Overactive Bladder and Urge Incontinence — MCQs

10 questions

What is mirabegron?

Which of the following drugs is not used for the treatment of overactive bladder?

A 50-year old woman complains of leakage of urine. Other than genuine stress urinary incontinence, the most common cause of urinary leakage is ?

Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

Which of the following is the most appropriate treatment for an overactive bladder in a patient with dementia?

The recommended non-surgical treatment of stress incontinence is:

3 pad test is done for:

A 68-year-old with depression and chronic pain is on amitriptyline. What side effect may arise if given oxybutynin for overactive bladder?

Urinary incontinence in uterovaginal prolapse is mostly due to:

Q10

A 40-year-old G3P3 complains of urge incontinence. Sometimes she gets the urge to void, but passes urine before reaching the washroom. She had three normal spontaneous vaginal deliveries of infants weighing between 3.5 and 3.8 kg. Urine examination is normal. All of the following are appropriate treatments in the management of this patient EXCEPT:

Overactive Bladder and Urge Incontinence Indian Medical PG Practice Questions and MCQs

Question 1: What is mirabegron?

A. Beta 3 agonist (Correct Answer)
B. Alpha 2 antagonist
C. Beta 1 blocker
D. Beta 2 blocker

Explanation: ***Beta 3 agonist*** - Mirabegron is a **beta-3 adrenergic agonist** that selectively activates beta-3 receptors in the bladder smooth muscle [1]. - This activation leads to **relaxation of the detrusor muscle** during the storage phase of the bladder fill-void cycle, increasing bladder capacity. *Alpha 2 antagonist* - **Alpha-2 adrenergic antagonists** primarily block alpha-2 receptors found in the central nervous system and some peripheral tissues [2]. - They are generally used for conditions like **hypertension** or **depression**, not bladder overactivity. *Beta 1 blocker* - **Beta-1 adrenergic blockers** (e.g., metoprolol) primarily target beta-1 receptors in the **heart**, causing decreased heart rate and contractility. - They are used for cardiovascular conditions like hypertension, angina, and heart failure, and do not affect bladder function in this manner [3]. *Beta 2 blocker* - **Beta-2 adrenergic blockers** are not typically used therapeutically as they would cause significant **bronchoconstriction** and other adverse effects due to their presence in the lungs and smooth muscles [3]. - While beta-2 receptors are present in some tissues, their selective blockade is not the mechanism of action for mirabegron.

Question 2: Which of the following drugs is not used for the treatment of overactive bladder?

A. Oxybutynin
B. Flavoxate
C. Duloxetine (Correct Answer)
D. Darifenacin

Explanation: ***Duloxetine*** - **Duloxetine** is a **serotonin-norepinephrine reuptake inhibitor (SNRI)** primarily used to treat major depressive disorder, generalized anxiety disorder, neuropathic pain, and **stress urinary incontinence (SUI)** [3]. - While it affects neurotransmitters involved in bladder control, its primary indication is SUI through increasing urethral sphincter tone, not directly treating the urgency and frequency associated with **overactive bladder (OAB)** [3]. *Darifenacin* - **Darifenacin** is a **M3 muscarinic receptor antagonist** that selectively targets receptors in the bladder, reducing detrusor muscle contractions [1]. - This action helps to alleviate symptoms of urgency, frequency, and urge incontinence characteristic of **overactive bladder (OAB)** [1]. *Oxybutynin* - **Oxybutynin** is a **non-selective muscarinic receptor antagonist** that relaxes the detrusor muscle of the bladder, decreasing bladder contractility [1], [2]. - It is a long-standing and commonly used medication for managing the symptoms of **overactive bladder (OAB)** and neurogenic bladder [2]. *Flavoxate* - **Flavoxate** is a **direct relaxant of smooth muscle** in the urinary tract, and it has mild anticholinergic, local anesthetic, and analgesic properties. - It is used to relieve symptoms like dysuria, urgency, and nocturia associated with various urinary tract conditions including **overactive bladder (OAB)** and interstitial cystitis.

Question 3: A 50-year old woman complains of leakage of urine. Other than genuine stress urinary incontinence, the most common cause of urinary leakage is ?

