Urinary Incontinence

Question 1

What is urinary incontinence?

Answer 1

Complaint of any involuntary leakage of urine = common, distressing, embarrassing, socially stigmatising, often hidden

Question 2

How common is urinary incontinence?

Answer 2

1 in 3 women

1 in 10 men

Question 3

What are the types of urethral incontinence?

Answer 3

Urge incontinence, stress incontinence, mixed incontinence, overflow incontinence

Question 4

How may urine leak by the extra-urethral route?

Answer 4

Ectopic ureter, vesico-vaginal fistula

Question 5

What are the two phases of the micturition cycle?

Answer 5

Filling (storage) and voiding phases

Question 6

What is compliance?

Answer 6

Ability of bladder to keep its pressure unchanged irrespective of bladder volume and afferent stimulation

Question 7

What pressures contribute to the storage phase?

Answer 7

Intravesical, atmospheric, abdominal, urethral

Question 8

What occurs in the voiding phase?

Answer 8

Detrusor pressure increases due to muscle contraction, urethral pressure is less than intravesical pressure so flow can occur, outflow mechanism relaxes

Question 9

What gives the tracing in urodynamics?

Answer 9

Cystomethogram = catheter in the bladder and rectum (to give abdominal pressure)

Question 10

What is the volume of a full bladder?

Answer 10

400ml

Question 11

What are patients asked to do during a cystomethogram tracing?

Answer 11

Cough three times

Question 12

How is the detrusor pressure calculated?

Answer 12

Abdominal pressure - intravesical pressure

Question 13

What are the anatomical components of the micturition reflex?

Answer 13

Bladder and sphincters, spinal bladder centre, brain, S2-3

Question 14

What nerves are involved in the micturition reflex arc?

Answer 14

Pelvic parasympathetic nerves, pudendal nerve

Question 15

What controls the micturition reflex arc?

Answer 15

Descending control from the brain inhibits or enables the arc

Question 16

What are some symptoms of outflow obstruction?

Answer 16

Bladder outflow is obstructed = huge palpable bladder, chronic retention, insensible incontinence, wet at night, renal impairment

Question 17

What is urge incontinence a part of?

Answer 17

The urge syndrome

Question 18

What are some features of urge incontinence?

Answer 18

Daytime frequency, small voided volumes, urgency provoked, enuresis (wet at night)

Question 19

What are some triggers for urge incontinence?

Answer 19

Key in door, sound of running water, standing up, coughing, laughing

Question 20

How are urge incontinence, urodynamic stress incontinence and detrusor overactivity diagnosed?

Answer 20

By urodynamics

Question 21

What can detrusor overactivity cause?

Answer 21

Urge incontinence = mostly middle aged women, most common cause

Question 22

What is detrusor overactivity?

Answer 22

Bladder dysfunction characterised by detrusor contractions occurring during inhibition of voiding

Question 23

What are some causes of urge incontinence?

Answer 23

Cystitis, tumour, excess central facilitation (stress), loss of central inhibition (paraplegia), destruction of S2-3 centre, pelvic surgery/fracture (parasympathetic nerve damage)

Question 24

What happens in urodynamic stress incontinence?

Answer 24

Urine leaks during increased intra-abdominal pressure = no detrusor contraction

Question 25

What causes urodynamic stress incontinence?

Answer 25

Due to damage to pelvic floor or urethral function = childbirth, smoking, obesity, diabetes, chronic cough

Question 26

When do people with urodynamic stress incontinence go to the toilet?

Answer 26

Early in the micturition cycle = frequent urination

Question 27

What are some features of an overactive bladder?

Answer 27

Often mixed picture = SUI often overlaps | Split into wet (37%) and dry (63%)

Question 28

What are some features of the examination?

Answer 28

Painless palpable mass arising from the pelvis = can't get below it, dull to percuss

Question 29

How is overflow incontinence treated?

Answer 29

Assess renal function and treat obstruction Catheterise and bladder rehab Teach intermittent self catheterisation

Question 30

How is urge incontinence treated?

Answer 30

Avoid caffeine, biofeedback, bladder retraining, time bladder emptying, botox injection (unlicensed) Neuromodulation (bladder pacemaker)

Question 31

What are some medical interventions for urge incontinence?

Answer 31

Enterocystoplasty Anti-muscarinics = oxybutynin, tolterodine Beta 3 adrenergics = mirabegron

Question 32

How is stress incontinence treated?

Answer 32

Weight loss and smoking cessation, pelvic floor physio Medication (not much role) = duloxetine (5HT and NE uptake inhibitor) Colpususpension open surgery largely replaced with minimally invasive tape procedures

Question 33

How is mixed incontinence managed?

Answer 33

Combination of urge and stress therapies = must ask which is more dominant

Question 34

What are some features of an ectopic ureter?

Answer 34

Rare = congenital, ureter joins on wrong side of sphincter mechanism, patient wet all the time

Question 35

What are some features of a vesico-vaginal fistula?

Answer 35

Urine falls out of hole = constant wetness | Caused by prolonged labour in developing world and pelvic surgery in developed world

Question 36

What is stress incontinence defined as?

Answer 36

Involuntary leakage on effort or exertion, or sneezing/coughing

Question 37

What is urge incontinence defined as?

Answer 37

Involuntary leakage accompanied by or immediately preceded by urgency

Question 38

What is urgency?

Answer 38

Complaint of sudden compelling desire to pass urine which is difficult to defer

Question 39

What is overactive bladder/urge syndrome?

Answer 39

Urgency, with or without urge incontinence, usually with frequency and nocturia

Question 40

What is detrusor overactivity incontinence defined as?

Answer 40

Incontinence due to an involuntary detrusor contraction

Question 41

What is mixed urinary incontinence defined as?

Answer 41

Involuntary leakage associated with urgency as well as effort/sneezing/coughing

Question 42

What are voiding symptoms?

Answer 42

Experienced during voiding phase = slow stream, spraying of stream, hesitancy, straining

Question 43

What is a frequency volume chart (FVC)?

Answer 43

Records volumes voided as well as the time of each micturition = day and night for at least 24hrs

Question 44

How long is a bladder diary recorded for?

Answer 44

3 days