3 - Continence Flashcards
How do you take a history for incontinence?
https://www.themedicaltextbook.com/urinary-incontinence-history-osce
In introduction say you might have to ask some sensitive questions
PC (see image): onset? intermittent or constant dribble? nocturia? eneuresis? volume of urine? issue when coughing? urgency?
Associated Symptoms: dysuria, frequency, haematuria, terminal dribbling, weight loss, night sweats, constipation, symptoms of prolapse
Past medical/surgical history: childhood enuresis, cancer, diabetes, childbirth
Medication history/allergies: especially diuretics, sedatives and anticholinergics
- Social history - occupation (especially if working with textile/rubbers - may increase risk of bladder transitional cell carcinoma) , stress at work, employment, fluid intake!!
- Smoking and alcohol history
- Family history
- Travel history
- ICE
If a patient has urinary incontinence they may be asked to fill out a bladder diary. How do you complete one of these?
- Each day record what and how much you drink (in mls or cups), and when you drink it
- Use a jug to measure the amount of urine
- If you leak urine, tick the column marked ‘wet’
- Urgency A to E (A is went to toilet for other reasons, could have held, E is wet by time got to toilet)
What is the Bristol Stool Chart and how do you interpret it?
- Type 1-2: constipation
- Type 3-4: ideal stools as they are easier to pass
- Type 5-7: diarrhoea and urgency.
What are some prostatic urinary symptoms?
- Hesistacy
- Weak flow
- Dribbling
- Feeling of incomplete emptying
What investigations and examinations should you do for a patient when they present with incontinence?
- PR exam: check prostate and constipation
- Bladder scan: residual urine test for overflow
- Bladder and Bowel diary
- PV exam: check pelvic floor muscles
- Abdo exam
- Urinalysis: rule out infection
- U+Es
- Cystometry
What patients may have pyuria on a urine dipstick but not actually have a UTI?
Poor specificity for UTI
- Dehydration
- Advanced age
- AKI
- STI
- Appendicitis and Diverticulitis
Why does have negative nitrites on a urine dipstick not rule out a UTI?
Only produced by gram negative bacteria, the following will have negative nitrites
S. saprophyticus, Pseudomonas or Enterococci
An MSU may show bacteria but a patient may not have a UTI, why is this?
Lots of people have asymptomatic bacteria!!!!
Only needs treating if pregnant, treat for 7 days
If a patient has symptoms of a UTI, what investigations should you do?
- <65 years old woman: Urine Dipstick. If positive Ni or Leu and RBC then likely UTI so only send MSU if previous antibiotic treatment has failed. If negative Ni but positive Leu send for MSU. If all negative then clear
- >65 years old or catheterised: Needs MSU straight away as will also show asymptomatic bacteria on dipstick
How is a UTI diagnosed?
CANNOT BE A UTI WITHOUT SYMPTOMS!!! Must have dysuria, frequency, urgency
Sometimes may not have symptoms as UTI is causing delirium
How do you interpret the results of a post void bladder scan?
Normal: 0-50ml, in elderly 50-100ml
Residue: Over 100ml but does not need acting on
Incomplete bladder emptying: >200mls, with >400ml being high
What are some of the different types of urinary incontinence?
Mixed
What are some examples of containment devices to help keep a person continent?
SHOULD NOT BE USED LONG TERM, JUST TEMPORARY WHILST OTHER MEASUREMENTS BEING PUT IN PLACE
- Absorbent pads
- Handheld urinal devices
- Convine Sheath
- Pessaries
What are some risk factors for the following types of incontinence:
- Urge
- Stress
- Overflow
- Functional
Urge: recurrent UTI, smoking, caffeine, high BMI
Stress: childbirth, hysterectomy
Overflow: constipation, prostatism, neurogenic bladder
Functional: alcohol, sedatives, dementia
What is the conservative management of urinary incontinence?
1st Line: switch to decaf drinks, good bowel habit, regular toileting, pelvic floor exercises, bladder retraining
Others: pads
Always exhaust non-pharmacological options first as risk of postural hypotension with drugs
What is the medical and surgical management of stress incontinence?
Medical
- Duloxetine
- Only if conservative fails and not a surgical candidate
Surgical
- Mid urethral slings: gold standard
- Colposuspension and fascial slings
- Bulking agents: if poor surgical candidate
- Incontinence pessaries: if prolapse
What is the medical and surgical management of urge incontinence?
Medical
- Mirabegron in elderly
- Oxybutynin, Tolterodine, Fesoterodine, Solifenacin
- Avoid oxybutynin in elderly as high ACBS
- Anticholinergics that stimulate parasympathetics to detrusor muscles
Surgical
- Intravesical injection of Botox: paralyse detrusor
- Sacral nerve stimulation
If mixed treat the predominant symptoms
How is overflow incontinence managed?
- Intermittent catheterisation
- Alpha Blocker (Tamsulosin, Doxazosin): for men with moderate to severe symptoms
- 5-a Reductase Inhibitors (Finasteride): for men with enlarged prostate
- Surgical: TURP if BPH, removal of bladder calculi if obstruction, urethral dilation of strictures
What are some drugs that can cause urinary retention? (most common cause BPH)
- TCA antidepressants
- Antimuscarinics
- Opioids
Fill out the following table for the drugs commonly used in continence management.
Which groups of people should you not use oxybutynin in and why?
Use Mirabegron instead
- to treat extrapyramidal side-effects of antipsychotic medications (risk of antimuscarinic toxicity)
- with delirium or dementia (risk of exacerbation of cognitive impairment)
- narrow-angle glaucoma (risk of acute exacerbation of glaucoma)
- chronic prostatism (risk of urinary retention)
- if two or more antimuscarinic drugs prescribed concomitantly (risk of increased antimuscarinic toxicity)
Why is it important to refer people with incontinence to an incontinence clinic?
- Can give psychological support
- Can teach how to catheterise
- Can give advice about other aids
What are the causes of faecal incontinence?
- Faecal impaction with overflow diarrhoea (most common)
- Neurogenic dysfunction
Why are elderly people more predisposed to faecal incontinence?
- Rectum becomes larger and anal sphincter can gape due to haemorrhoids and chronic constipation
- Lack of intra-abdominal pressure to force out constipated stool so become impacted
How should you assess faecal incontinence?
PR!!!!!!!!!!
- Classify any stool type in rectum (any stool in rectum is abnormal)
- Feel prostate
- Test tone and sensation, if diminished this suggests spinal cord pathology so manage urgently
- Visual inspection of anus
What are some things that raise your suspicion of faecal impaction?
Can occur higher in colon so if no stool in rectum can still suspect it!!!
- Smearing
- Small amount of type 1
- Copious amounts of type 6/7 with no sensation of defacation
If a patient is found to have urinary retention, what examination do you need to do?
PR!
Behind every full bladder is often a full rectum and/or large prostate
How can constipation/faecal impaction be fatal?
- Ischaemic bowel
- Stercoral perforation
Be carefully when palpating abdomen!
How is faecal impaction managed in simple terms?
- Firstly use enemas and stool softeners
- Once soft can then use stimulant
- Manual evacuation if difficult but risk of perforation
Any drugs prescribed that can cause constipation should be co-prescribed a laxative!!
How is chronic diarrhoea managed?
Ix:
Need to rule out underlying causes with bowel imaging, stool cultures, PR for faecal impaction and medication review
Mx
- Regular toileting
- Dietary review
- Low dose loperamide
How do you make a bowel habit diary?
Bladder and Bowel diary need a minimum of 3 days
