[11] Incontinence Flashcards
What is urinary incontinence/
Uncontrolled leakage of urine
Why is urinary incontinence important?
It is a common and distressing problem, with large impact on QoL
What is faecal incontinence?
Inability to control the passage of gas or stools through the anus.
What is nocturia?
Need to wake during the night to pass urine >2 times
What is nocturnal enuresis?
Urinary incontinence whilst sleeping
What is hesitancy?
Difficulty starting or maintaining flow of urine
What is urgency?
Sensation of imminently needing to pass urine
What is frequency?
Need to pass urine more often than normal
What is functional incontinence?
the patient is unable to reach the toilet in time
Give 2 causes of functional incontinence?
- Poor mobility
- Unfamiliar surroundings
What is stress incontinence?
Involuntary leakage of urine on effort or exertion, or sneezing or coughing
What is urge incontinence?
Involuntary leakage accompanied by, or immediately preceded by, urgency of micturition – there is a sudden and compelling desire to urinate that cannot be deferred
What is mixed incontinence?
Involuntary leakage associated with urgency and stress
What is overflow incontinence?
When bladder becomes dilated or flaccid, with minimal or no tone/function
What is true incontinence?
Continuous leakage of urine
How is continence maintained?
By the co-ordinated interaction of the bladder, urethra, pelvic floor muscles, and the nervous system
What happens to the pressure in the bladder as it fills?
Increases slowly
What rate does the bladder fill?
Usually 0.5-5ml per hour
What is the capacity of the bladder?
500ml
At what level of bladder fullness will the desire to void be felt?
About 250ml
When is continence maintained, with regard to pressure?
When pressure in the urethra exceeds bladder pressure
What does the process of micturition involve?
The voluntary relaxation of striated muscle around urethra, reducing urethral pressure, and a corresponding increase in bladder pressure as a consequence of detrusor contraction
What kind of nervous control is passing of urine under?
Parasympathetic
Where do bladder afferent signals travel?
From the bladder, ascend through the spinal cord and then project to pontine micturition centre and cerebrum
What nervous signals are sent from the pontine micturition centre upon the voluntary decision to urinate?
Neurones of the pontine micturition centre fire to excite the sacral preganglionic neurones
What is the result of the excitation of the sacral preganglionic neurones on the conscious decision to urinate?
There is parasympathetic stimulation to the pelvic nerve (S2-4) causing a release of ACh
What does the ACh released by the pelvic nerve cause?
Works on M3 muscarinic ACh receptors on the detrusor muscle, causing it to contract and increase intra-vesicular pressure
Other than sending nervous signals to the sacral preganglionic neurones, what is the role of the pontine micturition centre?
Inhibits Onuf’s nucleus
What is the result of the inhibition of Onuf’s nucleus?
Reduction in sympathetic stimulation to the internal urethral sphincter causing relaxation
What happens to the external urethral sphincter during micturition?
There is a conscious reduction in voluntary contraction of the external urethral sphincter, allowing for the distention of the urethra and passing or urine
What assists urination in the female?
Gravity
What assists urination in the male?
Bulbospongiosus contractions and squeezing along the length of the penis
What can cause stress UI?
- Urethral hypermobility
- Sphincter deficiency
What structures can be involved in urethral hyper mobility?
- Pelvic floor muscle
- Urethral support
What structures can be involved in sphincter deficiency?
- Pudendal innervation
- Urethral striated muscle
- Smooth muscle function
When is stress UI most commonly seem?
After childbirth
What is urge UI also known as?
Overactive bladder or detrusor over-activity
What can cause urge UI?
- Idiopathic
- Neurogenic
- Infective
- Bladder outlet obstruction
What is the most common cause of urge UI?
Idiopathic
What can cause neurogenic urge UI?
- MS
- Parkinsonism
- Stroke
- Spinal cord injury
What can cause infective urge UI?
UTI
What are the main causes of overflow incontinence?
- Detrusor failure
- Obstruction
What are the causes of detrusor failure?
- Neurological
- Medication induced
- Diabetes
- Spinal surgery
What are the causes of obstruction?
- Enlarged prostate
- Bladder stones
- Tumour
- Urethral stricture
What can cause functional incontinence?
- Inability to communicate need to go to toilet
- Immobility
- Sedation
- Unfamiliar surroundings
- Cognitive impairment
- Clothing
Where does functional incontinence often occur?
In hospital
What are the risk factors for UI?
