Evaluation and Treatment of Female Urinary Incontinence

Question 1

The external urethral sphincter is also called the ____________.

Answer 1

rhabdosphincter

Question 2

The sympathetic response does what to the micturition system?

Answer 2

• Epinephrine on alpha-1 stimulates constriction of the urethral sphincter
• Epinephrine on beta-2 and beta-3 leads to relaxation of the detrusor muscle

Question 3

When the bladder expands, the ___________ nerve sends sympathetic signals to the detrusor to relax.

Answer 3

hypogastric

Question 4

What neurotransmitters are involved in the storage phase of micturition?

Answer 4

Norepinephrine and serotonin

Question 5

Describe stress incontinence.

Answer 5

This occurs when physical stress (like sneezing or physical exertion) forces out urine through a weak urethra.

Question 6

Describe urge incontinence.

Answer 6

Urge incontinence occurs when urination suddenly occurs with feelings of urgency.

Question 7

_____________ is the most common cause of stress incontinence.

Answer 7

Urethral hypermobility

Question 8

List the subtypes of urgency incontinence.

Answer 8

• Myogenic
• Neurogenic
• Idiopathic

Question 9

People usually feel the first inklings of a need to urinate at ___________ mL.

People usually feel a “full bladder” at _____ mL.

People usually feel the need to void at ________ mL.

People usually feel an undeniable need to void at _________ mL.

Answer 9

100

200

250 - 400

500 - 800

Question 10

The levator ani muscles ____________ with defecation and urination.

Answer 10

relax

Question 11

The levator ani muscles rapidly __________ when coughing.

Answer 11

contract

Question 12

What kind of muscle fibers are found in the levator ani muscle?

Answer 12

Types I (slow twitch) to maintain tone and type II to rapidly contract with changes in pressure.

Question 13

_____________ is the most common side effect of anticholinergics.

Answer 13

Dry mouth

Question 14

Anticholinergics are contraindicated in those with _______________.

Answer 14

closed-angle glaucoma

Question 15

How common is female urinary incontinence?

Answer 15

15% to 50% of women are affected (even more in the elderly)

Question 16

During the filling phase, the ____________ muscle relaxes to keep pressure low.

Answer 16

(highly elastic) detrusor

Question 17

From which vertebral levels do the parasympathetic fibers of the urinary system originate?

Answer 17

S2 - S4

Note: the sympathetic fibers arise from T10 - L2.

Question 18

Which nerve controls the striated muscles of the urethra?

Answer 18

The pudendal nerve (S2 - S4)

Question 19

What kinds of epithelium line the urethra?

Answer 19

Stratified squamous (distally) and transitional (proximally)

Question 20

The urethral smooth muscle is under ___________ control.

Answer 20

cholinergic and alpha-adrenergic

Question 21

How is the urethra anatomically anchored?

Answer 21

• It passes through (and attaches to) the perineal membrane.
• It is anchored by ligaments to the pubic bone.

Question 22

How can you diagnose a “hypermobile urethra”?

Answer 22

If you insert a cotton swab into the urethra and then ask the patient to bear down, the swab should not move more than 30º from its original plane. Moving more than that indicates hypermobility and increased likelihood of stress urinary incontinence.

Question 23

True or false: people can normally inhibit the detrusor contractile reflex.

Answer 23

True. The detrusor muscle contracts when filled to a certain volume. Most people can inhibit this response to decrease intravesicular pressure while locating a place to void.

Question 24

How is the pressure in the bladder calculated?

Answer 24

(abdominal pressure measured in vagina) –(pressure in bladder measured in catheter)

Question 25

What is the utility of knowing the pressure of the bladder?

Answer 25

It can tell you if the detrusor muscle is overactive. For instance, if you ask a patient to Valsalva and the bladder pressure increases beyond the increase in abdominal pressure, then you know that the detrusor contracted inappropriately in response to the increased pressure.

Question 26

What is thought to cause urethral hypermobility?

Answer 26

Weakening of the vaginal wall

Question 27

Wakening at night to void is indicative of ____________ incontinence.

Answer 27

urge

Question 28

What causes fistulas between the vagina and the urethra?

Answer 28

• Surgery
• Forceps use during labor
• Irradiation

All are thought to damage the vasculature of the urethra which leads to necrosis of the urethral wall.

Question 29

What is the best test for diagnosing a ureterovaginal fistula?

Answer 29

Inject methylene blue into the urethra and then place a cotton swab into the vagina. If the cotton turns blue, then a fistula is likely present.

Question 30

The best treatment for stress urinary incontinence is __________.

Answer 30

Kegels

Question 31

If Kegels don’t work, then ____________ can also be used to treat SUI.

Answer 31

pessaries that “prop up” the vagina so that urethral hypermobility decreases

Question 32

Why does estrogen help SUI?

Answer 32

It leads to thickening of the urothelium (just like the endometrium) which decreases the urethral lumen size.

Question 33

___________ is the main neurotransmitter of the storage phase.

Answer 33

Norepinephrine

Question 34

List the three subtypes of stress urinary incontinence.

Answer 34

• Type 1: SUI in the absence of urethral hypermobility
• Type 2: SUI due to urethral hypermobility (most common)
• Type 3: SUI due to intrinsic urethral sphincter defect

Question 35

What is the mechanism of trospium?

Answer 35

M3 antagonist