A. Vesico vaginal fistula
B. Overflow incontinence
C. Detrusor dyssynergia
D. Urge incontinence (Correct Answer)

Explanation: ***Urge incontinence*** - **Urge incontinence**, characterized by an **involuntary leakage of urine accompanied or immediately preceded by urgency**, is the most common form of urinary incontinence after stress urinary incontinence, especially in older women [1]. - It results from **detrusor overactivity**, leading to sudden, strong urges to void that are difficult to defer. *Vesico vaginal fistula* - A **vesicovaginal fistula** involves an abnormal connection between the bladder and the vagina, leading to continuous and spontaneous leakage of urine into the vagina, which would present differently from typical urge symptoms [1]. - While it causes leakage, it's a relatively rare cause compared to urge incontinence and is often associated with prior surgery or radiation. *Overflow incontinence* - **Overflow incontinence** occurs when the bladder is overfilled and unable to empty properly, leading to continuous leakage of small amounts of urine due to retention [1]. - This is often caused by **bladder outlet obstruction** or **neurogenic bladder**, and the patient might report difficulty voiding or a sensation of incomplete emptying [1]. *Detrusor dyssynergia* - **Detrusor dyssynergia** describes a lack of coordination between the detrusor muscle contraction and external urethral sphincter relaxation, typically seen in neurological disorders [2]. - This condition is a specific type of voiding dysfunction that can lead to incontinence but is not the most common cause of leakage after stress incontinence in the general population.

Question 4: Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

A. Vesico-vaginal fistula
B. Stress incontinence
C. Uretero-vaginal fistula (Correct Answer)
D. Urge incontinence

Explanation: ***Uretero-vaginal fistula*** - **Post-hysterectomy** onset of continuous urinary dribbling, despite being able to void voluntarily, is highly suggestive of a uretero-vaginal fistula. - The ability to pass urine voluntarily indicates the bladder and urethra are intact, suggesting urine is leaking from a higher point in the urinary tract into the vagina. *Vesico-vaginal fistula* - In a vesico-vaginal fistula, urine would leak continuously from the bladder directly into the vagina, leading to complete and constant incontinence and typically **no ability to pass urine voluntarily** once the bladder is emptied. - This patient can still pass urine voluntarily, which makes a uretero-vaginal fistula more likely where one ureter is leaking but the bladder can still collect and empty urine from the other kidney. *Stress incontinence* - This involves involuntary urine leakage with activities that increase **intra-abdominal pressure** (e.g., coughing, sneezing, laughing). - It does not present as continuous dribbling unrelated to physical exertion and would not typically arise as a new symptom seven days post-hysterectomy in this manner. *Urge incontinence* - Characterized by a sudden, strong need to urinate followed by involuntary leakage, often due to **detrusor overactivity**. - It does not cause continuous urinary dribbling and the patient would not be able to pass significant amounts of urine voluntarily in addition to the continuous leakage.

Question 5: Which of the following is the most appropriate treatment for an overactive bladder in a patient with dementia?

A. Tolterodine (Correct Answer)
B. Mirabegron
C. Behavioral therapy/bladder training
D. Oxybutynin
E. Trospium

Explanation: ***Tolterodine*** - **Tolterodine** is a **muscarinic antagonist** that blocks acetylcholine receptors in the bladder, reducing detrusor muscle contractions and overactive bladder symptoms. - Unlike some other anticholinergics like oxybutynin, it has a **lower propensity to cross the blood-brain barrier** and thus a reduced risk of exacerbating cognitive impairment in patients with dementia. *Mirabegron* - **Mirabegron** is a **beta-3 adrenergic agonist** that relaxes the detrusor muscle, increasing bladder capacity. - While it has a different mechanism of action and is less likely to cause anticholinergic cognitive side effects than older anticholinergics, it can still cause **hypertension** and **tachycardia**, which may be problematic in elderly patients with comorbidities. *Behavioral therapy/bladder training* - **Behavioral therapy** and **bladder training** are important first-line treatments for overactive bladder. - However, for patients with **dementia**, cognitive impairment often makes adherence to and understanding of these complex therapies challenging or impossible without significant caregiver support. *Oxybutynin* - **Oxybutynin** is an **anticholinergic drug** that is effective for overactive bladder. - However, it has a **high affinity for muscarinic receptors** in the brain and readily crosses the blood-brain barrier, significantly increasing the risk of **cognitive impairment, confusion, and delirium** in elderly patients, especially those with pre-existing dementia. *Trospium* - **Trospium** is a **quaternary amine anticholinergic** that is hydrophilic and has minimal blood-brain barrier penetration. - While theoretically safer than oxybutynin in terms of CNS effects, it has **lower bladder selectivity** compared to tolterodine and may cause more peripheral anticholinergic side effects (dry mouth, constipation).

