Continence Flashcards
Urinary incontinence risk factors?
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery including hysterctomy
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
Family history
Classifications of urinary incontinence?
- overactive bladder (OAB)/urge incontinence
- stress incontinence
- mixed incontinence: both urge and stress
- overflow incontinence
- functional incontinence
What problems might incontinence lead to?
Increased falls risk
Requirement of carers/24 hour cares
Social implications
Skin breakdown
What might you ask about during a continence assessment to help establish the severity?
Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing
What should be examined for in a patient presenting with urinary incontinence?
Examination should assess the pelvic tone and examine for:
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
During the examination, ask the patient to cough and watch for leakage from the urethra.
The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system
What modifiable risk factors might contribute to urinary incontience?
Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)
Modified Oxford Grading System
The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
How might urinary incontinence be investigated?
A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology.
Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
What are the components of a complete continence examniation?
Review of bladder and bowel diary
Abdominal examination
Urine dipstick and MSU
PR examination including prostate assessment in males
External genitalia review (particularly looking for atrophic vaginitis in females)
A post micturition bladder scan
What is urge UI?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.
What is stress UI?
The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis.
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.
What is mixed UI?
Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.
What is overflow UI?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.
What is functional UI?
functional incontinence
comorbid physical conditions impair the patient’s ability to get to a bathroom in time
causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
The person has normal function of the neurological control mechanisms for urination. The bladder is able to fill and store urine properly. The person is able to recognize the urge to void. There are many possible causes of functional incontinence. Often, it involves environmental barriers that make it difficult for the person to get to an appropriate place for voiding. Also, another cause is a problem that prevents the person from moving instantly to get to the lavatory, remove clothing to use the toilet, or transfer from a wheelchair to a toilet. This includes musculoskeletal problems such as back pain or arthritis, or neurological problems such as Parkinson’s disease or multiple sclerosis (MS).
What is urodynamic testing?
Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around 5 DAYS before the tests.
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken:
Cystometry measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
Post-void residual bladder volume tests for incomplete emptying of the bladder
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Conservative/first line management of stress incontinence
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgical management of stress incontinence
Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape
Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support
Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, specialist centres may offer an operation to create an artificial urinary sphincter. This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.
What medication might be used to manage stress UI?
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
Pelvic floor exercises
Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel. Pelvic floor exercises should be supervised by an appropriate professional, such as a specialist nurse or physiotherapist. Women should aim for at least eight contractions, three times daily.
Management of urge UI?
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications (alpha 3 agonist)
Invasive procedures where medical treatment fails
Invasive options for overactive bladder that has failed to respond to retraining and medical management include what?
Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
Typical LUTS associated with BPH?
Hesitancy – difficult starting and maintaining the flow of urine
Weak flow
Urgency – a sudden pressing urge to pass urine
Frequency – needing to pass urine often, usually with small amounts
Intermittency – flow that starts, stops and varies in rate
Straining to pass urine
Terminal dribbling – dribbling after finishing urination
Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night
What is used to measure the severity of LUTs?
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms.
What is BPH?
Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.
The initial assessment of men presenting with LUTS involves what?
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
What might cause a raised PSA?
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
BPH vs Prostate cancer on DRE?
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
Medical management of BPH?
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate. They may be used together where patients have significant symptoms and enlargement of the prostate.
5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.
Surgical management of BPH?
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
What does TURP involve and what are the potential complications?
Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
Major complications:
Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms
What is TEVAP
Transurethral electrovaporisation of the prostate (TEVAP / TUVP) involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Bristol Stool Chart
Type 1 - hard lumps, like nuts
Type 2 - sausage-shaped, but lumpy
Type 3 - sausage-shaped, with cracks on the surface
Type 4 - like a smooth sausage or snake
Type 5 - soft blobs with clear cut edges
Type 6 - fluffy pieces with ragged edges, mushy
Type 7 - watery, no solid pieces
Types of urinary catheter
Foley Catheters. These are ‘standard’ indwelling catheters, retained in the bladder with an inflatable saline balloon.
Intermittent Catheters. These are catheters for short-term drainage of urine. Unlike Foley Catheters, they do not have inflatable balloons, and therefore must be held in place, usually for one-time use.
Coude Catheters. These catheters are made of stiffer material than other catheters, and have a curved tip at their end that allows them to slip past urethral obstructions.
External “condom” catheters (sometimes called “Texas” catheters). These catheters slip over the outside of the penis, and are therefore not inserted into the urethra. They carry a lower risk of infection, although they are at higher risk of falling off than indwelling catheters.
Suprapubic
