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OPIC (Y4) > 4- Incontinence, constipation and urinary retention > Flashcards

4- Incontinence, constipation and urinary retention Flashcards

1
Q

constipation is a

A

a condition in which you have fewer than three bowel movements a week.

change in stool:

  • frequency
  • volume
  • consistency
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2
Q

causes of constipation

A
  1. Colorectal dysfunction
    1. Bowel cancer
    2. Obstruction
    3. Prolonged colonic transit
    4. Irritable bowel syndrome
  2. Secondary to other systems
    1. Endocrine (hypercalcaemia)
    2. Neurological (parkinsons)
    3. Meds e.g. opioids, anticholinergics, iron
    4. Rare e.g. Ogilvie syndrome
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3
Q

approach to constipation

A
  • History
  • Exam
    • Abdominal
    • PR
  • Investigation
    • Drug chart review
    • Bloods
      • Ca2+
      • PTH
      • VitD
      • Pi
      • FBC/Hb
      • K+/Mg2+
    • Imaging
      • AXR
      • CTAP with contrast
    • Endoscopy/ colonscopy
    • Flexi-sigmoidoscopy
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4
Q

general management of constipation

A
  1. lifestyle
  2. oral laxative
  3. suppositories
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5
Q

oral laxatives: osmotic

A

macrogol and lactulose

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6
Q

oral laxatives: stimulant

A

senna

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7
Q

oral laxative: stool softeners

A

docusate

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8
Q

oral laxative: bulking agents

A

isphagula husk

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9
Q

suppositories: osmotic

A

glyceral and phosphate

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10
Q

suppositories: stoll softner

A

archis oil

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11
Q

faecal impaction can be

A

higher up than the rectum in some cases and a high degree of suspicion should be had if the clinical picture fits but the rectum is empty

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12
Q

faecal impaction general management

A
  • Utilising enemas for rectal loading and stool softeners and stimulants.
    • Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.
    • Manual evacuation is done in difficult cases and the risk of perforation is outweighed by the positive impact on patient symptoms and wellbeing.
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13
Q

faecal impaction: soft stool approach

A
  • Lifestyle
  • Senna
  • Glycerol suppository
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14
Q

faecal impaction: hard stool approach

A
  • Lifestyle
  • Macrogol +-senna
  • Glycerol/phosphate suppository or archis oil

If stool is hard then stimulants will not help as the stool requires softening. Some

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15
Q

prevention of constipation in older patients

A

in older patients any prescribed drugs that can cause constipation should be coprescribed with a laxative

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16
Q

PR exam

  • If empty rectum – need oral laxatives:
A
  • Give regularly and always if starting opiates
  • Combine stimulant and softeners (senna, laxido, sodium docusate, sodium picosulphate)
  • Titrate up or down depending on response
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17
Q

PR exam

A
  • If stool in rectum – need rectal preparations
    • Glycerine suppositories
    • Micolette/phosphate enema
    • Arachis oil +/- manual evacuation
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18
Q

bristol stool chart

A
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19
Q

Behind every full rectum is often a

A

full bladder and if a patient is found to have urinary retention then they MUST have a PR to assess for an impacted rectum and/or a large prostate if male.

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20
Q

Continence examination

A
  • Review of bladder and bowel diary
  • Abdominal examination
  • Urine dipstick and MSU
  • PR examination including prostate assessment in a male
  • External genitalia review particularly looking for atrophic vaginitis in females
  • A post micturition bladder scan
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21
Q

poor outcomes for constipated patients

A

Faeces can sometimes be palpated on abdominal examination if significantly loaded.

Beware that faecal impaction and constipation can kill, there is a risk of stercoral perforation and ischaemic bowel in those chronically constipated.

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22
Q

faecal incontinence

A

This is always abnormal and almost always curable.