Question 6: The recommended non-surgical treatment of stress incontinence is:

A. Electrical stimulation
B. Bladder training
C. Pelvic floor muscle exercises (Correct Answer)
D. Vaginal cone/weights

Explanation: ***Pelvic floor muscle exercises*** - **Pelvic floor muscle exercises** (Kegel exercises) are considered the **first-line non-surgical treatment** for stress urinary incontinence. - They aim to strengthen the **pelvic floor muscles**, which support the urethra and bladder, improving urethral closure pressure. *Electrical stimulation* - **Electrical stimulation** is a passive treatment method that involves using a probe to deliver electrical currents to the pelvic floor muscles. - It is typically used as a **secondary treatment** when active pelvic floor muscle training is difficult or ineffective, as it does not actively engage the patient in muscle control. *Bladder training* - **Bladder training** is a behavioral therapy primarily used for **urge incontinence** or mixed incontinence, not specifically stress incontinence. - It involves learning to suppress sudden urges to urinate and gradually increasing the time between voids to regain bladder control. *Vaginal cone/weights* - **Vaginal cones or weights** are devices inserted into the vagina that patients hold in place by contracting their pelvic floor muscles. - While they can be used to **improve pelvic floor muscle strength**, they are often considered an **adjunctive or secondary treatment**, not the primary recommended non-surgical approach.

Question 7: 3 pad test is done for:

A. Rectovaginal fistula
B. Urethrocoele
C. Stress incontinence (Correct Answer)
D. Urinary fistula

Explanation: ***Stress incontinence*** - The **3-pad test (pad weighing test)** is a standardized, objective method to **quantify urinary incontinence**, particularly stress incontinence - The test involves weighing absorbent pads before and after a specified period (1-hour test or 24-hour test) to measure the exact amount of urine leakage - **Stress incontinence** is the most common indication, where involuntary urine leakage occurs during activities that increase intra-abdominal pressure (coughing, sneezing, laughing, exercise) - The test helps **grade severity** (mild <50g, moderate 50-100g, severe >100g) and **monitor treatment response** - It provides objective documentation of incontinence severity for clinical decision-making *Urinary fistula* - A urinary fistula is an abnormal communication between the urinary tract and another structure (vesicovaginal, ureterovaginal fistula) - While severe continuous leakage occurs, diagnosis is made by **clinical examination**, **dye tests** (methylene blue test, double dye test), **speculum examination**, and **imaging** (cystoscopy, IVP) - The pad test is not the primary diagnostic method for fistulas, though it may show continuous heavy leakage *Rectovaginal fistula* - This is an abnormal connection between the rectum and vagina, causing passage of stool or gas through the vagina - The 3-pad test specifically measures **urine loss**, not fecal incontinence - Not relevant for rectovaginal fistula assessment *Urethrocoele* - A urethrocoele is a herniation or prolapse of the urethra into the anterior vaginal wall - This is a **structural/anatomical diagnosis** made by pelvic examination - While patients may have associated stress incontinence, the pad test measures the leakage, not the anatomical defect itself - Diagnosis is clinical, not based on pad testing

Question 8: A 68-year-old with depression and chronic pain is on amitriptyline. What side effect may arise if given oxybutynin for overactive bladder?

