Continence Flashcards
Normal physiology of continence
Continence is maintained by the co-ordinated interaction of the bladder, urethra, pelvic floor muscles and nervous system
-low pressure-high volume
600ml capacity
Desire to void at 250ml
Continent if urethral pressure exceeds bladder pressure
Normal physiology micturition
Voluntary relaxation of striated muscle around the urethra
- > decreased urethral pressure
- > detruser contraction
The micturition cycle
Frontal cortex-> voluntary control
Pontine micturition centre-> coordinates detruser contract in with urethral relaxation
Parasympathetic-> bladder contraction s2-4
-> Ach release -> M3 r’s -> detruser contraction *antimuscarinics=retention
Sympathetic -> bladder filling t11-l2
-> bladder neck and urethra contraction
-> pudendal -> voluntary control of external sphincter
*a adrenergics=retention
*a blockers=stress incontinence
Urge incontinence
Detruser over activity with leakage of urine
Involuntary leakage accompanied by urge
Stress incontinence
Increased intra abdo pressure and weak pelvic floor muscles/urethral sphincter
Involuntary leakage when laughing, sneezing etc
Mixed incontinence
Stress and urge
Functional incontinence
Unable to reach the toilet in time
Overflow incontinence
Leakage from a full bladder
Reflex incontinence
Serious neuro impairment
Transient causes of incontinence
Delirium Infection Atrophic vaginitis Pharmacological agents Psychiatric disorders Excess urine output Restricted mobility Stool impaction
Causes of faecal incontinence
Faecal loading with overflow Lack of fluids and poor diet Lower GI ca Haemorrhoids Sphincter injury Dementia
Medications which cause incontinence
Alcohol Caffeine Sedatives-> less mobile + increased urge Antipsychotics-> " +" A blockers-> relax sphincter ACEi's -> cough Ca2+ channel blockers-> retention Opioids-> retention + constipation Antihistamines-> "+" Antidepressants-> "+" A agonists-> retention
Bladder irritants
Carbonated drinks Tea and coffee Artificial sweeteners Corn syrup Foods high in spice, sugar, acidity
Continence history extras
Risk factors Sexual health Obs+gynae LUTS Childhood urinary symptoms Bowels Diabetes Comorbidities Previous surgery Impact on patients life Fluids, caffeine, smoking Bladder control self assessment questionnaire
Continence examination
MMSE Chronic lung disease, CCF Abdominal masses Distended bladder DRE Vaginal atrophy+ pelvic floor muscles Neurological, gait, sensation
Simple bedside tests incontinence
Freq./volume charts Urinalysis -> glucose -> protein -> leukocyte + nitrites -> blood Mircroscopy
Blood tests incontinence
FBC- infection
U and E’s- renal function and electrolytes
Glucose - diabetes
Ca- constipation and confusion
Imaging incontinence
Post void bladder scan
USS abdo - kidneys
CT urography - stones
CT abdo- masses
Specialist tests incontinence
Urodynamics
Cystoscopy
Risk factors for stress incontinence
Female Weaker bladder outlet Childbirth Obesity Surgery Prostatectomy
Risk factors for urge incontinence
Idiopathic
Neurogenic
Infective
Obstruction
Stress incontinence non medical treatments
Patient education
-smoking cessation
-weight reduction
-manage constipation
-decrease alcohol and caffeine
Community continence advisor and physiotherapist
- pelvic floor exercises
-home assessment
Pudendal nerve stimulation -> increase pelvic floor muscles
Vaginal cones -> increase pelvic floor muscles
Medical treatment of stress incontinence
Duloxetine -> serotonin and noradrenergic reuptake inhibitor
Limited evidence
3rd line
Surgical treatment of stress incontinence
Mid urethral sling insertion
Colosuspension
Injection of bulking agents in urethra
Non pharmacological treatments of overactive bladder
Patient education - decree fluid intake - reduce caffeine and alcohol - weight reduction - manage constipation Community continence advisor Behavioural therapy -bladder retraining Pelvic floor exercises
Medical treatments for overactive bladder
Antimuscarinics -> oxybutynin, foltenidone, donifenacin, trospium -> m3 antagonism-> reduced contractions
B3 adrenoceptor agonists-> help bladder relax
Intra vaginal estrogens
Botulinum toxin injection
Surgical treatments of overactive bladder
Sacral nerve stimulation
Augmentation
Antimuscarinic side effects
Blurred vision Cognitive impairment Hallucinations Dry mouth Tachycardia Nausea Constipation Retention
Medical treatment of bladder outlet obstruction
A blockers -> doxazocin -> reduce smooth muscle tone of the prostate
5 a reductase inhibitors-> finasteride-> reduce prostate volume
Epidemiology of incontinence
200 million people world wide 2/5 >60 female 30% of older people at home 50% in care homes 1/4 f 1/10 m
