Incontinence

Question 1

What are the main differences on history between a normal bladder and an overactive one?

Answer 1

• Emptying more than 8 times daily
• Emptying more than twice overnight
• Urgency

Question 2

What is the most common cause of urge incontinence?

Answer 2

• Detrusor overactivity (frequency, urgency, nocturia, incontinence)
• Mostly in older populations

Question 3

What is the underlying pathophysiology in stress incontinence? What will urodynamic studies show?

Answer 3

• Most common cause of incontinence
• Due to defects in pelvic floor/sphincter deficiency
• Urodynamics - involuntary leakage of urine during increased abdominal pressure in absence of detrusor activity

Question 4

Describe the important history and examination points to cover in a person with incontinence

Answer 4

• History
  
  • Stress - involuntary loss of urine on exertion
  • Urge - strong and sudden desire to void that is difficult to postpone and that may result in incontinence
  • Other symptoms - frequency, nocturia, leakage, pad use, quality of life, oral fluid and caffeine/alcohol intake. Prolapse symptoms, dysuria, haematuria, bowel symptoms
  • Obstetric/gynaecological history
  • Medical history (especially narrow-angle glaucoma)
  • Medications - anti-cholinergics, diuretics, antihypertensives
• Examination
  
  • General - mobility, MMSE, neurological, BMI, abdominal
  • Bimanual and external vaginal exam
  • Pelvic floor muscle strength (clench on finger)
  • Demonstrable stress continence
  • Prolapse

Question 5

List the investigations that you might consider in someone with incontinence

Answer 5

• UEC
• MSU
• Post-void residual (complete emptying?)
• Bladder diary/QoL questionnaires
• Urodynamics - uroflowmetry, cystometry, pressure profilometry
• Videourodynamics
• Cystourethroscopy

Question 6

Describe the management of stress incontinence

Answer 6

• Conservative
  
  • Pelvic floor exercises
  • Pads
  • Incontinence pessary
  • Topical oestrogen
• Surgical
  
  • Requires urodynamics to be performed pre-operation
  • Burch colposuspension, mid-urethral slings, fascial slings, peri-urethral injections

Question 7

Describe the management of urge incontinence

Answer 7

• Conservative
  
  • 1.5L fluids per day
  • Avoid alcohol, caffeine
  • Bladder retraining with physiotherapist
  • Pharmacological
    
    • Anticholinergics - oxybutynin, tolterodine
    • TCAs - imipramine (may be useful for nocturia)
    • Oestrogens (especially in post-menopausal)
• Surgical
  
  • Cystoscopy with hydrodistension
  • Cystoscopy with intravesical Botox injection
  • Sacral nerve stimulation
  • Bladder augmentation surgery (rarely done now, high morbidity)
  • Urinary diversion (rarely done, last resort)