What's up Ninja Nerds? In this video today we're going to be talking about urinary incontinence. This is a part of our clinical medicine section.
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We're gonna talk about three types that include stress, urge, and overflow incontinence. Now in stress incontinence, the concept behind this is that the patient is having increased intra-abdominal pressure. So that's what you really have to remember is that the patient is having some type of increased intra-abdominal pressure. And the reason why that is the problem is whenever the intra-abdominal pressure is really high it leads to kind of compression of the bladder. So imagine I have pressure in the abdomen it starts smashing down on the bladder.
All right as a result what's going to happen to the pressure inside of the bladder? It'll go up. So now the patient will have an increase in bladder pressure.
Now whenever the pressure in the bladder increases, the pressure in the bladder will go up. Is greater than the pressure of the muscles of the pelvic floor? Unfortunately, urine will leak out. So what you have to think of is, okay, there's a reason why the intra-abdominal pressure is going up.
It's increasing the bladder pressure. But if I also add another kind of problem. to the mix. So what if I add this to the mix now?
That these muscles that are part of our bladder outlet, they're really weak. So now what I'm going to do is I'm going to say I have a decreased bladder outlet strength. And really this is from the pelvic floor muscle.
You have to then realize if the pelvic floor muscles are weak and the intra-abdominal pressure is high to the point where the bladder pressure is high enough it could overcome these weak muscles and unfortunately as a result lead to urine being leaked out undesirably. The question that you have to ask yourself is what is increasing the intra-abdominal pressure? There's a couple different things. Often times the most common common causes are going to be certain types of triggers, like transient rises.
So coughing is going to be a really big one, sneezing, laughing. These will cause these quick transient rises in the patient's intra-abdominal pressure because what happens is when you cough, when you sneeze, when you laugh, you contract your abdominal muscles and that kind of decreases the actual cavity. volume of your abdominal cavity and there goes the pressure.
Another thing that also plays a role here as well that could be more of a longer lasting effect unfortunately is going to be obesity and then for a nine month period maybe pregnancy because these also will lead to this problem. Okay, so pregnancy, obesity, these are factors that are going to increase the intra-abdominal pressure. Now, if a patient who is usually coming in has this incontinence whenever they're coughing, laughing, sneezing, it's usually they also have under...
underlying obesity or they're pregnant. But on top of that, the other factor here is that they have to have a decreased bladder outlet strength. So something is weakening the bladder outlet, and there's usually two particular reasons.
One is the patient has had multiple children in the past. What do we call that? When you've had lots and lots and lots of childbirths that's caused kind of a lot of destruction, weakness, maybe injury during the actual birthing process to the bladder outlet muscles.
This is usually called multi-parity. So whenever somebody has multi-parity, so they have lots of children, this definitely will cause weakness to these muscles. The last one is menopause. It doesn't cause damage to the muscles.
What happens is in these states of menopause, these patients have low estrogen levels. Estrogen is very important because it helps to be able to maintain elasticity of the muscles and it also helps to be able to play a role in maintaining some degree of strength to some of these muscles. So whenever there's low estrogen levels like in post-menopausal women this will lead to weakening of the elasticity and strength of these pelvic outlet muscles.
So the combination of these is what leads to a patient who has what we call stress incontinence. Oftentimes the way that we classically present this so the classic findings are often described as this, that a patient will have incontinence after coughing, laughing, or sneezing. And then look through their history. Are they obese?
Are they pregnant? Are they post-menopausal? Or are they have had multiple children?
Those historical features will help you to think about the pathophysiology behind this disease. Increasing intra-abdominal pressure from the coughing, laughing, sneezing, along with obesity and pregnancy, in combination with the decreased bladder strength in patients who are, have had multiple pregnancies, or also, low estrogen levels. Okay, let's move on to the next one.
The next concept here is going to be urge incontinence. With urge incontinence, it actually is pretty straightforward. It's the loss of urine, unfortunately.
That's usually, it's going to have a preceding intense desire to have to go to the bathroom. Now, what's the trigger behind this? Well the primary trigger here is usually going to be that there is massive massive massive detrusor hyperactivity.
