DIP Episode 259 - The Clutch Incontinence Podcast (and upcoming 2CK Classes from 9/10-12)

Okay, welcome. I'm in divine. This is episode 259 of the Divine Intervention Podcast. And in this podcast, I'm going to be going over a topic that for some bizarre reason, many, many met students tend to get wrong. Right? I don't know why. It's a simple topic, but I'm really going to break it down here so that you never get it wrong every again. And this is going to be on the topic of incontinence. Right? It's going to be on the topic of incontinence. And as a reminder, for those of you taking your exams like early in October or late in September, you know, ahead of the era deadline, basically, don't forget that I have two courses that you may find to be helpful. These are probably the last courses. Well, if my schedule changes, then I may offer a one-way duration this month. But this coming week is the final week, at least, considering what scheduled, where I'm going to be offering two courses. So, there's going to be on the 10th, 11th, and 12th. On the 10th, I'm going to be offering a test-taking strategies class. Right? It's going to be from 4 to 6 p.m. Pacific time roughly. Although, I may go up until 6.30. Right? And basically, the course will talk about the course will essentially talk about test-taking strategies that are necessary for step 2, see key step 3. So, if that's something you're interested in, again, just kind of reach out to me, and I'll be happy to point you in the right direction. And then, the other class is the mainstream step 2, see key review class.

Right? It's the 10 hour class, but I'm holding it over two days. It's going to be on the 11th and on the 12th. Right? On the 11th and on the 12th. Right? And on both days, it's going to be from 2 to 5 p.m. Pacific time, and from 6.30 to 8.30 p.m. Pacific time on both days. Right? So, basically, if you want to get the tri-factor, basically from the 10th to the 12th, on the 10th, right? We'll meet from 4 to 6.30 p.m. Pacific time on the 11th. Right? That will be the test-taking strategies class. On the 11th, right? We'll meet from 2 to 5 p.m. Pacific time, and from 6.30 to 8.30 p.m. Pacific time, right? On both days. And then, on the 12th, same timing, 2 to 5 p.m. Pacific time, 6.30 to 8.30 p.m. Pacific time, and again, for the test-taking strategies class, again, this is something that I mean, I thought mbm testing strategies for years. Right? This will be a class that will really show you how to break down mbm questions. Right? And then, so it's like a 2 to 1 half hour class. And then, again, 5 hours on Friday, 5 hours on Saturday, we'll go through like the very, very high-yield concepts from internal medicine, OB-GYN, surgery, psych, PEEDS, Neuro, right? Again, many people have gone through these classes and they found it to be extremely helpful. So again, if it's something interested, feel free to reach out to me. Okay. So, let's jump right into this, right? So, you're in continents, right? So, let's talk about the physiology, right?

Let's basically talk about the physiology behind urinary in continents, right? Let's talk about the physiology, right? So, the thing is for the most part, right? You know, where do we store urine? We store urine in the bladder, right? We store urine in the bladder, right? We store urine in the bladder. And basically, right? The bladder is connected to the urethra, right? And, you know, the urethra is essentially the tube that allows urine to kind of get out of our bodies, right? So, basically, there are two things that have to be counterbalanced for you to maintain continents, right? For you to maintain continents. What are those things? Well, basically, it's a balance between your bladder contracting and your urethra closing, right? So, when you want to urine it, your bladder is going to contract through the trusser muscles, right? Those are the trusser muscles, the old contract, and that will force urine out of the bladder, that will get into the urethra. When the urine gets into the urethra, the thing is the urine, the sphincter, the sphincter is around the urethra. They will relax, and when they relax, they will let the urine get out of the body, right? That urethra sphincter is like a bringo of muscle, right? That surrounds the urethra, right? It surrounds the urethra, and the thing is, normally, right? Normally, the pressure in your urethra will exceed the pressure in your bladder, right? So, that keeps you continent, right? That keeps you continent of urine, right?

That keeps you continent of urine. But again, when you're ready to urinate, right? The trusser muscles will contract, right? That will raise the pressure in the bladder. The urethra sphincter muscles will relax, right? So, that will let you pass out urine, right? So, that's basically how things work, right? That's basically how things work. And remember that the urethra is not just supported by the urethra sphincter, right? It's also supported by, like, your pelvic floor muscles, right? Like those levator in-eye muscles, those things support the urethra, right? And that allows the urethra to close and close firmly, right? You know, to close as well as it should, right? To close as well as it should, right? So, there's something to keep at the back of your mind, right? On exams, right? So, now that we understand the physiology, right, let's begin to talk about how people get in continent, right? How people get in continent? So, let's talk about the first kind of in-continence, right? So, stressing continents, right? So, stressing continents is something that happens where the classic presentation will be a person has something where they have, like, contract, they have a... Anything that increases intra-dominal pressure, right? Let's see the cough, the sneeze, the valve salver, and bone, the pee on themselves, right? The cough, the sneeze, the valve salver, and then the pee on themselves, right? So, you may be like, okay, divine. What causes this?

