Continence

Question 1

Explain how you would take a continence history?

Answer 1

Presenting Complaint:
-Tell me about whats brought you in?
-Is it incontinence of urine or faeces?
-What type of incontinence? Stress/ urgency etc
-Do you leak?
-How do you currently manage it?
-Any pain or burning on urination?
-Any blood in urine or faeces?
-Do you feel like youve completly emptied your bladder or bowels when youve been?
-How often are you going?
-Any urinary hesitancy or dribbling?
-Any signs of infection? Fever, pain, etc

Past Medical History:
- Do you have any medical conditions?
-Any previous surgeries?

Drug History:
-On any current medications?
-Take any over the counter meds?
-Any drug allergies?

Social History:
-Do you drink alcohol?
-Do you smoke?
-Do you drink caffeine/ fizzy drinks?
-How much do you drink?
-Have you any children?
-How do you manage ADLs?
-What is your home situation?
-Is there anyone at home with you?

Family History:
-Any medical conditions which run in the family

Question 2

Suggest 6 things you should include in a continence examination?

Answer 2

1- Review of bladder and bowel diary
2-Abdominal examination
3-Urine dipstick and MSU
4-PR examination including prostate assessment in a male
5- External genitalia review particularly looking for atrophic vaginitis in females
6- A post micturition bladder scan

Question 3

What are 3 disadvanatges with urine dipsticks?

Answer 3

1. Not useful in >65s
2. A dipstick result alone is not suffice to make a diagnosis.
3. False positives are common e..g menstrual blood, not a recent urine smaple, exercise and dehydration can influence result.

Question 4

What does the presence of each of these on a urine dipstick suggest?
1-leukocytes
2-Nitrates
3-Proteins
4-Glucose
5-Blood

Answer 4

1- Infection
2-Infection
3-AKI
4-Dibetes, AKI
5-Haematuria from trauma, infection, inflammation, infarction, calculi, neoplasia, clotting disorders or chronic infection

Question 5

On bladder scanning a individual what volume of urine should you expect to see post void?

Answer 5

100ml post void residual volume is normal

Question 6

List 6 types of incontinence?

Answer 6

1-Stress incontinence
2-Urge incontinence
3-Mixed Incontinence
4-Overflow incontinence
5-Functional incontinence
6-Overactive bladder

Question 7

Define Stress Incontinence.

Answer 7

“The complaint of involuntary leakage of urine on effort or exertion, or on increasing abdominal pressure e.g. sneezing or coughing”

Question 8

Define urge incontinence.

Answer 8

“The complaint of involuntary leakage of urine accompanied by urgency.”

Question 9

Define mixed incontinence.

Answer 9

“The complaint of involuntary leakage of urine on effort, exertion or on increasing abdominal pressure, associated with urgency.”

Question 10

Define overflow incontinence

Answer 10

“Inability to completely empty the bladder ( due to a weak bladder muscle or blockage) resulting in the frequent involuntary leakage of urine.”

Question 11

Define overactive bladder.

Answer 11

A frequent and sudden urge to urinate that may be difficult to control

Question 12

Define functional incontinence.

Answer 12

Physical inability to get to the toilet in time e.g. reduced mobility, reduced motor movement undoing zip.

Question 13

Complete this table for urge incontinence

Answer 13

Question 14

Complete this table for stress incontinence.

Answer 14

Question 15

Complete this table for mixed incontinence.

Answer 15

Question 16

Complete this table for functional incontinence.

Answer 16

Question 17

Complete this table for overflow incontinence.

Answer 17

Question 18

Complete this table for overactive bladder.

Answer 18

Question 19

How would you investigate incontinence?

Answer 19

Bedside:
-History
- Abdominal exam (Inc. DRE,external genitalia examination)
- Bladder diary
- Urine dip
- Urine MSC
- Bladder scan (post void)

Bloods:
-FBCs
-U&Es
-CRP
-LFTs

Imaging:
- CT pelvis/ KUB

Other:
-Cystoscopy
-Urodynamic flow testing

Question 20

Suggest 4 ways incontinence can impact an individual?

