Incontinence

Question 1

Define Stress Incontinence

Answer 1

Complaint of involuntary leakage of urine on effort or exertion, sneezing or coughing etc

Question 2

Define Urodynamic Stress Incontinence (USI)

Answer 2

Its a disorder diagnosed by Cystometry

Leaking with coughing in the absence of detrusor contraction

Question 3

Define Urge Incontinence

Answer 3

Involuntary urine leakage accompanied by urgency of micturition

Question 4

Define Overactive Bladder Syndrome

Answer 4

Urgency that occurs with (wet) or without (dry) incontinence (and freq & noturia usually)

Question 5

Define Detrusor Overactivity

Answer 5

Diagnosis of cystometry if involuntary detrusor contraction occurs

Question 6

Define Overflow Incontinence

Answer 6

Usually due to chronic bladder outflow obstruction

Question 7

Define Functional Incontinence

Answer 7

Patient unable to reach toilet in time for functional reasons ie poor mobility/ unfamiliar surroundings

Question 8

Define Detrusor Overactivity

Answer 8

Urodynamic diagnosis characterized by involuntary detrusor contractions during filing phase

Spontaneous or provoked (eg coughing)

Question 9

Outline the Epidemiology of Incontinence

Answer 9

Of incontinent women;

• 50% Stress incontinence
• 35% Overactive bladder syndrome

Question 10

Outline the Aetiology of Stress Incontinence

Answer 10

• Pregnancy & vaginal delivery
• Obesity
• Elderly [esp post-menopausal]
• Previous surgery/ prolapse

Question 11

Outline the Aetiology of Urge Incontinence

Answer 11

• Detrusor instability or hyperreflexia leading to involuntary detrusor contraction
• Idiopathic
• Secondary to Neurological problem [cerebral/ spinal]

Question 12

Outline the Aetiology of Overactive Bladder syndrome

Answer 12

• Idiopathic
• Following operations for Stress Incontinence
• Involuntary detrusor contractions in the presence of underlying neuropathy (MS/ spinal injury)

Question 13

Outline the mechanism of Urinary Stress Incontinence

Answer 13

• Inrease in intra-abdominal pressure (‘stress’)
• Bladder compressed & pressure rises
• Bladder pressure exceeds urethral pressure (which should be maintained by pelvic floor & bladder neck)
• Incontinence

Question 14

Outline the mechanism of Overactive Bladder Syndrome

Answer 14

Detrusor muscle contracts strong enough to overcome urethral pressure & patient leaks (urge incontinence)

Spontaneously or with provocation (eg coughing)

Question 15

Outline the investigations for Incontinence

Answer 15

• Urine dipstick
  
  • • for Leukocytes & Nitrites/ or symptomatic ⇒ MSU culture & sensitivities
• Urodynamic Studies [prior to surgery & unsure]
  
  • Frequency volume charts [to gain more info]
  • Pad tests [to determine amount of fluid lost]
  • Urinary flow rate [ml/s, assess voiding function]
  • Residual volume
  • Multichannel cystometry
    
    • Catheter: Vesicle pressure & flow rate
    • Rectal pressure transducer: Abdominal pressure
    • Detrusor pressure = Vesicle pressure - Abdominal pressure
    • Leak point pressure = pressure during vesicle filling that it contracts
  • Ambulatory urodynamics [cystometry while doing things]
  • Electromyography [muscle activity around urethral sphincter

Question 16

Outline the management of Stress Incontinence

Answer 16

• Lifestyle
  
  • Loose weight
  • Address chronic cough
• Conservative
  
  • Pelvic floor muscle training (PEMT) for 3months by Physio
  • Vaginal ‘cones’/ sponges
• Medical
  
  • Duloxetine [SNRI] - enhances urethral striated sphinter activity via centrally mediated pathway
• Surgery
  
  • Tension-free vaginal tape (TVT)
    
    • Synthetic polypropylene tape place in U-shape under mid-urethra via small vaginal ant. wall incision
    • Tension then adjusted
  • Trans-obturator tape (TOT)
    
    • Same as TVT except passed through transobturator foramen
    • Retropubic space not entered & so bladder perforation rare
  • Injectable periurethreal bulking agents
    
    • ​Not very good

Question 17

Outline the management of Overactive Bladder Syndrome/ Urge Incontinence

Answer 17

• Conservative (urge)
  
  • Bladder retraining (inc time between voids)
• Medical
  
  • Anticholinergics (antimuscarinics) [suppress detrusor overactivity]
  • Oestrogens [in postmenopausal women]
  • Botulinum toxin A (BTX) [blocks neuromuscular transmission, weakening detrusor]
    
    • Retention may require self-catheterisation
• Other
  
  • Neuromodulation & S3 nerve stimulation [suppresses detrusor contraction]