Typically, stressing continents is caused when you have, like, something that has caused the urethra to lose support, right? So, in women, for example, right, if a woman, you know, has had pregnancy, has had, like, a vaginal delivery, right? If a woman is really obese, right? Remember, if you're obese, you have chronically increased intra-dominal pressures, right? When a woman has had all those things, so as a woman gets older, right? You know, those things will cause the urethra to lose its support, right? Either the urethra's finger could be damaged itself, or those pelvic floor muscles, those levator in-eye muscles, right? Remember, one thing that makes those muscles strong, those, one thing that makes those muscles have tone is estrogen. So, when you become postmenopausal, those muscles lose a lot of tone, right? And they lose a lot of tone, right? That can increase the risk of those things being floppy, right? So, normally, the blood and urethra, right? Like, they get pressure transmitted to them equally, right? But again, if those muscles around or those urethra's fingers lose tone, right? Then guess what's going to happen? Like, literally, guess what's going to happen? The thing that's going to happen, right? The thing that's going to happen is that you're pretty much going to have a situation where when pressure is transmitted to the blood and urethra, it'll be transmitted on equally, right? Because the urethra is floppy, it doesn't really get that pressure, right?

So, the person, right, will then peel themselves, right? So, again, anything that increases intra-dominal pressure, right? Anything that increases intra-dominal pressure, okay? Anything that increases intra-dominal pressure. Again, these things are all very high yields to know on exams, right? All very high yields to know on exams, all very high yields to know on exams. And how do we diagnose stressing continents? You're going to do the Q-tip test, right? If you have more than 30 degrees of rotation on the Q-tip test, then that's positive for stressing continents. And the way we treat this is, because we know that the problem involves those pelvic flomosos that are not strong enough. We can try to make them a little stronger, and we can do that by doing a Kiggle exercise, right? You can do Kiggle exercises, K-E-G-E-L, right? Kiggle exercises. If the Kiggle exercises don't work, you can do something called a sling procedure, right? You can do something called a sling procedure, right? You can do the mid-irithral sling procedure, the mid-irithral sling procedure, okay? Mid-irithral sling procedure, right? Now, the next kind of incontinence I'm going to talk about is urging continents, right? The most common kind of incontinence in men is actually urging continents, right? The most common kind of incontinence in men is urging continents, right? Urging continents. And usually, urging continents in a guy is going to be caused by BPH, right? It's going to be caused by BPH, right?

So, what is the pathophys behind urging continents? Well, the pathophys behind urging continents is those that are trusser muscles, they are working too well, they are a little too excited. You know, they are already like kind of giggly in a sense, right? So, they are super, super, super excited, right? So, the thing that will happen is because those that trusser muscles, they are super excited, essentially what's going to happen is, right? The person will have like something we call overactive bladder, right? Sometimes you may see it referred to as the trusser muscle hypertonia or the trusser muscle hyper motility, right? So, what you can see is the trusser muscle hyperactivity doesn't matter, right? But basically, those that trusser muscles, they are working too well. So, the person has this constant urge to pee, right? The person has the constant urge to pee, constant urge to pee, right? Constant urge to pee, right? Constant urge to pee. So, that urging continents, because those that trusser muscles, they have this constant urge to pee, well, the way you are going to fix that problem on an in-beam exam is you are like, okay, the trusser muscles, your little tachy tachy tachy tachy tachy tachy, right? Let's try to get you a little calmer, let's try to get your little quieter, right? So, the way you deal with that is, guess what? You're going to give those people an anti-collinergic agent, right? And the anti-collinergic agents you can use, you can use oxybutinin, right?

So, these are almost grainy receptor blockers. You can use oxybutinin, you can use toteridine, right? You can use dyrphenacinus, sulfenacinus, you can use trospium, right? The monicubes can remember for that is on the darn toilet, right? On the darn toilet, on the darn toilet, right? So, oxybutinin, toteridine dyrphenacin, sulfenacin, and trospium, right? And trospium, right? And trospium, right? And trospium. So, again, big thing you want to keep in mind there, right? Big thing you want to keep in mind there, right? Big thing you want to keep in mind there. Now, again, you notice I'm repeating myself so more because I just want you guys to get this stuff down, right? I feel like this thing is pretty easy, right? This stuff's pretty easy, something you should know I know pretty well, right? And I already talked about stressing continents, first of all, remember stressing continents usually, if you see it in a guy, it's going to be because the guy has had some kind of prostate surgery, right? Like, either the person has had like removal of the prostate or they've had like, turp, right? Well, you do like a trans-yory through the reception of the prostate for BPH, or if you've done like radiation therapy, right? Or something that random does like called a bricky therapy, right? All those things can all give rise to stress a incontinence, right? Can give rise to stress a incontinence.