Answer 20

1. Physical Health: Skin Irritation, frequent moisture from leakage can lead to skin problems like rashes or infections.

2. Emotional Well-being: Stress and Anxiety, Worrying about accidents or the need to find restroom facilities can cause significant stress.

3. Social Life: Social Withdrawal, fear of accidents or embarrassment might lead someone to avoid social events or activities they once enjoyed.

4. Relationships: Impact on Intimacy, Incontinence can affect intimate relationships, leading to concerns about embarrassment or practical difficulties during intimate moments.

Question 21

When would you refer someone to the continence team?

Answer 21

A GP can refer you to your local continence service and in some cases you may be able to refer yourself.

Question 22

True or false?

Faecal incontinence is always abnormal and almost alwasy curable.

Answer 22

True

Question 23

What is the most common cause of faecal incontinence?

Answer 23

The most common cause of faecal incontinence is faecal impaction with overflow diarrhoea.

Question 24

Why is faecal incontinence more likely to occur in the elderly population?

Answer 24

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.

Question 25

What pathology does reduced anal tone and sensation suggest?

Answer 25

Reduced anal tone and sensation suggests spinal cord pathology and should be managed urgently.

Question 26

True or false.
Soft stool can fill the rectum and cause faecal impaction, as well as hard stool.

Answer 26

True.
Small amounts of type 1 stool or copious type 6/7 stool with no sensation of defaecation should raise the suspicion of impaction with overflow diarrhoea.

Question 27

Faeces can sometimes be palpated on abdominal examination if the patient is significantly loaded.
Suggest 2 risks of significant faecal impaction.

Answer 27

1-Bowel perforation
2-Ischemic bowel

Question 28

What is the difference between constipation and faecal impaction?

Answer 28

Constipation is faeces which is hard or difficult to pass.
Faecal impaction is the blockage of the bowel or rectum as a result of hard stool.

Question 29

Suggest 3 ways to manage faecal impaction.

Answer 29

1-Enemas
2-Laxatives
3-Manual evacuation

Question 30

What are the 4 types of laxatives, give an example for each.

Answer 30

1. Bulk forming laxatives e.g. Isphagula husk
2. Osmotic laxatives e.g lactulose
3. Stimulant laxatives e.g senna
4. Faecal softner laxatives e.g. docusate

Question 31

In older patients any medications which can cause constipation should be co-prescibed with laxatives.

Suggest 2 medications which can cause constipation.

Answer 31

1- Opiates e.g. codeine
2-Tricyclic antidepressants e.g. Amytriptyline

Question 32

What is chronic diarrhoea?

Answer 32

Chronic diarrhoea is defined as loose/watery stools, which occur three or more times a day and lasts for 4 or more weeks

Question 33

Suggest 4 casues for chronic diarrhoea?

Answer 33

1-Medications e.g. antibiotics, NSAIDs, PPIs
2-Diet e.g. caffeine, alcohol, fatty foods.
3-Medical conditions e.g. IBS,
4-Infection e.g gastroenteritis

Question 34

Suggest how you would investigate chronic diarrhoea?

Answer 34

Bedside:
1-History
2-Abdominal examination
3-Stool sample
4-DRE
Bloods:
4-CRP/ESR
5-FBC
6-Faecal calprotectin (inflammed bowel)
7-LFTs
8-FIT test (blood in stool)

Question 35

Suggest how you would treat chronic diarrhoea?

Answer 35

1-Modify diet e.g. avoid caffeine, alcohol, trigger foods
2-Medications e.g. loperamide
3- Ensure adequete fluid intake to prevent dehydration

Question 36

How does loperamide work?

Answer 36

Loperamide works by slowing down food as it goes through the gut. The body can then draw in more water from the intestines, so that the poos get firmer and you poo less often.