Scenario 2: Irenes Incontinence

Irene Smith is a 48 year old female, and presents to her GP with a long-standing problem of
urinary incontinence. She has had incontinence for a few years (2 years) but has recently
noticed deterioration in her symptoms. She finds herself leaking daily and has to wear 3 pads
per day. She has wanted to seek medical attention for her problem for a while but has been too
embarrassed to see her male GP. She smokes 20 cigarettes per day for the last 28 years.
Her past medical history includes chronic back pain, for which she has undergone spinal surgery.
She has had 2 children approximately 20 years ago; her first was a forceps delivery, and her
second was a large baby weighing 10lbs 6oz.
On examination she is overweight; her Body Mass Index has been calculated by the clinic nurse
as being 32. She has mild hypertension.
Introduction questions
What types of urinary incontinence do you know?
Stress Incontinence
Urge Incontinence
Mixed Incontinence
Unexplained incontinence
What risk factors for incontinence are detailed in the history and examination?
Child birth especially instrumental or difficult deliveries
Obesity
Smoking
Spinal problem may contribute to incontinence
The GP wants to perform some initial investigations to exclude the possibility of other urological
problems what test could s/he perform?
Urine dipstick looking for non-visible haematuria or infection
Renal tract ultrasound may be able to identify any renal and bladder masses
Further History
1. Urinary symptoms she leaks on laughing, coughing and sneezing. She also has urinary
frequency and urgency and occasionally leaks before she can get to the toilet. She is
bothered by her symptoms and limits her daily activities as she fears that she may leak
through onto her clothes. She also admits to occasional faecal incontinence; she is
incontinent of both flatus and faeces. It is a particular problem if she ever has a stomach
upset as she is unable to leave the house, as a consequence she will not travel overseas.
2. She is still sexually active but has occasionally leaked urine during intercourse.
3. Her friend has recently undergone surgery for a similar problem and she would like to explore
a similar sort of operation.
Examination
General Examination - Overweight female
Cardiovascular System BP 132/87, pulse regular
Respiratory System Few basal crepitations, nil else
GI System Abdomen is soft and non-tender. Digital rectal examination reveals poor anal
tone, normal sensation
Musculoskeletal System Not Necessary
Nervous System Some limitation of back flexion and extension
Genitourinary System vaginal examination - poor pelvic floor squeeze.
Urinalysis Nil
Psychiatric Exam she has previously had depression but is not currently on anti-depressants
Investigations
Which of the following investigations should be performed after the initial out-patient meeting?
1. Midstream Urine
2. Renal tract Ultrasound & residual measurement
3. 3 Day Bladder Diary
4. 24 hour Pad Test
5. Flexible Cystoscopy
Investigation Results