So the detrusor muscle is the muscle of the actual bladder and whenever this muscle is contracting like a mad dog it'll increase the bladder pressure. And if the bladder pressure overcomes the bladder outlet strength, it'll lead to incontinence. So this is the primary pathophysiology here is that there's increased the truss or muscle activity.
We then have to generate the question, what's... causing the increase the trusser activity. It's usually some type of neurological dysfunction or it could be due to inflammation.
And usually that's a form of urinary tract infections. Now what happens is in neurological diseases, there's a couple that you could remember. This is kind of an interesting one.
You can see this in patients who have Parkinson's disease where they can have this disorder. You can see this in patients with strokes. You may even see this in other patients as well with spinal cord injuries, usually injuries above the brain stem. All right, so how is it doing this? How are we actually kind of increasing this to trust our muscle activity?
Well, generally what happens is if you have these neurons that are supposed to come down to your spinal cord, they're supposed to go to these muscles of the bladder. Now normally what happens is you have neurons that are supposed to have an inhibitory control of the detrusor muscle So they're supposed to be inhibiting them, right? That's their normal function But what if I lose the inhibitory function? So we're gonna see is we're gonna have what's called a loss of inhibition If I have a loss of inhibition, now this muscle is hyperactive.
It's able to become extremely stimulated and will increase the actual contractions, cause an increase in bladder pressure, and lead to urinary incontinence. The other concept is urinary... tract infections these cause direct you know mucosal and detrusor muscle irritability and so these are going to also stimulate this type of process now sometimes in patients who have urgent condens it could be completely idiopathic but I want you to think if it's not idiopathic first remember could it be a neurological loss of inhibition to the detrusor muscle or inflammation usually due to infections like UTIs that's causing increased detrusor area irritability and activity Now, with urge incontinence, the classic finding in this patient is that they will have loss of urine, right?
Their loss of urine though is usually preceded by a strong urge. So it's usually an urge to go to the bathroom followed by what we refer to as incontinence. Oftentimes these patients have frequent bouts of nocturia where they have to go to the bathroom during the night consistently consistently consistently so it's usually a increased urge to have to go to the bathroom followed by incontinence or nocturia that is oftentimes the most common presentation for these patients.
Alright so urge incontinence, hyperactivity of the detrusor muscle, stress incontinence, increased intra-abdominal pressure and bladder outlet weakness. The last one is overflow incontinence. Now in this one the patient will have incontinence but it's usually they have a continuous dribbling type of incontinence. So they have this hesitancy where they actually have to feel like they go to gotta go to the bathroom but they don't feel like they completely empty their bladder and they dribble a lot oftentimes.
So what's the reason behind this one? It's the exact opposite of this one. So oftentimes the trusser muscle is just not contracting. So one reason is it could be due to a decrease in detrusor muscle activity.
So that begs the question, what is leading to this increased detrusor muscle activity? Well, one is it could be due to neurologic dysfunction. You're like, okay, wait a second, Zach. You told me that that thing causes urge incontinence, which causes decreased detrusor activity, and now it can also cause a decrease in detrusor activity, so I can get both?
I can get a decrease and an increase in detrusor activity? Yeah, you can, and that's what kind of of as unfortunate about this as you can get both of them. I would say oftentimes with neurological dysfunctions though you're more likely to get overflow incontinence than you are to get urge incontinence though. Alright with that being said what are some of the things that we have to remember?
Oftentimes it's usually going to be things like multiple sclerosis, diabetes oftentimes are going to be the big ones that cause neuropathy so they affect the actual peripheral nerves. Sometimes you can even see it in spinal cord injuries as well. So you can even see this in spinal cord injuries. So I'll put spinal cord injuries.
But either way, in this scenario here, you're losing some of the modulatory function. So you're losing some of the modulatory function as opposed to be able to stimulate this detrusor activity. So you lose loss of stimulation.
Because of that, your distrust or muscle activity is going to decrease. If it decreases, it's not going to be able to generate enough contraction to increase the bladder pressure, to overcome the bladder outlet strength, and then lead to urine flow. The other concept is it actually could be due to medications.
