Urinary incontinence

Question 1

what in urinary incontinence

Answer 1

involuntary leakage of urine

Question 2

what is stress urinary incontinence

Answer 2

leakage on effort or exertion, sneezing or coughing

urine leaks whenever urethral resistance is exceeded by increased abdominal pressure

Question 3

what causes stress urinary incontinence

Answer 3

bladder neck/ urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency

Question 4

what muscles aids the action of the external urethral sphincter in women

Answer 4

levator ani

Question 5

what is urge urinary incontinence

Answer 5

leakage accompanied by or immediately preceded by urgency

Question 6

what causes urge urinary incontinence

Answer 6

bladder overactivity (detrusor instability) 
less commonly pathology that irritates the bladder (infection, tumour, stone)

Question 7

what is mixed urinary incontinence

Answer 7

a combination of stress UI and urge UI

Question 8

what does bed wetting in elderly men indicate

Answer 8

high pressure chronic retention

Question 9

what is post micturition dribbling and what causes it

Answer 9

dribbling immediatley after leaving the toilet

due to urine pooling in the bulbar urethra

Question 10

what does a constant leak of urine suggest

Answer 10

fistulas communications between the bladder and vagina (due to surgical injury at the time of hysterectomy or caesarian section)
can also be an ectopic ureter draining into the vagina

Question 11

what should you suspect in a young girl with a constant leak of urine

Answer 11

ectopic ureter (draining into the vagina)

Question 12

what nerve conditions can cause urinary incontinence

Answer 12

cerebral cortex:

• stroke
• MS
• brain injury
• parkinsons
• cerebral palsy

spinal cord:

• lesions
• trauma
• spina bifida
• MS

peripheral nerve damage
-diabetes

Question 13

where is the sacral mictrurition centre

Answer 13

S2-4

Question 14

what are the risk factors for urinary incontinence

Answer 14

female
caucasian
genetic predisposition
neurological conditions
anatomical disorders
child birth (SVD, increasing parity, pregnancy (stress UI)
pelvic, perineal and prostate surgery (radical hysterectomy, prostatectomy, TURP
(causing pelvic muscle and nerve injury or damage to external urethral sphincter)
radical pelvic radiotherapy
diabetes

Question 15

what anatomical disorders can cause UI

Answer 15

vesicovaginal fistula, ectopic ureter (girls), urethral diverticulum, urethral fistual, bladder extrophy,
epispadias

Question 16

what factors can promote UI

Answer 16

smoking (chronic cough) 
obesity 
infection (UTI)
increased fluid intake 
poor nutrition 
ageing 
cognitive defect 
poor mobility 
oestrogen deficiency

Question 17

what should you ask in a history of UI

Answer 17

type
triggering factors 
frequency +degree of bother 
RFs
previous surgery 
bowel symptoms 
symptoms of sexual dysfunction/ pelvic organ prolapse on women

Question 18

what are the red flags in UI

Answer 18

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

Question 19

what should you include in a female exam for UI

Answer 19

chaperoned pelvic exam
ask patient to cough or strain and look for anterior and posterior vaginal wall prolapse, uterine or vaginal vault descent and urinary leakage

internal pelvic exam to assess voluntary pelvic floor muscle strength and bladder neck mobility

inspect the vulva for oestrogen deficiency (vaginal atrophy)

Question 20

what should you do in both sexes for an exam for UI

Answer 20

abdo- palpable bladder (urinary retention)
neurological exam to asses gait, anal reflex, perineal sensation and lower limb function
DRE to exclude constipation, rectal mass and to asses anal tone

Question 21

what are the exam red flags in UI

Answer 21

new neurological deficit
haematuria
urethral, pelvic or bladder mass and suspected fistula

Question 22

what investigations into UI

Answer 22

bladder diary (frequency volume chart) 
urinalysis +/- culture 
flow rate 
post void residue (USS)
pad testing 

blood tests, imaging, cytoscopy (if suspecting anatomical abnormality or fistula)

Question 23

what will flow rate charts look lik

Answer 23

low long curve= BOO
lots of ups and downs= straining, intermittent flow

women flow will be higher than mens due to shorter urethra

Question 24

what is urodynamics

Answer 24

2 way catheters that senses both the bladder and abdominal pressure in order to isolate the bladder pressure
(cystometry)