- Female gender
- Obesity
- Age
- Neurological disease
- Urinary infection
- Post-menopausal
- Post-hysterectomy
- Bladder outlet obstruction
Why are females more at risk of UI?
- Bladder outlet weaker
- Childbirth
Why is the bladder outlet weaker in females?
Due to shorter urethra and lack of prostate
What damage occurs during childbirth that increase the risk of UI?
Combination of ligament and nerve damage
Why does obesity increase the risk of UI?
Causes increased strain and weakening of pelvic floor
Why does age increase the risk of UI?
- Reduced bladder capacity
- Reduced blood flow
- Reduced total collagen
- Slowing of nerve conduction time
- Degenerative changes to urethral support structures
What simple investigations can be done in UI?
- Frequency/volume charts
- Urinalysis
- Blood tests
- Imaging
Why can frequency/volume charts be helpful in UI?
Help determine cause of urinary incontinence
How should frequency/volume charts be completed?
Patients should complete a diary over a 3 day period that records fluid intake, volume of urine passes, and episodes of incontinence
What does frequent small volumes of urine on frequency/volume chart indicate?
Overactive bladder
What does >1/3 of 24 hour urine produced at night on frequency/volume chart indicate?
Noctural polyuria
What does >2500ml/24 hours on frequency/volume chart indicate?
Polyuria
What should be checked for on urinalysis in UI?
- Glucose
- Protein
- Leucocytes and nitrates
- Blood
What might glucose on urinalysis indicate in UI?
Diabetes
What might protein on urinalysis indicate in UI?
Primary kidney pathology
What might leucocytes and nitrates on urinalysis indicate in UI?
UTI
What might blood on urinalysis indicate in UI?
- Renal stones
- UT malignancy
What blood tests should be done in UI?
- FBC
- U&Es
- Glucose
- Calcium
Why should calcium be done in UI?
Useful to rule out hyperglycaemia. which can cause constipation and confusion
What imaging may be done in UI?
- Post void bladder scan
- USS abdo
- CT urography
- CT abdo
- Intravenous urogram
When is a post-void bladder scan the 1st line diagnosis?
To rule out retention
When might USS abdomen be done in UI?
Required if renal failure to evaluate kidney size and look for signs of obstructive uropathy
When might CT urography be done in UI?
If considering renal stones
When might CT abdomen be done in UI?
Exclude abdominal or pelvic masses if suspected
When might IV urogram be done in UI?
Useful if renal stones are suspected, but largely superseded by CT urography in most centres
What specialist investigations may be done in UI?
- Uroflowmetry
- Ultrasound cystodynamogram
- Cystometry
- Videourodynamics
- Ambulatory urodynamics
What does uroflowmetry measure?
Urine flow rates
Is uroflowmetry invasive?
No
What is uroflowmetry useful for?
Diagnosing bladder outlet obstruction
What is an ultrasound cystodynamogram?
Combines pre and post void bladder scanning and gives information regarding functional bladder capacity, flow rate, and post-void bladder volume
What is cystometry?
Measurement of bladder pressure, sensation, capacity, and compliance during filling and voiding
What happens in cystometry?
The bladder is filled with saline whilst a pressure transducer is placed in the bladder and rectum
What is videourodynamics?
Combination of cystometry and radiographic screening
What is done in ambulatory urodynamics?
Measurement of physiological fillings and pressures during patients daily routine
How is ambulatory urodynamics done?
Uses pressure transducer and connects it to small device and uses electronic continence pads
I haven’t done pads n catheters n shit, do u want me to or do you know it?
:)
What patient education should be done in stress UI?
- Smoking cessation
- Weight reduction
- Managing constipation
- Reducing alcohol and caffeine
What is the first line management for women with SUI or mixed UI?
Pelvic floor muscle exercises
What should be offered regarding pelvic floor muscle exercises?
Supervised pelvic floor muscle training for at least 3 months
What should programmes of pelvic floor muscle training consist of?
At least 8 contractions performed 3 times a day
What pharmacological management is there for stress UI?
Duloxetine
Who should be offered surgical management for stress UI?
- Women who prefer pharmacological management to surgical
- Not suitable for surgical treatment
What kind of drug is duloxetine?
SNRI
How does duloxetine work in SUI?
Increases activity of external urethral sphincter during filling phase
What are the surgical options for stress UI?
- Colposuspension
- Autologous rectus fascial sling
What happens in colposuspension?
The neck of the bladder is lifted up and stitched into this position