And oftentimes, these medications are anti-cholinergics. Now, there's different types of anticholinergics, but oftentimes the anticholinergics that act on what's called the muscarinic type 3 receptor is going to be the primary ones. And what they're going to do is, is they are going to inhibit the muscarinic 3 receptor. Now, there's so many different types of anticholinergics, but the ones that are most pertinent here are going to be things like oxybutynin. Another one could be tolteridine.
and another one could be Sola Fenicin. Either way with these drugs what they do is they go and they bind to the m3 receptor. When they bind to the m3 receptor they block the effect of other types of particularly acetylcholine binding to that site.
And what they do is they'll act kind of like an antagonist. And when they act as an antagonist, normally what acetylcholine wants to do is cause bladder contractions. In this scenario, it'll actually decrease the bladder contractions.
And so what you'll see is you'll see a decrease in detrusor muscle activity and this will lead to a inability for the actual urine to flow out. Well if the urine's not flowing out Zach that sounds like retention. It is and oftentimes that's what happens from this detrusor activity is that you lead to retention and then the bladder starts filling excessively.
So this causes an increase in bladder filling and distension. And over time that distension will become so profound that the bladder outlet won't be able to kind of hold on anymore and urine will start dribbling out. So that's the concept. You need to increase retention, increase bladder distension, and then...
eventually you'll lead to incontinence. Okay, that's one concept. There's another reason patients can develop overflow incontinence.
The other one is they can have what's called a bladder outlet obstruction. So this one is very, very common. So bladder outlet obstruction. obstruction. In this disease it's something that's usually near the actual bladder outlet near the actual prostatic urethra that's compressing it and it's impeding urine from being able to flow.
from the actual bladder into the urethra. So this process is being inhibited and as a result it causes retention, bladder distention, and eventually the pressure will become so high that you won't be able to kind of keep the urine in and it'll start dribbling and dribbling and dribbling out. Now what are some things that actually can cause compression around this urethra area?
There's a big little gland there, a little donut-shaped gland. It's called the prostate. And patients who have what's called benign prostatic hyperplasia, this can lead to compression of the prostatic urethra, lead to bladder outlet obstruction, an increase in urine retention within the bladder, increase in bladder distension, and then eventually the pressure will overcome and then lead to small little dribbling of urine. That's oftentimes the classic finding in these patients.
So the classic findings... is that they usually have a feeling that they can't completely empty their bladder. So it's what we call incomplete emptying of the bladder.
And oftentimes, in addition to that kind of sensation, they will often have dribbling of urine. And that is their incontinence. So we're seeing incontinence in the form of dribbling. You can see this in the form of urge preceding the loss of urine or nocturia. Or you can see that preceding some type of event such as a coughing, sneezing, laughing that's triggering an increase in intra-abdominal pressure.
And This describes the types of incontinence, the pathophysiology, and the classic findings along with the causes. What are some potential complications that can arise from all of these types of incontinence, but with an emphasis on overflow incontinence? All right, my friends, so now we're gonna talk about some of the complications that can arise in urinary incontinence.
It's nothing intense, but it is important to realize that overflow incontinence can actually carry two particular big complications. One is urinary tract obstruction. And that's kind of the pathophysiology when you think about it. If a patient has overflow incontinence primarily, how does this kind of work? Well, whenever you have overflow incontinence, we talked that these patients will kind of oftentimes they'll dribble a little bit.
The two particular pathophysiologies that we actually, we said behind this is that you have some type of bladder outlet obstruction, like in the scenario of BPH, or you have decreased detrusor activity, right? So we said that that was the primary pathophysiological reasons. So two reasons is one is there was decreased detrusor muscle activity, or there was a bladder outlet obstruction. Now, in both of these scenarios, what happens is is that if the detrusor isn't contracting, you're not generating enough bladder pressure to overcome the pressure of the bladder outlet and to push urine out. Or if you have a bladder outlet obstruction, like in the scenario of BPH, which is a very, very common cause, your bladder pressure, even if it's high enough, the bladder outlet is so tight that it's compressing the urethra and preventing urine from being able to flow outwards.
