Week 6- Approach to Urinary Incontinence Flashcards by Claire Evans

What occurs during the urine storage phase?

Bladder fills and relaxes
Urethral sphincter remains closed
abnormalities result in urinary incontinence

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What occurs during the Urine Voiding phase?

Bladder contracts
Urethral sphincter/ Urethra relaxes

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Which phase is true urinary incontinence?

Urine Storage Phase

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Under what control does the storage phase occur?

under sympathetic control
* Contraction of outflow tract + active relaxation of the detrusor muscle
* Beta adrenergic receptors in the bladder

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How is urine stored?

When the outlet tract pressure exceeds the vesicular pressure

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What is overflow incontinence?

Failure of voidance
Increased Intravesicular pressure

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What three things may cause True Incontinence?

Urethral sphincter mechanism incompetence
Ectopic Ureters
Lower Motor Neuron Bladder

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What may cause paradoxical incontinence?

Detrusor atony
Functional Obstructions…

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What is dysuria?

Difficult or painful passage of urine

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What is stranguria?

Straining or hesitancy prior to or after urination

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What is pollakiuria?

Increased frequency of urination

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What is nocturia?

The urge or need to urinate at night

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What is enuresis?

unconscious leaking of urine from a sleeping animal

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What does a bladder with urethral disease look like?

Stranguria, Tense/ Full bladder

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What does a bladder with sacral disease look like?

Soft bladder
Easily expressed
Other neuro signs

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What does a bladder with sphincter incompetence look like?

Soft bladder
No over-distension
No stranguria/ dysuria
No other neuro signs

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What may predispose to infection?

Altered Urethral Defence Mechanisms (Sphincter Incompetence)

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What two medications relax the detrusor muscle, allowing the bladder to enter the storage phase?

Phenylpropanolamine
Oestriol

What is USMI?

Urethra weakens and becomes leaky

Why is USMI more common in spayed bitches?

Lack of estrogen= decreased muscle tone

How would you treat USMI?

Weight loss
Therapeutics
Phenylpropanolamine
Ephedrine
Oestriol

What are the aims of USMI Surgery?

Increase urethral resistance: Artificial Urethral Sphincter
(AUS) or collagen implant (intraurethral bulking agent).
* Collagen injected around proximal urethra.
* 70% improve but deteriorate over 12 months.
* Can be repeated but expensive.
* Move bladder neck into abdomen: colposuspension,
urethral sling, transvaginal sling, cystourethropexy.
* Colposuspension: 50% cured, 40% improved.

What is detrusor overactivity?

Rare in small animals – recognised in humans (OAB).
* Bladder fails to relax during storage phase
* Detrusor hyperactivity (neurologic)
* Detrusor instability (non-neurologic)

What is the treatment for detrusor overactivity?

aimed at increasing bladder capacity/decreasing spasticity (voidance).
* Antimuscarinic (anticholinergic) agents (propantheline, oxybutynin)
* Relaxants (imipramine)

What do ectopic ureters result from?

Results from dysembryogenesis of the metanephric ducts.

What are the signs and signalment of ectopic ureters?

Often evident from birth but not always – may be mistaken for poor house training! * Continuous incontinence but may be intermittent. * More commonly seen in bitches. * Some breed predispositions - WHWT, Border terrier, Newfoundland, Siberian Husky, Lab and Golden Retrievers

How might you diagnose ectopic ureters?

Urinalysis, but it is susceptible to UTI's Radiography or Contrast Radiography Ultrasonography- may often see a distended ureter (hydroureter/hydronephrosis)

What is the gold standard for diagnosing ectopic ureters?

Transurethral Cytoscopy

How might you treat ectopic ureters?

* Suregery is required for correction * Intramural EC: transurethral cytoscopic ablation of intramural ectopic ureters * Nephrectomy if required

What is patent urachus?

Foetal urachus remains patent * Evident early in life and can be surgically corrected

What is iatrogenic uretovaginal fistulation?

Occurs when a ureter is accidentally incorporated into the vaginal ligature during an ovariohysterectomy. * Patient unwell few days post-sx, then incontinent * Don’t confuse with USMI * Tx: anastomose ureter to bladder or nephrectomy/ureterectomy.

What is detrusor atony?

Over distention damages tight junctions resulting in weak, uncoordinated or absent bladder contractions

What does detrusor atony look like on a physical exam?

often bladder is large but flaccid.

What is the treatment for detrusor atony?

address any underlying cause, relieve any obstruction (catheterise if necessary), manually express bladder (neurological cases)

What medication would you use for detrusor atony?

Parasympathomimetics like bethanechol (only effective on intact smooth muscle cells). * Relax US: prazosin, phenoxybenzamine (IUS), diazepam (EUS).

What is the prognosis for detrusor atony?

Prognosis dependent on cause: recovery of detrusor reasonable for acute cases but guarded prognosis if chronic.

What is reflex dyssynergia?

Functional abnormality - failure of coordination of sphincter relaxation and detrusor contraction. * Initiation of detrusor contraction stimulates simultaneous contraction of sphincter muscles. * Leads to bladder distension → bladder atony, UTIs.

In what dog breeds is bladder dyssnergia most common?

Large and giant breeds of dog

What causes reflex dyssnergia?

neurogenic: lesions of spinal cord; non-neurogenic: idiopathic (‘IRD’: idiopathic reflex dyssynergia)

What is the treatment for reflex dyssynergia?

want to prevent bladder distension and restore normal detrusor contraction. * Catheterisation * Parasympathomimetic (bethanechol) to restore detrusor contraction and a sympatholytic agent (prazosin) to allow sphincter relaxation (decreasing outflow resistance). * Monitor for UTIs

What does lower motor neuron bladder cause?

storage issue. * Sacral spinal cord segments and nerve roots + pudendal nerve + pelvic nerve. * Weakness here causes urine dribbling – not aware that bladder is full, no detrusor tone, can express bladder easily. Often absent perineal reflex, tail paresis and absent tail sensation. * Tail pull injury. * Lumbosacral disease. * Fibrocartilagenous embolism. * Neoplasia.

What does upper motor neuron cause?

overflow issue. * Lesion cranial to sacral segments. * Bladder distension and increased tone, very difficult to express. * Overdistension → permanent damage, detrusor atony. * Can develop reflex micturition.

How might you treat neurological incontinence?

with catheterization, manual expressing, ensure no UTI, relax US (prazosin 0.5mg/kg PO BID, phenoxybenzamine 0.5mg/kg TID PO, improve contraction with bethanecol.