  • less common than UI but more distressing
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23
Q

causes of faecal incontinence

A
  • faecal impaction with overflow diarrhoea.
  • neurogenic dysfunction
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24
Q

pathophysiology of faecal incontinence

A
  • As the body ages the rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chronic constipation. ·
  • Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.
  • It is abnormal for there to be faeces in the rectum at any time unless passing stool.
  • If anal tone and sensation is diminished then this suggests spinal cord pathology and should be managed urgently.
25
Q

faecal incontinence examination

A

PR vital

  • prostate
  • anal tone
  • sensation
  • visual inspection around anus
  • stool type assessed if in rectum
26
Q

causes of chronic diarrhoea

A
  • IBS
  • IBD
  • infection
  • coeliac
27
Q

investigating chronic diarrhea

A

All underlying causes must be excluded by

  • bowel imaging
  • stool culture
  • potentially causative medications removed
  • PR- Faecal impaction must be excluded
28
Q

management of chronic diarrhea

A
  • Treat underlying cause
    • Abx if c.diff
    • medication for IBD
    • etc
  • Regular toileting in the first instance and dietary review ·
  • Low dose of loperamide (including paediatric doses) can be trialled and then constipating and enema regimes can be used if this does not work.
29
Q

management of chronic diarrhea

A
  • Treat underlying cause
    • Abx if c.diff
    • medication for IBD
    • etc
  • Regular toileting in the first instance and dietary review ·
  • Low dose of loperamide (including paediatric doses) can be trialled and then constipating and enema regimes can be used if this does not work.
30
Q

define urinary incontinence

A

Complaint of any involuntary leakage of urine… associated with…

  • Massive impact on QoL
  • Social exclusion
  • Sense of shame
  • Just put up with it attitude
  • types of UI stress
  • urge UI*
  • Mixed UI*
31
Q

types of UI

A
  • stress UI*
  • urge UI*
  • mixed UI*
32
Q

summarise stress UI

A
  • Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
    • In men: Abdominal abnormality involving supporting tissues around bladder neck and proximal urethra
    • In female: pregnancy, childbirth, older age- weakened pelvic floor
33
Q

Principles of UI management

A
  • Neither drug therapy nor pads are first line management for patients with urinary incontinence.
    • Most intervention is simple to begin with including switching to decaffeinated drinks, good bowel habit, improving oral intake, regular toileting and pelvic floor exercises and bladder retraining
    • When non-pharmacological measures have been exhausted then pharmacological measures can be trialled.
    • Remember that anticholinergics are not good in older people and oxybutynin whilst good for younger patients is not good for older people. Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.
34
Q

management of stress UI

A
  • Conservative measures
    • PMFT for 3 months 3x a day
    • Duloxetine- stimulates urethral sphincter
  • Surgical intervention
    • Rectus sheath – 10cm- used as hammock to urethra (tension- free vaginal tape)
    • Bladder neck bulking injection
    • Artificial urinary sphincter (last line)
35
Q

urge UI (same as OAB)

A

Urge UI describes an overactive bladder (detrusor hyperactivity), which leads to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.

36
Q

causes of UUI

A
  • Neurogenic causes (such as a previous stroke)
  • Infection
  • Malignancy
  • Idiopathic.
  • Medication, such as anticholinergics, can also result in urge UI.
37
Q

presentaqtion of urge UI

A
  • ‘Key in the door scenario’
  • Symptoms
    • Urgency
    • Overactive bladder syndrome
      • Frequency
      • Nocturia
38
Q

management of urge UI

A
  • Conservative
    • Bladder retraining
    • Fluid intake
      • Cut out alcohol and caffeine
    • Anticholinergics/ anti-muscarinics
      • Oxybutynin (try for 4 weeks, if intolerable give another)
        • Dry eyes and mouth
        • Constipation
        • Avoid older people
    • B3 agonist- Mirabegron
      • Arrhythmia
      • HTN
      • Palpitations
  • Surgical intervention
    • Botox- under local anaesthetic
      • Inject lining of bladder detrusor
      • Contraindicated in myasthenia gravis
      • Can cause urinary retention- intermittent catheter (until botox wears off)
    • Sacral nerve stimulation- increases inhibition
      • Battery lasts for 5 years
    • Final line- Clam ileocystoplasty
      • It involves cutting open the bladder, like a clam, and sewing a patch of intestine between the two halves.
        • Side effects: issue of detrusor contracting, mucus from bowel tissue, stones
39
Q

Summary of UI drugs

A
40
Q

Mixed incontinence

A
  • Urge and stress
  • Patient needs to decide which symptoms of urge and stress bother them most- treated accordingly
41
Q

Acute urinary retention

A

Acute urinary retention is defined as a new onset inability to pass urine*, which subsequently leads to pain and discomfort, with significant residual volumes.

42
Q

Chronic urinary retention

A

Chronic urinary retention is the painless inability to pass urine*. These patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation, therefore minimal discomfort despite potential large intra-vesical volumes.