Question 25

what is the conservative treatment for UI

Answer 25

pelvic floor exercises (improvement in 30% of women- 8 contraction 3x daily) weight loss, smoking cessation, avoid constipation, modify fluid intake biofeedback- ability and strength of pelvic floor contraction is fed back to patients as a visual/ auditory signal electrical stimulation of the pelvic floor (no proven) medication

Question 26

what medication for stress UI

Answer 26

duloxetine- inhibits re-uptake of both serotonin and noradrenalin (increases sphincteric muscle activity during bladder filling)

Question 27

what is injection therapy for UI

Answer 27

injection therapy -bulking materials (silicone, teflon) injected into bladder neck and periuretheral muscles to increase outlet resistance (mainly for female SUI secondary to demonstrable intrinsic sphincter deficiency w/ normal bladder muscle function) aim to achieve urethral mucosal apposition and closure of the lumen 50-80% success but deteriorates with time, repeated treatments often needed

Question 28

what are the indications of injection therapy for UI

Answer 28

UTI, untreated bladder overactivity, bladder neck stenosis

Question 29

what are the complications of injection therapy for UTI

Answer 29

temporary urinary retention, de novo urge incontinence, UTI, haematuria

Question 30

what is retropubic suspension

Answer 30

to treat stress incontinence caused by urethral hypermobility elevate and fix the bladder neck and proximal urethera in a retropubic position in order to support the bladder neck and regain continence

Question 31

what is the surgical treatment for UI

Answer 31

``` injection therapy retropubic suspension burch colposuspension (elevation of vaginal wall to lateral pelvic wall) urethral stapes and slings artificial urinary sphincter ```

Question 32

how do urethral tapes and slings work

Answer 32

lift up urethra and hold in place to prevent urethral movement

Question 33

what are the complications of urethral slings

Answer 33

– voiding dysfunction (retention or de novo bladder overactivity - vaginal, urethral and bladder perforation/erosion - pain - damage to bowel or blood vessels

Question 34

how does a artificial urinary sphincter work

Answer 34

provides a constant circumferential pressure to compress the urethra. To void, the pump is squeezed, which transfers fluid to the reservoir balloon, thereby deflating the cuff. The cuff then automatically re-fills within 3 minutes used for mod/ severe SUI/ uretheral sphincter deficiency good long term success

Question 35

what are the complications of an artificial uretheral sphincter

Answer 35

urethral atrophy, mechanical failure, urethral erosion, bladder overactivity or reduced compliance, infection

Question 36

what is bladder over activity

Answer 36

``` detrusor overacitivity causes -urgency (+/- urge incontinence) -frequency -nocturia ```

Question 37

what is the conservative treatment for an overactive bladder

Answer 37

``` pelvic floor exercises biofeedback acupuncture electrical stimulation behaviour modification: fluid intake, stimulants (caffeine, alcohol), bladder training ```

Question 38

what medication for an overactive bladdr

Answer 38

anticholinergics (antimuscarinics) which inhibit contractions -oxybutynin, solifenacin, tolterodine... beta adrenoreceptor agonists; β3 sub-typE induce detrusor relaxation. β3-AR agonists increase bladder capacity with no change in micturition pressure and the residual volume -Mirabegron

Question 39

what causes bladder overacticity

Answer 39

acetylcholine acts on muscarinic receptors on the bladder smooth muscle to cause involuntary contractions and provoke symptoms of bladder overactivity

Question 40

what are the contraindications for anticholinergics for bladder overactivity

Answer 40

uncontrolled open angle glaucoma, myasthenia gravis, BOO, bowel disorders (UC, bowel obstruction)

Question 41

what are the side effects of anticholinergics

Answer 41

dry mouth, constipation, blurred vision, urinary retention, cognitive impairment

Question 42

what are the contraindications to beta agonists

Answer 42

uncontrolled hypertension

Question 43

what are the treatments for refractory cases of overactivity of the bladder

Answer 43

intravesical botulinum toxic (sparing the trione, temporarily paralyses detrusor) neuromodulation (sacral nerve stimulation (S3) to inhibit detrusor activity) clam ileocystoplasty (attaching segment of ileum to increase bladder volume) ileal conduit urinary diversion with stoma (intractable cases only)