Case 15 - Incontinence

Question 1

History 
Examination
Investigations
Differential diagnosis
treatment plan

Answer 1

History

• stress or urge
• frequenct, nocturina, urgency
• amount of leakkage
• voiding difficulty
• assocaited anal incontinence or constipation
• chronic cough
• weight gain
• diuretic use, caffeine intake
• obs history

Inv
-urinalsysis, culture
-bladder diary
urodynamic evaluation

treatment

• encoruage weight loss
• treat constipation - preferbably by dietary means
• stop smoking and any other causes of chronic cough
• topical oestrogen
• pelvic floor muscle and bladder training

Question 2

What is ‘stress incontinence’? How does it differ from ‘urge incontinence’?

Answer 2

Urinary incontinence - involuntary leakage of urine, due to the bladder pressure exceeding the urethral pressure.

Stress incontinence - most common type, involuntary leakage of urine that occurs on effort or exertion or with sneezing, or coughing,

• can be caused by urethral hypermobility which an be due to damage to nerves, muscles and connective tissue which normally support the urethra.
• confirmed with urodynamic testing

Urge incontinence

• sudden urge to urinate with leakage associated with or immediatley after,
• bladder contracts when it shouldnt causing some urine to leak.
• due to detrusor musfcle overactivity.

overactive bladder
-due to heightened sensory afferents, increased level of neurotransmitters, ect which causes the bladder to contract inapporpireatly.
Symptoms - urinary frequency increase during day and night, urgency, urge incontinence, bed weting,
-urodynamic testing
-urge inocnitnece with no known cause.

urodynamic testing - measures bladder pressure and flow and intraabdominal rectal pressure.,

Question 3

What therapies are utilised to treat these two conditions?

Answer 3

Gneral

• encourage weight loss
• treat constipation - dietary
• stop smoking, or other causes of chronic cough
• topical eostrogen
• pelvic floor muscle and bladder training

Stress - conservative measures tried for 3 months before surgery.
-Surgical management - suspension and sling operations to elevate the bladder neck and support the urethra,

Overactive bladder
-combination of bladder training techniques and anticholinergic medications.
Botulinsim toxins can be injected into the detrusor muscle for temporary benefit.

Bladder training

• aim at vodiign deferment when urge starts with 1-5mins
• aim at 2l/day fluid
• reduce caffeine intake
• motivate and reinforce success

Question 4

3. What are risk factors for the development of stress incontinence?
   - look this up

Answer 4

• elderly women
• childbirth
• obesity
• diabetes
• smoking

Question 5

4. Which underlying causes of incontinence (or exacerbating factors) may be potentially reversible?

Answer 5

Causes
Stress incontience - atrophy or damage to pelvic floor muscles, liagaments or fascia (childbirht, menopause)

Urgency incontinence - Detrusor muscle voeractivity, can be neurogenic or secondayr.
-idopathic - aging
-neurogenic- stroke, multiple slcerosis, spinal cord injury,
Secondary -UTI, STI, interstitail cystitis, atrophic vaginitis, surgical treatmen

Question 6

Which investigations may be useful in assessing a patient with incontinence

Answer 6

-urinalsysis, culture
-bladder diary
urodynamic evaluation

Question 7

Which medications may exacerbate incontinence?

Answer 7

Sympathomimetics - psuedoephedrine 
Alpha blockers
Ace inhibitors
tricyclic antidepressants 
Antihistamines
antypsychotics
calcium channel blocekrs
diuertics
iron 
opiods
sedatives