In these scenarios, if this happens, you're not able to get urine to flow out. As a result, the urine will build up inside of the bladder. As urine builds up in the bladder, what happens?
You actually start to cause... an increase in the distension of the bladder, right? So now what happens is your bladder will start to distend.
As the bladder starts to distend, the problem here is that if the bladder pressure is super high, and you can't cause it to flow outwards, and if you do it's usually dribbling, then what's going to happen is sometimes from this high bladder distension it can cause the bladder pressure to rise and it causes retrograde flow of urine. So now what happens is bladder pressure goes up and then this leads to retrograde flow of urine. Now, from here, if I have a retrograde flow, it's going to look like this. The flow will actually start having urine kind of backing up through the ureter.
It may even back up into the kidney. So what we'll actually see with these patients is that oftentimes... They'll have an enlarged bladder, and they'll even have an enlarged ureter and an enlarged kidney. One of the big things here is that as the bladder distends, bladder pressure goes up, retrograde flow starts to increase.
These patients can get a lot of pressure. get what we refer to as hydronephrosis and that's one of the big big problems here is that their kidney can actually start to look a lot bigger so you can actually get distension of the kidney the problem here is that whenever patients generate hydronephrosis sometimes this can actually become so bad where it's hard for the glomerulus to filter off plasma to make urine and so what may happen is is in severe hydronephrosis sometimes this may impede the glomerular filtration rate. And if it impedes the glomerular filtration rate, these patients can develop something called a AKI, especially if it's acute.
And so oftentimes the most common presentation is these patients will develop something called a post-renal AKI. So oftentimes when you look at these patients, what you'll actually see is that they may have a couple different features associated with a post-mortem AKI. One is they may have a increase in their they may have a decrease in their urine output and an increase in their BUN. So I would watch for a increase in the creatinine, increase in the BUN, and a decrease in their urine output.
And this is usually very acutely. Now the other thing is that you want to look for hydronephrosis. So oftentimes patients will get these renal ultrasounds and so when you get the renal ultrasound What you'll see is, you'll see a very large and kind of like dilated kidney. So the kidney will be much, much bigger.
And it'll be fluid filled, fluid locked. And that'll be present and most easily identified on a renal ultrasound. Then if you did a bladder scan, this is the other component here. If you did a bladder ultrasound. You would also see that in these patients it would be diagnostic because they would have a very distended bladder.
And this is all because of the urine retention factor, whether it be from the detrusor not contracting or the bladder outlet causing obstruction of the actual prostatic urethra. So you really want to think about this in patients who have maybe BPH, maybe BPH. maybe some type of like neurogenic bladder. And then from there, they also have a post-renal AKI, so injury to their kidneys.
And on top of that, very poor urine output and maybe even hydronephrosis in a very distended bladder. All right, beautiful. The other concept is urine.
urinary tract infection. In this one, it's actually the same concept. This really would only become pertinent and present in overflow incontinence. And we already talked a little bit about these ones, but again, it will be decreased to trust our muscle activity, or it could also be due to a bladder outlet obstruction, the scenario of BPH. Either way, in these scenarios, urine is not flowing out.
If it's impeded from flowing out... It will then kind of accumulate inside of the bladder. So you'll have an increase in the amount of urine. And it'll start to become retained. With that increase in urine retention comes a very profound problem.
When you retain urine, one of the things that actually happens here is it can lead to an increase in bacterial colonization. So bacteria normally in a normal human being if you were to have urine being made it would flow from the kidneys or flow into the ureter into the bladder and you pee it out you clear bacteria consistently but in these patients they're not clearing their urine so they're not clearing the bacteria in their urine and it builds up if it builds up it then can lead to an increased risk of infection and so now these patients have a very high risk of Infection. Now here's the thing, it may cause an infection in one of two ways.
It may infect just the bladder, so sometimes the bacteria can actually stay in the bladder and start causing irritation and inflammation of just the bladder. That's referred to as cystitis. So one formation could be cystitis. The other one is, sometimes if there's a left retrograde flow, what can happen?