Although usually it results within a few weeks to months after the person has, after the person has that a prostate surgery. Okay, right? So that's what you find with stressing continents. We've talked about stressing continents. We've talked about urging continents. Now, one thing I want to say about urging continents is the post-veter zero volume, right? The post-veter zero volume, the post-veter zero volume, if the post-veter zero volume is in the tens of milliliters, right? If it's in the tens of milliliters, that's going to be urging continents, right? As you see, when we get to overflowing continents, overflowing continents happens overflowing continents, overflowing continents. How do I put this? You have post-veter zero volumes in the hundreds of milliliters, right? Tens of milliliters for urging continents, post-veter zero volume in the hundreds of milliliters for overflow incontinence, right? So for overflow incontinence, for overflowing continents, right? So what happens in overflowing continents? Basically, the detrusor muscles, unlike in urging continents where, ooh, these detrusor muscles work better than good. In overflowing continents, those detrusor muscles are like, meh, whatever, right? Very like a basic altitude, right? So those detrusor muscles are like, we don't feel like contracting because normally, the detrusor muscles are supposed to sense, right? That, oh, blood is full, okay, let's go pee, right?

But they're like, mmh, they don't feel like working, right? So you may see it on exams as detrusor, hypotonia, or detrusor, hypomobility, or detrusor, hypomotility, right? If you see that, right? Or detrusor hyporeflexia, right? Hyporeflexia, if you see that, that's the pathophys behind overflow incontinence, right? That's the pathophys behind overflow incontinence, right? That's the pathophys behind overflow incontinence, behind overflow incontinence, right? So now, what's the big picture thing to keep out the back of your mind with overflowing continents? The big picture thing to think, keep out the back of your mind is, because the detrusor muscles are not working, we need to give something cool energy to make them spurs stop, right? We need to give something cool energy, right? So for those people, you can give them Bethany call, right? You can give them Bethany call, that's a muskete receptor agonist, or you can give Kaba call, right? That's also muskete receptor agonist, or you can give new stigmin, remember, new stigmin is an acerocholinesis inhibitor, right? If you inhibit acerocholinesis, the levels of acerocholine will go through the roof, and that will lead those detrusor muscles to contract. Although, if a person has overflow incontinence and they have acute urinary retention, you can very easily fix the symptoms by doing, what is this thing called? You can insert, you can do like urinary catheterization, right?

You can perform a urinary catheterization to fix their problem relatively quickly, right? Fix your problem relatively quickly, okay? And then, I guess one last thing I will see, right? In kids, right? There is in kids, again, you see all these things are controlled by the nervous system, right? When a child is born, a child has barely any nervous system, right? So, I mean, they have a pretty decent nervous system, if not, they'd be dead, right? But, you know, the nervous system is not well developed, right? That's why kids peel themselves, right? But as the nervous system begins to develop, right? Then they begin to not have those problems happen anymore, right? So, and then, you know, there's another kind of incontinence you may see, it's called like mixed incontinence. That one, basically, they'll have like multiple features of multiple kinds of incontinence, right? And that's pretty much it. So, I think that's all I'm going to say, at least if you listen to this podcast, I know this stuff. Chances are you probably get almost 100% of your incontinence questions right on tests. Although, I guess maybe one other thing I can talk about is a urethro diverticulum, right? A urethro diverticulum, right? Something that people tend to struggle with on exams is kind of annoying to understand as well, but let me break it down for you, right? The thing is, the classic way urethro diverticulum will present is you'll be a person that has urinary incontinence.

And you'll notice a temporal association with Wendy just P, right? So, oh, the person peed like a few minutes ago and then be having incontinence. If you see that, think about a urethro diverticulum. Sometimes you may even see them refer to it as a urethro cell, right? As a urethro cell. So, what in the world does that stuff mean, right? What in the world does that stuff mean? Well, or why is it like that? A urethro diverticulum, remember a diverticulum is an outpouching, right? It's an outpouching of something, right? So, urethro diverticulum means you've outpouched your urethra, right? So, think about it. When does urethra get put to use? It's when you pee, right? So, this is why these people's incontinence has a temporal association with Wendy P, right? So, the thing is, when you pee, urine will flow through the urethra. So, you pee normally, but some urine will collect in that pouch. If you collect in that pouch, you then notice, man, I've finished peeing, but I'm still dribbling some urine, right? That's a urethro diverticulum. That's the classic way it presents, on exams. And again, please don't forget to subscribe to the You Tube channel, right? So, the You Tube channel, it's called Divine Intervention, you're seemingly podcasting videos, right? And then don't forget, right? I have a podcast website, Divine Intervention Podcast.com, please subscribe. It's a Word Press website. And then I have this podcast on Apple Podcasts, on Spotify, on Google Play.