1. MSU negative
2. Renal Tract Ultrasound demonstrated a simple cyst on the left kidney, and her bladder
empties to completion.
3. 3 Day Bladder Diary This demonstrated 3-4 incontinence episodes per day. It also
demonstrated that she consumes 6-8 mugs of tea and coffee per day and at least one can of
diet coke per day.
4. 24 hour pad test weighed 53 g
5. Flexible Cystoscopy patulous urethra, normal bladder
What are the Differential Diagnoses?
Stress Incontinence
Urge Incontinence
Mixed Incontinence
Faecal Incontinence
Patient Management
Conservative management
Initial management involves reducing caffeine intake, the patient is advised to reduce her intake
to one or two cups per day. In addition she should attempt to lose weight and stop smoking and
a referral to a dietician and smoking cessation clinic should be offered. Pelvic floor physiotherapy
is also recommended and the patient should be encouraged to try and persevere for at least 6
months.
Overactive Bladder Management
Medical treatment is usually with anti-cholinergics such as oxybutynin. Side effects include dry
mouth, blurred vision and constipation. Resistant overactivity may be treated with intradetrusor
Botulinum injection.
Stress Incontinence
Limited medical treatments available, only one is Duloxetine a selective serotonin reuptake
inhibitor. Only used in female stress incontinence with limited use.
Scenario Review
Irene returns to see you after 6 months. She has been attending regular physiotherapy for the
last 6 months, and has managed to lose 3Kg of weight. She is on regular Oxybutynin with
minimal side effects. Her urinary incontinence episodes are reduced to 3 per day and she has
noticed some improvement in her faecal incontinent episodes.
She has discussed the surgical options with her family and has decided that she would like to
undergo surgical intervention
What are the surgical options for the management of stress incontinence?
Mid-urethral tapes are the mainstay of treatment; a nylon mesh is placed via a vaginal
incision and paced retropubically or transobturator.
Burch colposuspension
Midurethral bulking injection.
Scenario Review
The patient undergoes a mid-urethral tape placement and has an uneventful recovery. She
attends for out-patient follow-up 6 months later, and has decided due to the success of her
recent urological surgery that she would like to be referred to a specialist for her faecal
incontinence.
1. What options are available for the management of faecal incontinence?
Pelvic floor physiotherapy
2. Medical treatment constipating medications such as codeine
3. Biofeedback
4. Surgery
Anal Sphincter repair
Stimulated muscle transposition
Artificial sphincter

Colostomy

Sc02 L02 - The Pelvis and Perineum see anatomy document

Define the greater and lesser pelvis, and know the boundaries of the lesser pelvis: inlet and
outlet
List the main features of the hip bones, and its joints and ligaments
Define the boundaries of the pelvic wall and floor
Know the parts of the pelvic diaphragm and their relative importance.
Know the innervation of the pelvic diaphragm
Describe the position, shape and form of the pelvic organs in both sexes.
Know the main neurovasculature of the pelvic wall and viscera.
Define the perineum and its boundaries.
Describe the perineal membrane, deep pouch & contents.
Give an account of the blood supply and venous and lymphatic drainage of the perineum.
Know the origin, course and distribution of the pudendal nerve.

Sc02 L03 - Structure of Bladder, Prostate, Urethra see anatomy document

Know the locations of the external urethral openings, and appreciate the fundamentals of
catheterisation;
Know the form and position of the bladder, and its relations in both sexes;
Define detrusor muscle, bladder neck and trigone;
Know the supports of the bladder
Have a basic understanding of the micturition reflex and voluntary control, and know the
procedures for catheterisation;
Know the differences in the urinary sphincters between the sexes;
Understand the prostate gland and prostatic urethra so as to be able to explain in simple terms
the significance of the locations of the urethral sphincter, the effects of prostatic enlargement
and the metastasis of prostatic malignancy to the vertebral column;
Know the consequences of urethral rupture.
Sc02 L04 - Physiology and Pharmacology of Urinary Incontinence

Outline the regulation of urine storage and voiding by the nervous system
Define the following terms: Lower urinary tract symptoms (LUTS), overactive bladder,
stress incontinence, urge incontinence, detrusor overactivity (neurogenic and idiopathic)
Describe the use of muscarinic receptor blockers in the treatment of conditions involving
overactive bladder, including mechanisms of action and major adverse effects
Describe the use of botulinum toxin in the treatment of refractory overactive bladder,
including mechanisms of action
Describe the use of 3 adrenoceptor agonists in treating LUTS
Describe the use of selective 1adrenoceptor agonists, 5 reductase inhibitors and PDE
5 inhibitors to treat male LUTs
Efferent pathways and neurotransmitter regulation of the lower urinary tract

Afferent Aand C fibres from the detrusor (the smooth muscle that contracts), which
carry sensations of bladder fullness and respond to noxious stimuli, run into the spinal
cord and synapse with spinal interneurons and with neurons that project to brain centres
involved in bladder control
Control of urine storage

Distension (bladder fullness)

