress urinary incontinence?

Answer 1

leakage on effort or exertion, sneezing or coughing
occurs as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency
urine leaks whenever urethral resistance is exceeded by increased abdominal pressure

Question 2

what is urge incontinence?

Answer 2

incontinence accompanied by or immediately preceded by urgency
may be due to bladder over activity (detrusor instability)

Question 3

other types of urinary incontinence?

Answer 3

bedwetting in elderly men (high pressure chronic retention)
post micturition dribble (poor urine pooling in bulbar urethra)
constant leak of urine (fistulous communication between the bladder and vagina
can be due to surgical injury at time of hysterectomy or caesarean section
can be due to presence of an ectopic ureter draining into the vagina instead of the bladder (common in young girls)

Question 4

risk factors for urinary incontinence?

Answer 4

female
Caucasian
genetic
neurological disorders
anatomical (vesicovaginal fistula, ectopic ureter, urethral diverticulum, urethral fistula, bladder extrophy, epispadias)
childbirth
pelvic, perineal and prostate surgery (hysterectomy, prostectomy, TURP biopsy)
radical pelvic radiotherapy
diabetes

Question 5

promoting factors in urinary incontinence?

Answer 5

smoking (causes cough)
obesity
infection
increased fluid intake
poor nutrition
ageing
cognitive problems
poor mobility
oestrogen deficiency

Question 6

red flags?

Answer 6

pain
haematuria
recurrent UTI
significant voiding/obstructive symptoms
history of pelvic surgery/radiotherapy

Question 7

female examination?

Answer 7

ask patient to cough or strain and look for prolapse and urinary leakage
internal pelvic examination can be performed to assess voluntary pelvic floor muscle strength and bladder neck mobility
inspect vulva for oestrogen deficiency

Question 8

both sexes examination?

Answer 8

examine abdomen for palpable bladder

Question 9

basic investigation?

Answer 9

bladder diary (frequency/volume)
urinalysis +/- culture
flow rate and post void residue
pas testing
can do bloods, imaging, cystoscopy for complex cases

Question 10

when and how is cystometry used?

Answer 10

overactive bladder
thinking about treatment
thin catheter with 2 lumina (one fills bladder, one goes in rectum?)
measures abdominal pressure and bladder pressure and compares the two

Question 11

how is a true detrusor muscle reading found?

Answer 11

measure abdominal pressure (via rectum) and bladder pressure
subtract abdominal from bladder to give detrusor muscle reading

Question 12

conservative treatment for urinary incontinence?

Answer 12

pelvic floor exercises (8 contractions, 3 times per day for 3 months)
lifestyle
biofeedback (technique where ability and strength of pelvic floor contraction is fed back to patient as visual/auditory signal)
medication - duloxetine which inhibits reuptake of both serotonin and noradrenaline which acts to increase sphincteric tone

Question 13

surgical treatment?

Answer 13

injection therapy (bulks up urethra which increases outlet resistance, used for stress incontinence)
injected submucosally into urethral mucosa

Question 14

contraindications for injection therapy?

Answer 14

UTI
untreated overactive bladder
bladder neck stenosis

Question 15

what is used if conservative and injection therapy fails?

Answer 15

retropubic suspension
treats female stress incontinence mainly causes by urethral hypermobility
elevates and fixes bladder neck and proximal urethra in retropubic position in order to support bladder neck and regain continence

Question 16

how are suburethral tapes and slings used?

Answer 16

The tape is inserted under the waterpipe /urethra and brought out through two small incisions above the pubic bone or the groin

Question 17

complications of tapes and slings?

Answer 17

voiding dysfunction
perforation/erosion
pain
damage to bowel or blood vessels

Question 18

pubovaginal slings?

Answer 18

uses segment of rectal fascia 10-20cm long which is placed under the neck of the bladder or under medial urethra and acts as a support to prevent downward slippage of the bladder neck and urethra during physical activity

Question 19

when are artificial urinary sphincters used?

Answer 19

males with incontinence after radical prostatectomy

moderate to severe stress incontinence

Question 20

how does AUS work?

Answer 20

inflateable cuff placed around bulbar urethra or bladder neck
pressure regulating balloon placed extraperitoneally ……….

Question 21

what is overactive bladder?

Answer 21

causes urge incontinence
urgency with/without urge incontinence, usually with frequency and nocturia
usually causes by bladder (detrusor overactivity)

Question 22

conservative management fo overactive bladder?

Answer 22

pelvic floor exercises, biofeedback, acupuncture and electrical stimulation therapy may provide some benefit
behavioural modification - modify fluid intake, bladder retraining

Question 23

medcation?

Answer 23

anticholinergic (antimuscarinincs) drugs which inhibit contractions and increase bladder capacity
- oxybutynin
- solifenacin
beta-adrenoreceptor agonists (relax detrusor and increase bladder capacity)

Question 24

side effects and contraindications of antimuscarinics?

Answer 24

dry mouth, constipation, blurred vision, photophobia, glaucoma, difficulty urinating
contraindications
-    glaucoma
- obstruction
- peptic ulcer

Question 25

whenis intravesical botox used?

Answer 25

injected at multiple (20) sites under the bladder mucosa or into detrusor sparing the trigone
flooding incontinence, resistant to other treatments

Question 26

if intravesical botox doesn’t work?

Answer 26

artificial electrical stimulator
sacral nerve stimulation of bladder’s nerve to supply (suppresses reflexes responsible for involuntary detrusor contraction
stimulates S3 afferent nerve

Question 27

what is clam ileocystoplasty?

Answer 27

if botox doesn’t work
operation to bi-valve the bladder into 2 flaps which destroys ability to contract in a normal way
then take a length of small bowel which has be de-tubularised and anastamosed with bladder dome creating a larger bladder volume

Question 28

ileal conduit urinary diversion?

Answer 28

last resort treatment, only for intractable cases
both ureters are anastamosed and connected to a short length of ileum which is brought out cutaneously as a stoma
urine collects in a bag