43
Q

Chronic urinary retention

A

Chronic urinary retention is the painless inability to pass urine*. These patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation, therefore minimal discomfort despite potential large intra-vesical volumes.

44
Q

Chronic urinary retention

A

Chronic urinary retention is the painless inability to pass urine*. These patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation, therefore minimal discomfort despite potential large intra-vesical volumes.

acu

45
Q

chronic urinary retention causes

A
  • BPH
  • Urethral strictures
  • Prostate cancer
  • Pelvic prolapse in women (cystocele, rectocele, uterine prolapse)
  • Pelvic masses
  • Neurological causes
46
Q

chronic urinary retention presentation

A
  • Painless urinary retention
  • Voiding LUTS such as weak stream and hesistancy
  • Reduced functional capacity
  • Overflow incontinence
  • Nocturnal enuresis
  • Palpable distended bladder with no tenderness
47
Q

investigations for chronic UR

A
  • Post-void bedside bladder scan- shows volume of retained urine
  • Routine blood tests
  • If high pressure retention- US to look for hydronephrosis
48
Q

management of chronic UR

A
  • Patients with very high post-void volumes (arbitrarily >1L) or evidence of high pressure retention should be catheterised with a long-term catheter. Those with high post-void volumes should also have urine output monitored for post-obstructive diuresis
  • The patients should not undergo a Trial WithOut Catheter (TWOC), especially if evidence of high-pressure chronic retention, due to concerns of repeat renal injury. Instead they should have a long-term catheter before definitive management is planned; alternatives to this include ISC or suprapubic catheterisation.
  • Definitive management of chronic retention depends on the underlying cause.
49
Q

complications of chronic UR

A
  • Urinary tract infections
  • Bladder calculi
  • Chronic kidney disease- high pressure retention
50
Q

RF for acute UR

A
  • Older male patients
51
Q

causes of acute UR

A
  • BPH
  • Urethral stricture
  • Prostate cancer
  • UTI (can cause the urethral sphincter to close)
  • Constipation
  • Severe pain
  • Medications (anti-muscarinic or spinal or epidural anaesthesia)
  • Neurological causes (peripheral neuropathy, nerve damage, UMN disease)
52
Q

acute UR presentation

A
  • Acute suprapubic pain
  • Inability to micturate
  • Palpable distended bladder
  • Suprapubic tenderness
  • PR examination
    • Prostate enlargement
    • Constipation
53
Q

acute UR investigation

A
  • Post void bedside bladder scan will show the volume of retained urine
  • Routine bloods
  • MSU
  • US looking for hydronephrosis
54
Q

management of acute UR

A

Management

  • Immediate urethral catherization
  • Underlying cause treated e.g. BPH Tamsulosin
  • Review of patients medication

Definitive management

  • Patients with large retention volume (>1000ml) need to be monitored post catherization for evidence of post-obstructive diuresis
  • Patients with high pressure urinary retention
    • Keep catheter in Situ until definitive management e.g. TYRP
  • If no evidence of renal impairment -TWOC (catheter removed 24-48hrs after insertion)- if pt voids successfully then successful
55
Q

complication of acute UR

A

UKI which can lead to CKI

56
Q

causes of neurogenic bladder in older patietns

A
57
Q

Low pressure vs high pressure urinary retention

A
  • High Pressure Urinary Retention refers to the urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract leading to hydroureter and hydronephrosis, impairing the kidneys’ clearance levels.
  • Such patients present in retention with associated deranged renal function, and hydronephrosis will be subsequently confirmed on imaging (typically ultrasound as first line). Repeat episodes of high-pressure chronic retention can cause permanent renal scarring and chronic kidney disease (CKD).

By contrast, low pressure retention occurs in patients with retention with the upper renal tract unaffected due competent urethral valves or reduced detrusor muscle contractility / complete detrusor failure.

58
Q

Post-Obstructive Diuresis

A

Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate.

This over-diuresis can lead to a worsening AKI. Consequently, those patients at risk should have their urine output monitored over the following 24 hours post-catheterisation.

  • Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.
59
Q

Post-Obstructive Diuresis

A

Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate.

This over-diuresis can lead to a worsening AKI. Consequently, those patients at risk should have their urine output monitored over the following 24 hours post-catheterisation.

  • Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.

OPIC (Y4) (20 decks)

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