You know, please subscribe. Any little bit of support always helps, right? Any little bit of support always helps, right? And what is my life lesson for today? What is my life lesson for today? So, my life lesson for today involves something I think I will call the battle of the mind, right? And you'll be like, oh, what is the mind about your say? So, I've kind of talked about this lesson before, but I think it beers repetition, especially with all the stuff that has been going on in this world, right? With all the stuff that has been going on in this world, right? You know, COVID, this, that, could be Brian, Dine, and all that stuff. I will just say one thing that is very important in maintaining your mental health or maintaining like a good quality of life is actually watching what you feed your mind with, right? Watching what you feed your mind with. I can go off on a big tangent with this, but I'm going to be reasonable here. I'm going to be reasonable here, right? But basically, if you feed your mind with garbage, your life will not be good, right? I mean, literally, there's a part of the Bible that says, as a man think getting his heart, so he is, right? As a man think getting his heart, so he is, right? As a man think getting his heart, so he is. So, the thing is, and there's even a part of the Bible that says that faith comes by hearing and hearing by the word of God. If you feed your mind with good stuff, you'll have a good life, right?

Even the Bible says, oh, guard your heart with all diligence. Why? Because every issue of your life comes from it, right? Guard your heart with all diligence, right? Because every issue of your life comes from it. So you're supposed to, like, almost like place a gate over your heart. What were you putting to your mind, right? If all you put into your mind are friends that keep putting you down, keep putting you a failure, keep putting you a stupid person or whatever, right? Or you watch news channels. Again, I'm not going to put myself in trouble. I'm not going to mention any specific news channels. But you guys listen to this. You're smart people. You know what I'm talking about. The news channels where pretty much all they talk about is COVID, COVID, COVID. They almost never talk about good things that are happening in the world. They always talk about bad, bad, bad, bad, bad things that are happening in the world. Guess what? When you listen to those things, you notice that you don't sleep well. You feel like crap and you feel beat down, right? Because you are feeding your mind with terrible stuff, right? Or some of the music that exists in the world. Just, again, I'm not going to mention anything. I'm not going to defame anyone online, right? But basically, if you keep listening to those nasty, nasty things, keep listening to bad, bad, bad, bad things. Again, I promise you, you'll feel like crap all the time. What do you feed your mind with? Like think about it, right?

Like if you watch a feel-good movie, right? A feel-good movie, right? You'll usually sleep well. You'll feel pretty good, right? Contrast that with a person, right? That watch is a terrible, like, horror movie or something like that. Right? Where they are killing a lot of people. You're going to have nightmares, right? Because you'll feed your heart with crap, right? So please, I'm begging you because the thing is, as a person in medicine, right? Again, mental health is very important because we face a lot of stressors every day, right? So what's what you feed your mind with? If you feed your mind with good, you'll get good from your life, right? Literally everything you do as a physical human being arises as a thought in your heart. So if you want to do good, if you want to have a good life, watch your mind, watch what you're thinking about, right? Watch what you're thinking about. So thank you for listening. I wish you all the very best. Again, if you're interested in any of these two classes, send me an email through the website and I will give you some more information. So thank you for listening. I'll see you next time. God bless you. Thank you.

The balance between bladder contraction and urethral sphincter closure/relaxation.

Coughing, sneezing, and laughing (or any activity increasing intra-abdominal pressure).

Becoming postmenopausal, leading to loss of tone in pelvic floor muscles.

ON THE DARN TOILET (Oxybutynin, N-butyl-oxybutynin/Tolteridine, Dryphenacine, Solifenacin, Trospium).

Hundreds of milliliters.

Detrusor hypotonia or hyporeflexia (underactivity).

The Q-tip test; more than 30 degrees of rotation.

Prostate surgery (TURP) or radiation therapy/brachytherapy.

Anticholinergic agents, which relax the overactive detrusor muscle by blocking acetylcholine receptors.

Muscarinic receptor agonists (e.g., Bethanecol) or Acetylcholinesterase inhibitors (e.g., Neostigmine).

Dribbling of urine immediately after voiding, suggesting leakage from an outpouching.

Detrusor hyporeflexia or hypotonia.

The Q-tip test; more than 30 degrees of rotation.

Prostate surgery (TURP) or radiation therapy/brachytherapy.

Anticholinergic agents, which relax the overactive detrusor muscle by blocking acetylcholine receptors.

Muscarinic receptor agonists (e.g., Bethanecol) or Acetylcholinesterase inhibitors (e.g., Neostigmine).

Dribbling of urine immediately after voiding, suggesting leakage from an outpouching.

Detrusor hyporeflexia or hypotonia.