Urinary Incontinence

Question 1

Is incontinence a natural part of the aging process?

Answer 1

No

Question 2

Is most incontinence multifactorial or single cause?

Answer 2

Multifactorial

Question 3

What are the different types of incontinence?

Answer 3

Stress
Urge 
Overflow 
Mixed
Functional
Abnormal communications of the urinary tract - fistulae

Question 4

What is stress incontinence?

Answer 4

Urine leakage when intra abdominal pressure exceeds urethral pressure.

Due to weakened pelvic floor muscles - not supporting urethra

Question 5

What can cause the leakage in stress incontinence?

Answer 5

Sneezing, coughing, laughing, straining, lifting, exercise

Question 6

Does stress incontinence usually occur in men or women?

Answer 6

Women

Question 7

What are some risk factors for stress incontinence?

Answer 7

Pregnancy (vaginal delivery) - damage to pelvic floor muscles and weakening of urethral sphincter 
Constipation - recurrent strain 
Obesity 
Pelvic surgery e.g TURP 
Conditions that cause chronic cough

After menopause muscles become weaker

Question 8

What is urge incontinence?

Answer 8

Frequent voiding, often cannot hold urine. Due to overactive bladder as a result of detrusor hyperactivity (can also occur in obstruction).

Nocturnal incontinence is common

Question 9

What can cause urge incontinence?

Answer 9

Idiopathic 
Infection 
Malignancy 
Neurological - stroke, PD, Alzheimer’s disease, MS, spinal cord injury 
Bladder outlet obstruction 
Diabetes 
Diuretics

Question 10

What are the symptoms of urge incontinence?

Answer 10

Frequent voiding
The urge to empty the bladder is soon followed by uncontrollable emptying
Can be sudden and without warning
Enuresis (bed wetting)

Question 11

What is overflow incontinence?

Answer 11

Involuntary release of urine from an over full bladder. Often due to bladder outlet obstruction. Can also be due to detrusor underactivity.

Question 12

What can cause overflow incontinence?

Answer 12

Prostate enlargement - BPH, malignancy
Kidney and bladder stones
Strictures due to inflammation / infection
Malignancy

Autonomic neuropathy e.g DM, MS
Anticholinergics
Alpha agonists - sphincter contraction
Calcium channel blockers - reduced smooth muscle contraction

Question 13

What is functional incontinence?

Answer 13

Physical (e.g poor mobility), cognitive or behavioural disability that impairs ability to use toilet

Question 14

In mixed urinary incontinence, which types are often seen together?

Answer 14

Stress and urge

Question 15

When taking a continence history, what should be included?

Answer 15

Symptoms - storage, voiding, pain, dysuria, haematuria
Oral intake and types of drinks - caffeine
Bowel habits - type and frequency
PMH - diabetes, neurological conditions
Drug history
Collateral history
Past surgery
Obstetric and gynaecological history in women

Question 16

What investigations should be done?

Answer 16

Review bladder and bowel diary - frequency and volume chart
Urine dipstick and MSU
Post micturition bladder scan
DRE - prostate and stool
Bloods - FBC, PSA, CRP, U&E (kidney damage), LFT, Alkaline phos (malignancy), HbA1c

Urodynamic studies

Question 17

What physical examinations should be done?

Answer 17

Abdominal examination - feel and percuss for palpable bladder, palpate for masses or enlarged kidneys, DRE
External genitalia review - atrophic vaginitis in females
Vaginal examination - prolapse

Neurological examination - assess gait, check dorsiflexion of toes (S3) and perianal sensation (L1-2), sensation of sole (S1)

Cognition - AMT for cognitive decline
CVS

Question 18

In terms of management, what should be addressed first?

Answer 18

Lifestyle factors

• weight loss
• switch to decaf drinks
• smoking cessation (nicotine can irritate bladder and coughing can increase pressure)
• regular toileting
• good bowel habit
• improve oral intake

Question 19

How should stress incontinence be managed?

Answer 19

Pelvic floor retraining - 8 contractions at least 3 times per day for at least 3 months
Weight loss if appropriate
Duloxetine (urethral contracture) - not likely to be a cure, it can help in making it less of a problem
Surgery - tension free vaginal tape (like a sling to support urethra and bladder neck)

Question 20

What type of muscle is the detrusor muscle?

Answer 20

Smooth muscle - fibres running in all different directions

Controlled by the autonomic nervous system

Question 21

Describe the internal urethral sphincter

Answer 21

A thickening of the bladder wall, proximal part of the urethra

Primary function in men: prevent retrograde ejaculation of semen

Question 22

Is the IUS well developed in men or women?