A. Severe dry mouth (Correct Answer)
B. Bradycardia
C. Increased sweating
D. Urinary incontinence

Explanation: ***Severe dry mouth*** - Both **amitriptyline** (a tricyclic antidepressant) and **oxybutynin** (an anticholinergic for overactive bladder) have significant anticholinergic effects. - The combination of these two drugs can lead to an additive effect, causing pronounced anticholinergic side effects such as **severe dry mouth**, blurred vision, constipation, and cognitive impairment. *Bradycardia* - **Anticholinergic drugs** typically cause **tachycardia** (increased heart rate) by blocking the parasympathetic nervous system's muscarinic receptors on the heart, rather than bradycardia. - While amitriptyline can affect cardiac conduction, severe bradycardia is not a typical **additive anticholinergic side effect** in this context. *Increased sweating* - **Anticholinergic drugs** like amitriptyline and oxybutynin inhibit the activity of sweat glands, which are primarily innervated by cholinergic nerves. - Therefore, the combination of these drugs would likely lead to **decreased sweating** (anhidrosis) rather than increased sweating. *Urinary incontinence* - **Oxybutynin** is prescribed specifically to treat **overactive bladder** and reduce urinary incontinence by relaxing the detrusor muscle. - Therefore, it would improve rather than worsen urinary incontinence; however, it can cause **urinary retention** due to its anticholinergic effect, especially in older male patients.

Question 9: Urinary incontinence in uterovaginal prolapse is mostly due to:

A. Detrusor instability
B. Urge incontinence
C. True incontinence
D. Stress incontinence (Correct Answer)

Explanation: ***Stress incontinence*** - This is the most common type of urinary incontinence in uterovaginal prolapse, especially with **cystocele**, due to weakened pelvic floor muscles and altered urethrovesical angle. - The prolapsed organs reduce support for the urethra and bladder neck, leading to leakage with increased **intra-abdominal pressure** (e.g., coughing, sneezing, lifting). *Detrusor instability* - This refers to involuntary contractions of the **detrusor muscle**, causing a sudden, strong desire to urinate (urgency), often leading to leakage. - While it can coexist, it is not the primary cause of incontinence directly attributable to the mechanical effects of uterovaginal prolapse. *Urge incontinence* - Characterized by an urgent need to urinate followed by involuntary leakage, often due to **detrusor overactivity**. - Although it can occur in individuals with prolapse, it is a functional bladder issue rather than a direct mechanical consequence of the anatomical descent associated with prolapse. *True incontinence* - This is a broad term that can encompass continuous leakage or total loss of bladder control, often associated with neurological damage, fistula, or severe anatomical defects. - While prolapse can contribute to some forms of incontinence, "true incontinence" does not specifically define the predominant mechanism seen in most cases of uterovaginal prolapse.

Question 10: A 40-year-old G3P3 complains of urge incontinence. Sometimes she gets the urge to void, but passes urine before reaching the washroom. She had three normal spontaneous vaginal deliveries of infants weighing between 3.5 and 3.8 kg. Urine examination is normal. All of the following are appropriate treatments in the management of this patient EXCEPT:

A. Kegel exercises
B. Biofeedback
C. Bladder training
D. Antidepressants (Correct Answer)

Explanation: ***Antidepressants*** - **Tricyclic antidepressants (TCAs)** like imipramine have anticholinergic properties that can help with urge incontinence, but they are **NOT first-line therapy**. - **Anticholinergic medications** (oxybutynin, tolterodine, solifenacin) are the **preferred pharmacological agents** for urge incontinence, not antidepressants. - TCAs have **significant side effects** including sedation, orthostatic hypotension, and cardiac effects, making them less suitable as initial treatment. - They are typically reserved for **refractory cases** or when anticholinergics are contraindicated. *Kegel exercises* - **Pelvic floor muscle training (Kegel exercises)** is recommended as **first-line therapy** for urge incontinence per ACOG guidelines. - While more effective for stress incontinence, they improve overall **pelvic floor function** and bladder control. - They help strengthen the **periurethral and pelvic floor muscles**, which can help suppress detrusor contractions. *Biofeedback* - **Biofeedback** is an effective adjunct to pelvic floor muscle training for urge incontinence. - It helps patients **identify and control pelvic floor muscles** correctly during Kegel exercises. - Provides real-time feedback to improve the efficacy of **behavioral therapy**. *Bladder training* - **Bladder training** is a **cornerstone first-line treatment** for urge incontinence. - Focuses on **scheduled voiding** and gradually increasing the inter-voiding interval. - Helps patients learn to **suppress urgency** and regain bladder control through behavioral modification.

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