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Flashcards in Urinary Incontinence Deck (22)
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1

How does the CNS affect bladder control?

Pons = facilitates voiding of the bladder
- promotes micturition cycle but can also override it with help of the cerebral cortex

Cerebral cortex = inhibts voiding of the bladder
- can override the micturation reflex if the person consciously decides its not time to void

**voiding centers around the detrusor muscle action

2

Difference between transient/acute and chronic urinary incontinence

Transient
- < 6 months
- has a reversible underlying cause always

Chronic
- > 6 months
- differs into subset types
- usually reversible but not always

3

Stress incontinence

**Damage/weakness to the pelvic floor, urethral hyper mobility and/or intrinsic sphincter deficiencies are the causes of this.
- vaginal delivery and surgical complications are the top 2 mechanical causes of this!

Is triggered by anything that causes increased **intra-abdominal pressures**
- laughing, sneezing, coughing, exercise, etc.

When intra-abdominal pressure increases, patients with stress incontinence either dont have the pelvic muscle strength to push back and therefore the pressures forces the urine out, or they just straight up have weak sphincters which allows for easily pushed out urgency (outlet incompetence)

Risk factors:
**Highly associated with obesity, repeated vaginal delivery, menopause, injury to the urethra and prostate surgeries

**Diagnosis = bladder stress test under valsalva maneuver/ increased abdominal pressure

Treatment = kegal exercises, alphas agonists weight loss and pressaries (prosthetic device that is inserted into the vagina to support internal structure)
- DONT GIVE ORAL ESTOGEN

4

Urgency incontinence

Caused by detrusor overactivity (uninhibited contractions/ decreased sympathetics or increased parasympathetics ((almost always parasympathetics))
- causes extreme urge to urinate and involuntary urination

**Highly associated with UTIs (can cause over sensitivity to parasympathetics and subsequent involuntary contractions fo the detrussor), neurological disorders, any cause of bladder outlet obstruction and tumors

**patients will often say “ i cant get to the bathroom fast enough”
- also patients often experience nocturia often

diagnosis = detrusor overactivity tests

Treatment = #1 = (kegel exercises, bladder training, and distraction relaxation techniques)
- #2 = antimuscarinics (oxybutynin is #)

5

Red flag symptoms for urinary incontinence

Rapid onset urinary incontinence

Pelvic pain

Hematuria

6

Overall risk factors for urinary incontinence

Obesity

Functional impairments

Dementia

Medications

High levels of vaginal deliveries

High impact exercise

7

Overflow incontinence

Incomplete emptying due to detrusor underactivity (decreased parasympathetics) or outlet obstruction
- causes weakened/intermittent streams and hesitancy. Leads a to leakage with overfilling of bladder

Has high levels of post-void residues on catheterization or ultrasound

**Highly associated with diabetes (will show polyuria), bladder outlet obstruction (especially benign prostate hyperplasia (BPH)) and neurogenic bladder issues (especially MS)

Diagnosis = PVR test (volume left will be >200 cc)

Treatment = catheterization, release the obstruction if present, alpha blockers if BPH.

8

Mixed incontinence

Features of both stress and urgency incontinence
- **very often seen in pregnant patients who get UTIs during pregnancy**

9

How does aging affect urinary incontinence?

Decreased:
- bladder contractility
- bladder capacity
- attenuated striated muscles
- vaginal mucosal activity and urethral closure pressure in females

Increased:
- post-void residual volume (PVR)
- prostate hypertrophy (males)
- uninhibited bladder contractions

10

What is always done in urine diagnostics and urinary incontinence

Urinalysis

**rarely ever need urodynamic testing and almost nerve used in initial work ups**

11

Should you perform cystoscope/urodynamic or renal/bladder ultrasounds of an uncomplicated overactive bladder patient in the initial work up?

NO

*Only do this if you cant solve it on initial work up or if it is a complicated case*

12

Mnemonics for causes of transient incontinence

1) “DIAPPERS”

Delirium
Infection
Atrophic vaginitis
Urethritis
Pharmaceuticals
Psychological disorders
Endocrine disorders
Restricted mobility
Stool impaction

2) “TOILETED”

Thin, dry vaginal and urethral epithelium
Obstruction
Infection
Limited mobility
Emotional/psychological disorders
Therapeutic medications
Endocrine disorders
Delirium

13

Common medications that cause incontinence

Diuretics

Anticholinergics/antihistamines

Antipsychotics/antidepressants

Sedatives/hypnotics

Alcohol

Narcotics

A-adrenergic agonists/antagonists

CCBs

14

How does the angle of the urethra change with the valsalva maneuver in normal patients and stress incontinence patients?

Normal = <30 degrees

Stress = > 30 degrees

15

Extra strategies for making Urinary incontinence

Be aware of fluid intake

Avoid bladder stimulants (such as caffeine)

Avoid taking diuretics after 4pm

Reduce physical barriers to the toilet

Avoid constipation

Perform pelvic floor exercises

Cease smoking

16

Broad physiology of micturation in males and females

1) both have parasympathetics from pelvic nerves to innervate the detrusor muscle in the bladder
- contraction of this muscle voids bladder

2) both have sympathetic nerves that use a1 receptors to control the internal urethral sphincter. B3 receptors are used by both to inhibit the detrusor muscles in the bladder as well

3) both have somatic innervation provided by the pudendal nerve to consciously control external urethral sphincter

17

First line treatment of all urinary incontinence issues

Lifestyle modifications
- weight loss
- pelvic flood exercises
- bladder training

Decrease water intake if >64oz a day
- also decrease caffeine, carbonated beverages and alcoholic beverages

18

2nd line treatment for all urinary incontinence

Drug therapies for specific incontinence types
- MUST do lifestyle changes first since even if they dont work alone, studies have shown increased efficacy of medications when these lifestyle changes have been in place

Common drug therapies
- anti-muscarinic = urge and overactive
- B3 agonists = urge
- topical estrogen = stress

**third and last line is surgery**

19

Which receptors in the micturation tract are G-protein coupled?

Muscarinic receptors = Gq -> PLC/IP3/DAG/Ca2+ increases

B3 receptors = Gs -> AC/cAMP increases

20

General physiological background of urinary process

Filling phase
- sympathetics predominant by inhibiting the detrusor (B2) and tonic contraction of the internal sphincter (a1)
- umbrella (dome) cells of the urothelium will flatten and expand allowing for the bladder to stretch and fill with urine

Voiding phase
- parasympathetic predominant by both inhibiting tonic sympathetic tone oft he detrusor and by M receptor activation. Also induces tonic inhibition of the internal sphincter via M receptors also
- umbrella cells straighten up as bladder voids
- pudendal nerve is required to consciously void urine

21

difference between external and internal urethral sphincters

External:
- voluntary control via the pudendal nerve
- is made up of skeletal muscle

Internal:
- involuntary control via sympathetics (a1) and parasympathetics (M1)
- is made up of smooth muscle

22

What is the micturation center of the spine?

S2 and 3

Receives tonic information from the urinary bladder and signals to the pons when it is time to void.
- **the pons can choose to override the micturation reflex if the person decides it is not a good time to urinate
- activates micturation reflex which disables tonic sympathetic activity and signals parasympathetics to function.