Urinary Incontinence Answers 2007

1. Contrast and compare urge and stress incontinence by completing the following table:

Urge Incontinence
Stress Incontinence
abrupt desire to void cannot be suppressed (voiding of urine before you can reach the toilet)
- most common cause of incontinence >75 years of age
hypermotility of bladder neck and urethra or intrinsic sphincter problems
- most common type in women <75 years of age
Anatomical cause
inappropriate contraction of detrusor muscle during bladder filling
- idiopathic
- related to aging (unclear mechanism)
- decreased cortical inhibition (CVA/stroke, Parkinson's disease, Alzheimer's disease, brain tumour)
- bladder irritation (UTI, bladder cancer, stones)
hypermotility of bladder neck and urethra (85% of cases)
- associated with aging, hormonal changes (menopause), traume of childbirth or pelvic surgery
intrinsic sphincter problems (15% of cases)
- due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes
Autonomic pharmacological rationale for drug treatment
medications to relax the bladder (more bladder specific as you go down)
- propantheline
- imipramine (used low dose in children)
- oxybutynin (tablet, 2x weekly patch available)
- tolterodine
- solifenacin
- darifenacin

- last two are M3 receptor antagonists - responsible for emptying, contraction and involuntary contractions that can cause UTI (used 3rd line)
- atropine would cause CNS effects (not bladder-selective)
medications to tighten the tap
- drug treatment usually secondary (try pelvic floor exercises)
- phenylpropanolamine (not used much)
- oestrogen (orally, transdermally or transvaginally) to help strengthen the bladder outlet in post-menopausal women, limited evidence (if atrophic vagina related to oestrogen deficiency

2. With regard to urinary incontinence, which of the following statements is not correct?
a) It is present in <20% of older men living in the community
b) Its prevalence increases with age
c) It is considered normal in nursing home care for older people
d) It is present in >20% of older women living in the community

a) present in 10-15% of community dwelling older men
b) prevalence increases with age (but is not a part of normal aging)
c) found in 50% of nursing home residents
d) present in 25-30% of community dwelling older women

therefore, C is not correct

3. Which of the following medications should not be used in the treatment of urge incontinence?
a) Oxybutynin
b) Phenylpropanolamine
c) Propantheline
d) Imipramine

For urge incontinence, you need to use a medication with anticholinergic effects, which is a) oxybutynin, c) propantheline and d) imipramine. b) phenylpropanolamine is used in stress incontinence and using this in urge incontinence may lead to overflow incontinence (bladder is overfilled)
4. Which of the following drugs/drug classes is not implicated in the exacerbation of urinary incontinence?
a) Calcium channel blockers
b) Caffeine
c) Anticholinergics
d) Lithium

a) calcium channel blockers such as verapamil can lead to constipation, exacerbating urinary incontinence
b) caffeine is a diuretic
c) anticholinergics are used in the treatment of urinary incontinence
d) lithium can lead to polyuria

Therefore, c) anticholinergics are not implicated in the exacerbation of urinary incontinence, however they can worsen the condition if used in the wrong type (relaxing the bladder in overflow incontinence, end up making the bladder relax and fill up more)
Wouldn't this be very dodgy as an exam question then, as anticholinergics can undoubtedly exacerbate most types of urinary incontinence apart from urge, while the incidence of verapamil-induced incontinence via constipation is probably not very common at all??