Some of that infected urine containing lots of bacteria can back up from the ureter, can go to the kidney, and can cause an infection of the kidney. And this is referred to as pyelonephritis. So you can also see pyelonephritis.
so with this being said these patients are definitely very high risk for cystitis and for pyelonephritis how would these often present although both usually present with urinary symptoms so urgency frequency and dysuria are oftentimes the most common manifestations. So you wanna watch out for that. So watch out for these patients to have features such as they can have urgency, so they may present with, so their presentation is they may have a history of overflow incontinence and then come in with urgency, frequency, and dysuria. Lastly, in this patient population you may think, okay, they may have overflowing incontinence, but if they have frequency, urgency, and dysuria, I should really rule out a urinary tract infection. So oftentimes with these patients you have to obtain what's called a urinalysis.
And so if the urinalysis is positive and we'll talk about this more in the UTI section. In other words, it's positive for leukocyte esterase, for nitrites, for lots of white blood cells, for bacteria present within the urine, maybe even some casts. This would definitely be suggestive of a urinary tract. infection and you would start antibiotics on these patients.
All right, so again, urinary tract obstruction, urinary tract infection are more pertinent when it comes to overflow incontinence due to the retention factor. The last one can occur in any type of urinary incontinence, oftentimes more so with patients who have urge incontinence, overflow incontinence, or even again in stress incontinence. What happens with this one? It's actually pretty straightforward. If a patient has consistent incontinence, the urine that they actually release is acidic, it has materials that can cause agitation and dermatitis.
And so what happens is often times you'll have increased urine that's constantly and unfortunately being lost. This lost urine can lead to agitation to the nether regions. Okay, and so oftentimes this will present initially maybe as just a irritation of the skin, which we refer to as dermatitis.
And this may just present as an itchiness, a redness, kind of a little bit more around the perianal region. However, this may continue to progress. So if the patient starts to have dermatitis, and then all of a sudden, from continuous incontinence, this may progress. Sometimes it can start causing an infection. of the skin and this can present as cellulitis.
This is usually in very very severe forms of incontinence where the patients are oftentimes bed bound. They're in the hospital, they're not moving. The other one is that sometimes from this dermatitis and from pressure they may even develop ulcers and again These are terrible things that you never want to see.
I'd say it's oftentimes more common in patients who are in the hospital, usually bed bound. They're oftentimes very incontinent and they're causing lots of dermatitis that over time causes cellulitis and ulcers to form. This would be a very common thing. to think about, usually, dermatitis would be the more common one in an outpatient setting.
This is usually something we think about, like similar to the diaper rash. All right, my friends, so this covers the primary complications that are associated with incontinence. Again, with the primary emphasis that overflow incontinence will cause urinary tract infections and obstructions, and all of them can cause skin breakdown if chronic or very consistent and bed-bound. All right, let's talk about the diagnostic approach.
So when we talk about diagnosing a patient with urinary incontinence and figuring out if it's overflow, if it's stress, if it's... it's urge, it's really more clinical diagnosis. It's not something that requires a lot of labs or imaging or significant workup.
So oftentimes you think about the patient, do they say that they have incontinence when they're coughing, laughing, sneezing? You really don't need to go any further. It's probably stress incontinence. If you really wanted to, you could do something called a bladder stress test or Q-tip test. And so essentially what you do is you insert a Q-tip up into the area of the urethra, and then you'll have the patient cough.
You'll have them drink fluid usually, kind of fill up their bladder. And then what you'll do is you'll You'll either have them cough or you'll push down on the area where their bladder is. And then if it wets the Q-tip or they have a bout of incontinence, it suggests that it's stress incontinence.
And that's called a bladder stress test. And if it's positive, it's usually suggestive and diagnostic of stress incontinence. And another patient who has a sudden urge followed by periods of incontinence, it definitely suggests urge incontinence. You just have to figure out what's the potential etiology here. If they're having frequent urges and desire to go to the bathroom with frequent periods of going to the bathroom, then you want to think, okay, it could be idiopathic.