The parasympathetic input causes detrusor constriction; thus inhibiting parasympathetic
outflow prevents this
Control of bladder voiding

Sympathetic and motor activity inhibits detrusor contraction (thus prevents voiding, and
promotes storage)
Urethral and sphincter constriction is also inhibited now thus relaxed sphincter and urethral
Parasympathetic input switched on: detrusor contracted (Ach), relaxes Urethra (Nitric oxide)
EMPTIES!
Lower urinary tract symptoms (LUTS): storage, voiding ad post micturition symptoms
Storage symptoms: increased daytime frequency, nocturia, urgency and incontinence

Stress incontinence: Involuntary loss of urine on effort, exertion, cough, sneezing,

occurs when the pelvic floor muscles become weakened (eg. as a result of childbirth);
thus increases in intraabdominal pressure force urine through the external urethral
sphincter.

Urge incontinence: Involuntary loss of urine associated with an abnormally strong

desire to void. Usually due to idiopathic (of unknown cause) detrusor overactivity
(DO).

Mixed incontinence: Stress and urge incontinence coexist.

Voiding symptoms: slow and intermittent stream, hesitancy, straining

Post-micturition symptoms: feeling of incomplete emptying, post-micturition dribble4
General syndromes (set of signs and symptoms indicative of a disease/disorder)
Overactive bladder syndrome urgency with/without urge incontinence; urgency without
incontinence is itself a therapeutic target
LUT symptoms suggestive of bladder outlet obstruction; more common in males
Prevalence of LUTs: the EPIC study (2006)
19165 adults (over 18 years) in the UK, Canada, Germany, Italy and Sweden interview by
telephone
LUTS categories defined according to the International Continence Society 2002 guidelines

Storage (two-thirds); most common LUT syndrome

Detrusor Overactivity (DO)
The bladder normally does not contract during the storage phase
In DO however - the bladder undergoes phasic contractions or contracts uncontrollably when full
DO is thought to be the main cause of urgency (strong desire to void, fear of leaking) & urgencyassociated incontinence
DO is the main target for pharmacological treatment of LUTs. Types of DO:
Neurogenic: conditions resulting in de-inhibition of the pontine micturition centre (dementia or
stroke)
Spinal cord dysfunction (eg. Multiple Sclerosis) can cause bladder C fibre afferents to become
hypersensitive; this allows emergence of segmental reflexes
Idiopathic: arising for no apparent reason. Multiple hypothesis exist:
Neurogenic: due to reduced CNS suppression of parasympathetic outflow during storage
Myogenic: increased spontaneous detrusor contractions or better coordination of small localised
contractions
This could possibly be due to more myofibroblasts
Urotheliogenic: Myofibroblasts and afferent nerve fibres in the suburothelium are increased in
DO; the urothelium/suburothelium release more ATP increase in detrusor spontaneous activity
or increase afferent firing

The lining of the bladder lumen has both barrier and regulatory functions
The bladder urothelium is the least permeable type of epithelium in the body
As the bladder fills and stretches, the apical membrane first unfolds to increase its surface area
With further filling: cytoplasmic vesicles are inserted into the membrane to further increase the
surface area
When the bladder empties: the lateral membrane unfolds and the apical membrane refolds the
cells become more columnar
Approx 90% of the apical membrane area consists of plaques which comprise regular arrays of
uroplakin subunits
Uroplakins serve to reduce membrane permeability

1. Bladder stretch releases ATP from the urothelium. It binds to P2X3 receptors on
afferent nerve endings, activating them. The urothelium thus acts as the sensor of
bladder fullness.
2. The urothelium regulates the contraction of the detrusor smooth muscle by releasing
both relaxing and constricting factors, thus amplifying or modulating nervous signals.
3. Myofibroblasts (cells with properties of both smooth muscle and fibroblasts) in the
suburothelium serve to amplify the effects of substances released from the
urothelium on the detrusor and on afferent nerves.

