Urinary Incontinence

Question 1

How does the CNS affect bladder control?

Answer 1

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

Question 2

Difference between transient/acute and chronic urinary incontinence

Answer 2

Transient

• < 6 months
• has a reversible underlying cause always

Chronic

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

Question 3

Stress incontinence

Answer 3

• *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

Question 4

Urgency incontinence

Answer 4

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 #)

Question 5

Red flag symptoms for urinary incontinence

Answer 5

Rapid onset urinary incontinence

Pelvic pain

Hematuria

Question 6

Overall risk factors for urinary incontinence

Answer 6

Obesity

Functional impairments

Dementia

Medications

High levels of vaginal deliveries

High impact exercise

Question 7

Overflow incontinence

Answer 7

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.

Question 8

Mixed incontinence

Answer 8

Features of both stress and urgency incontinence

- very often seen in pregnant patients who get UTIs during pregnancy

Question 9

How does aging affect urinary incontinence?

Answer 9

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

Question 10

What is always done in urine diagnostics and urinary incontinence

Answer 10

Urinalysis

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

Question 11

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

Answer 11

NO

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

Question 12

Mnemonics for causes of transient incontinence

Answer 12

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

Question 13

Common medications that cause incontinence

Answer 13

Diuretics

Anticholinergics/antihistamines

Antipsychotics/antidepressants

Sedatives/hypnotics

Alcohol

Narcotics

A-adrenergic agonists/antagonists

CCBs

Question 14

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

Answer 14

Normal = <30 degrees

Stress = > 30 degrees

Question 15

Extra strategies for making Urinary incontinence

Answer 15

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

Question 16

Broad physiology of micturation in males and females

Answer 16

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

Question 17

First line treatment of all urinary incontinence issues

Answer 17

Lifestyle modifications

• weight loss
• pelvic flood exercises
• bladder training

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

Question 18

2nd line treatment for all urinary incontinence

Answer 18

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

Question 19

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

Answer 19

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

B3 receptors = Gs -> AC/cAMP increases

Question 20

General physiological background of urinary process

Answer 20

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

Question 21

difference between external and internal urethral sphincters

Answer 21

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

Question 22

What is the micturation center of the spine?

Answer 22

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.