It could be UTI, it could be neurological. Let me rule out a UTI first. So I'm going to go ahead and say, let me get a urinalysis with microscopy.
If it comes up positive, it's probably UTI. Treat them for that. See if they get better.
If it's negative, it's potentially neurological or idiopathic. And you may have to do a little bit of a further work up there. For continuous small volume leakage like dribbling and hesitancy and they feel like they want to go to the bathroom but they aren't able to completely eliminate, and these patients who have small volume dribbling a lot of the time, it really kind of screams overflowing continence.
You just have to ask yourself the question, do they have evidence of retention of urine. So what you're going to have the patient do is go to the bathroom, try to eliminate as much as they can from their bladder. Then you're going to do what's called a post-void residual.
You're going to bladder scan them. It's like a special ultrasound and you're going to try to get a look at their bladder after they urinated. so after they've voided. And you're going to take and kind of measure out the volume that's still remaining inside of the bladder after they've voided. It's called a post-void residual.
If the post-void residual is greater than 200 milliliters, it suggests a degree of retention. It tells me that something is wrong where the detrusor is not contracting, or it tells me that there's a bladder outlet obstruction. So how do I determine which one it is? Get a DRE.
The digital rectal exam will tell me if the prostate is as big as an apple. And if it is, that's probably likely. cause it's compressing the prostatic urethra and they're not able to empty their bladder.
So if it's positive, it's probably BPH. If it's negative though, and I don't see a very enlarged prostate, then I need to start thinking that it could be neurogenic bladder from underlying neurological diseases like diabetes or MS, or potentially it could even be due to medications. And I should start trying to DC those medications and see if they get any better. All right. So that's how we would diagnose urinary incontinence.
How do you treat it? Well, it depends upon the type, right? So stress incontinence with these patients, again, they have a weak pelvic. pelvic floor. And oftentimes they also have increased intra-abdominal pressure.
So you can't really do anything about coughing, laughing, sneezing. Those things are going to happen. Obesity and pregnancy, again, you can try your best to lose weight, but oftentimes it's more about strengthening the bladder outlet. So some things that we'll do is we'll actually help them work on those muscles and strengthen them a little bit. So even if there is increases intra-abdominal pressure, their bladder outlet will be strong enough to prevent that urine leakage.
So Kegel exercises are going to be the best way to be able to strengthen some of those pelvic muscles. if the muscles are actually having decreased elasticity and strength, not due to a problem necessarily, you know, if it's related to low estrogen states, so in other words, their menopause, I would go ahead and kind of give them estrogen to help to increase the elasticity and the strength of those muscles. So that's where you can do use like estrogen creams.
All right. The next thing is you have to then support the bladder outlet. All right.
So if you've kind of worked on Kegel exercises, if they are menopausal and that could be their potential trigger and you put them on estrogen and the patient is still having periods of stress incontinence, then you need to do something that's going to be. really reinforcing around the bladder outlet. So one thing that you could do is if you don't want to undergo a surgical procedure is you can insert in what's called a vaginal pessary. And it's this kind of tool here that really helps to lock in and push against the actual bladder outlet, support it and prevent urine from being again. leaked out undesirably.
If a patient is a good surgical candidate and they don't want to undergo a pessary, then they can do what's called a mid-urethral sling, where you're literally going to undergo a procedure where it wraps this sling around this bladder outlet and reinforces it and strengthens it and prevents, again, urine leakage during periodic increases in intra-abdominal pressure. Urgent incontinence is really about training the patient's bladder, especially since they'll have increased periods of detrusor contractions. It's kind of having a good voiding schedule. That's been shown to potentially improve the patient's incontinence. but oftentimes you just have to settle down that detrusor muscle.
You have to inhibit it. And so what we may be doing for these patients with a very overactive bladder is trying to work on suppressing those detrusor contractions. And one drug category is anticholinergic.
This could be a bunch of things. Oxybutynin is a very common one, tolteridine, sulfenacin. These are generally given and what they're going to do is they're going to help to block the M3 receptor.