Acetylcholine acts on multiple muscarinic receptors in the bladder

M3 receptors are of primary importance in contracting detrusor smooth muscle cells

Their activation causes contraction by 1. opening Ltype Ca2+ channels 2. inhibiting
myosin phosphatase
M2 receptors facilitate contraction by inhibiting ongoing relaxation by cyclic AMP
M2 receptors normally play a small role, but probably become more important in
overactive bladder.
Muscarinic receptor blockers may reduce urgency by inhibiting the abnormal
contractions of the detrusor muscle which occur in overactive bladder during the
storage phase.
But, muscarinic receptor blockers become ineffective at blocking effects of
acetylcholine on the detrusor in animal models of overactive bladder
So, the crucial muscarinic receptors therefore might be on the urothelium, and may
be regulating the release of ATP which stimulates the afferent nerves, thereby
promoting voiding.

Mechanisms of muscarinic receptor-mediated contraction of detrusor muscle

PHARMACOLOGICAL TREATMENT OF URINARY INCONTINENCE

Drugs are mainly used to treat urinary continence resulting from overactive bladder
1. Muscarinic receptor antagonists are used most commonly
2. BOTULINUM toxin A can be used it these dont work
3. 3 adrenoceptor agonists are a newer option
4. A1 adrenoceptor antagonists and 5a reductase inhibitors used for male LUT syndrome
MUSCARINIC ANTAGONIST FOR OVERACTIVE BLADDER (ob)
Most of the muscarinic receptor antagonists used to treat OB have some selectivity my M3 over
other M receptors
Most widely used drug: OXYBUTYNIN (Selectivity: M3>M1 >> M2)
Given the wide distribution of muscarinic receptors in the body, these drugs often cause
predictable side effects:
Dry mouth (most common), constipation, blurred vision, tachycardia (seldom occurs)
Clinical trials suggest that patients generally tolerate the drugs well, but their effectiveness may
wane with time

BOTULINUM TOXIN A BoNT/A

Botulinum toxin is used (off licence) for the treatment of refractory overactive bladder
First use for OB was reported by Schurch et al (2000) for patients with neurogenic bladder
overactivity which was not responding to anti-muscarinics
Subsequently has also been used for idiopathic OB
BoNT/A is injected into the detrusor muscle at numerous sites via a needle threaded through a
flexible cystoscope (tube introduced into the bladder through the urethra).
Treatment is on an outpatient basis, taking approx. 20 minutes
The treatment produces a long-lasting (10 month) improvement in bladder function (increased
urine storage, improvement of symptoms); equally effective if repeated!
BOTOX works on nerve terminals, blocking vesicle release by degrading SNAP-24, a protein
involved in the docking and fusion of vesicles with the plasma membrane
Sc02 L05 Problems and Processes in the Consultation PRACTICE OF MEDICINE
LECTURE
Describe key benefits of good communication
Describe important patient inputs into the consultation
Describe different types of doctor - patient interaction
Review key outcomes for the patients related to the consultation
Describe the elements of the message that are problematic in doctor patient communication
Describe methods to improve communication and adherence
Sc02 L06 - Scenario Debriefing Mr Arun Sahai

What are the physiological process involved in micturition and defecation?

Urine is expelled from the bladder by a process called micturition (complex process)
Smooth muscle of the bladder, smooth and striated muscle of the urethra and striated muscle of
the pelvic floor
CNS higher CNS centres, pontine micturition centre and the sacral spinal cord (S2-4)
Peripheral Nervous System Parasympathetic and sympathetic components of the nervous
system
Pelvic and hypogastric nerves respectively
The somatic nervous system too Pudenal nerve

Other Learning Sessions:

Dissection (Sc02 DR session 2): Anatomy of the urinary system
Pathology workshop (Sc02 Path Wks): Renal disease
Living Anatomy (Sc02 Living anatomy): Living anatomy of abdomen/pelvis