Answer 22

Men

Question 23

Describe the external urethral sphincter

Answer 23

It is part of the pelvic floor

Skeletal muscle - under voluntary control, so when you decide to urinate, the EUS actively relaxes

Question 24

The stretch receptors in the bladder wall are innervated by a sensory neurone that projects into which part of the spinal cord?

Answer 24

S2,3,4 keeps the piss and shit off the floor

Area of micturition and defication

Question 25

Describe the storage reflex arc

Answer 25

The sensory neurones attached to stretch receptors in the bladder wall ascend up to T10- L2 segment (known to contain sympathetic neurones) synapses with sympathetic preganglionic neurones, which project onto post-ganglionics. These post ganglionics project onto 2 sites - detrusor itself and IUS. Sympathetics inhibit contraction of detrusor (beta 3 receptor) and stimulate internal sphincter (alpha 1 receptor) = STORAGE As volume increasing, pressure not spiking (as muscle stretching)

Question 26

What supplies the EUS?

Answer 26

Somatic motor fibres that run along the pudendal nerve. These fibres at S2,3,4 excite skeletal muscle at EUS, causing it to contract (nAChr receptor)

Question 27

What is the name of the centre within the pons that controls the somatic fibres that close the EUS?

Answer 27

L centre

Question 28

Is the voiding reflex primarily mediated by the sympathetic or parasympathetic system?

Answer 28

Parasympathetic

Question 29

Describe the voiding reflex arc

Answer 29

The sensory neuron attached to stretch receptors enters into the spinal chord at S2,3,4 where it synapses with parasympathetic neurones. The parasympathetic neurones project to the bladder and synapse in the bladder wall with a short post- ganglionic neuron. The effect = excitation of detrusor. Receptor = M3

Question 30

Under high levels of bladder stretch, a sensory neuron activates which area in the pons?

Answer 30

M centre - projects down onto parasympathetics to EXCITE them = a positive feedback loop

Question 31

When the M centre is activated what is inhibited?

Answer 31

The L centre and sympathetics

Question 32

How should urge incontinence be managed?

Answer 32

Lifestyle factors Bladder retraining - minimum 6 weeks Bladder stabilising drugs: - antimuscarinics first line e.g oxybutynin or tolterodine - beta 3 agonist e.g mirabegron (may be useful if concerns about anticholinergic side effects in elderly) Botox of the bladder neck

Question 33

What drug could be taken to prevent nocturia?

Answer 33

Loop diuretics mid afternoon

Question 34

How do antimuscarinic drugs work on the bladder?

Answer 34

Prevent contraction

Question 35

What are some antimuscarinic side effects?

Answer 35

``` Blind as a bad Dry as a bone - dry mucous membranes Red as a beet - vasodilation Mad as a hatter - delirium, confusion Full as a flask - retention and constipation Hot as a hare - lack of sweating ``` Also dizziness FALLS risk in elderly

Question 36

What medication is used to treat BPH?

Answer 36

Alpha blockers - relax prostatic smooth muscle e.g Tamsulosin, doxazocin 5 alpha reductase inhibitors - stops conversion of testosterone to more potent form (to promote cell division) e.g Finesteride (can take 6 months for symptom benefit)

Question 37

What is an important side effect of alpha blockers in the elderly?

Answer 37

Postural hypotension

Question 38

What is the most common cause of urinary incontinence in the elderly?

Answer 38

Infection

Question 39

What are some storage symptoms?

Answer 39

Frequency Urgency Nocturia

Question 40

What are some voiding symptoms?

Answer 40

``` Post micturition dribble Hesitancy Intermittent stream Terminal dribble Feeling of incomplete emptying ``` (Bladder outlet obstruction usually)

Question 41

Is duloxetine recommended for stress incontinence as first or second line management?

Answer 41

No Could be as alternative to surgery but inform about side effects

Question 42

How is urge incontinence managed?

Answer 42

Lifestyle - reduce fluid intake especially in evening, reduce caffeine and alcohol, weight reduction, manage constipation Medical - antimuscarinics that act on M3 receptor (use with caution in elderly) e.g oxybutynin, tolteridone, darifenacin, trospium, solifenacin, propiverine. The first 3 are NICE recommended first line agents Oxybutynin not in older adults with frailty or PD If contraindicated or intolerable side effects: beta 3 adrenoreceptor agonists (mirabegron) Intravaginal oestrogens - NICE recommends their use for women who have vaginal atrophy and symptoms of overactive bladder