Now, if you guys remember when acetylcholine hits these M3 receptors, it's going to cause an intense contraction of the bladder. So if I give things that'll block acetylcholine, acetylcholine, it won't allow for that contraction and therefore reduce the contractions and therefore the urge to have to go to the bathroom and the subsequent incontinence. Another drug that you can do if patients are having side effects related to the anticholinergics is you can give something called a sympathomimetic. So there's beta-3 receptors that are present potentially on the actual bladder.
And whenever norepinephrine binds onto these receptors, it's actually been shown to inhibit the contractions. And so if I give them a drug that acts like norepinephrine, like myra bagron, it'll bind onto the B3 receptors. or the beta-3 receptors, and then cause relaxation of the muscle, therefore reducing the detrusor contractions and reducing the episodes of incontinence.
If patients are having some type of dyssynchrony from detrusor contractions, in other words, they have a loss of inhibition signals from the nervous system, sometimes in patients who have tried bladder training, they're not responding to the actual medical therapy, we can do something called a sacral nerve stimulator. And essentially, with a sacral nerve stimulator is you're trying to allow for inhibitory input to the bladder to allow for more control. to the bladder and say, hey, stop receiving these stimulatory signals.
I'm going to give you some more inhibitory signals of when I want you to contract and when I don't want you to contract. For patients with overflow incontinence, you have to eliminate the urine that's in their bladder. So oftentimes if it's a really large post-void residual greater than 400, 500, it's best to make sure that you don't precipitate a urinary tract obstruction causing a post-renal AK.
you don't allow for them to retain that urine and increase the risk of urinary tract infections. And so oftentimes it's best to put in a catheter. Maybe that would just be an intermittent catheterization, empty the bladder and start your therapies, or you insert a catheter and you keep that catheter in.
such as a Foley catheter. Either way, it's best to drop out that urine out of the bladder so that you reduce the risk of urinary tract obstructions and urinary tract infections. Then as you've done that, start working on therapies to help improve the detrusor contractions as well as eliminate the bladder outlet obstruction.
So let's improve the detrusor contractions here because maybe it's due to medications. In these particular scenarios, maybe it was because I was putting them on anticholinergic drugs, discontinued the anticholinergic drugs, and sometimes these aren't commonly utilized, you can use cholinergic agonists because if you give bethanacol, it will activate the M3 receptors and induce contractions. But there is potential side effects related to these drugs. So oftentimes if it's due to anticholinergics, discontinue them.
If it's due to some pathomimetics, discontinue them and oftentimes they may improve. If it is a neurological problem though, this is maybe the indication of bethanacol. All right. If a patient has BPH though, that's a different story.
You can give them cholinergic agonists all day. It's not going to help. You need to relieve the obstruction from that big bulky prostate that's the size of the moon there. So what do we do for these patients?
Oftentimes, the first thing that you can do is try to relax the internal urethral sphincter. So we can give them alpha-1 blockers. And they may help a little bit to kind of open up this area here, the prostatic urethra. This is drugs like tamsulosin, doxazosin, prazosin, and tarazosin. And what these are going to do, again, is they're going to help to relax the internal urethral sphincter by inhibiting the alpha-1.
receptor that'll relax it, that'll open up that bladder outlet and hopefully eliminate some of the urine. So it's going to provide more symptom control. There is other drugs that you could use. We'll talk about it more in the actual prostate disorders lecture, such as the 5-alpha reductase inhibitors. They're going to be more designed to decrease the size of the prostate, but again, we'll talk about that a little bit more later.
The other thing that you could do is especially if a patient has not improved with medical therapy and they have BPH and maybe you've put them on combination alpha-1 blockers and 5-alpha reductase inhibitors, is you can do something called a TURP. It's a transurethral section of the prostate. And you basically go up through the urethra. urethra and cut out chunks of the prostate. And by resecting out chunks of this prostate, you'll open up and restore normal flow back to the urethra and allow for the patient to not have these consistent periods of overflow incontinence.
That kind of covers a lot about the treatment of urinary incontinence, and that covers everything that we need to know for this lecture. I really hope that it made sense. I hope that you guys enjoyed it.
Love you. Thank you. And as always, until next time.