Continence Flashcards
What are the types of urinary incontinence?
Urge Overflow Stress Bladder outlet obstruction Mixed Fistulae Functional
What are the voiding (obstructive) lower urinary tract symptoms?
Hesitancy Straining Weak flow Terminal dribbling Prolonged voiding Retention Overflow incontinence Pain
What are the storage (irritative) lower urinary tract symptoms?
Frequency Urgency Nocturia Urge incontinence Small voided volume
How would you examine a patient?
Cardiorespiratory - assess for respiratory/heart failure
Abdomen - palpate for masses, enlarged kidneys, distended bladder, DRE exam
Mental state - perform a cognitive assessment
Pelvis - check for vaginal trophy or prolapse, assess pelvic floor muscle strength, assess for stress incontinence
Neurological - assess gait, look for clues to neurological diagnosis, check dorsiflexion of the toe, check perineal sensation, sensation of the sole, posterior aspect of the thigh
What is urge incontinence?
Failure of the bladder to store urine because of high bladder pressure
as seen in overactive bladder syndrome
What is stress incontinence?
weakness of the urinary outlet
What is mixed incontinence?
A combination of stress incontinence and urge incontinence
What is bladder outlet obstruction?
A bladder that is overfull and overflows
What are fistulae?
Abnormal communications of urinary tract
What is functional incontinence?
incontinence due to more general impairment
for example - cognitive, functional, affective
What are the key points to taking a history?
Consider lower urinary tract symptoms - storage or voiding
Determine fluid intake, timing and types - caffeine, alcohol
Systems review - diabetes/CKD
Obstetric history in women
Assess effect on quality of life
Medication history
What are the red flag symptoms?
Pain on micturition
Haematuria
Prolapse beyond the introits
Suspicion of prostate cancer
What effect does alcohol have on urinary incontinence?
polyuria
frequency
delirium
What effect do ACE inhibitors have on urinary incontinence?
Cough
Stress incontinence
What effect do anticholinergics have on urinary incontinence ?
Urinary retention
Overflow
What effect do diuretics have on urinary incontinence?
Polyuria
Frequency
Urgency
What effect do opiates have on urinary incontinence?
Delirium
Sedation
Constipation - overflow incontinence
Urinary retention
What effect do TCAs have on urinary incontinence?
Urinary retention
Overflow
What investigations should be carried out to investigate incontinence?
- Urinalysis
- MSU for microscopy, culture and sensitivity
- Post-void bladder scan
- Frequency volume chart (bladder diary)
More complex investigations
- uroflowmetrey
- video urodynamics
- ambulatory urodynamics
What are the causes of stress incontinence?
instrumentation during childbirth and/or pelvic floor damage
Vaginal prolapse
Post-prostatectomy in men
How should stress incontinence be managed?
lifestyle measures - smoking cessation, weight loss, reduced caffeine/alcohol intake
Pelvic floor exercises - 6/12 first line
Medication - duloxetine (SNRI) - limited evidence
Surgery
- mid-urethral sling insertion
- colposuspension
- bulking agent injections
What are the causes of overactive bladder?
Idiopathic - most common
Neurogenic - parkinsons, MS, stroke or spinal cord injury
Infective - UTI
Bladder outlet obstruction
How should overactive bladder be managed?
Lifestyle measures - weight loss, reduced caffeine/alcohol intake, time drinks - not after 8pm, manage constipation
Behavioural therapy - bladder training = 1st line
Pelvic floor exercises
Continence advisors
Medication - anticholinergic, B3 adrenoceptor agonists
Intravagnial oestrogen
Intradetrusor botox injections
Sacral nerve stimulation
What are the causes bladder outlet obstruction?
phimosis stricture sexually transmitted diseases trauma blood clot calculi BPH cancer of prostate or bladder cancer of cervix or colon
What is the definition of polyuria?
?mls in 24 hrs
> 2500mls in 24 hours
What is retention?
?mls after voiding
> 100mls after voiding
When do you think about catheterising a patient?
250-300mls
How is frequency described?
?times per day
> 8 times a day
How is nocturia described?
? times per night
> 3 times a night
How do calcium channel blockers effect continence?
decrease smooth muscle contractility
What are the causes of transient incontinence?
DIAPPERS
- Delirium
- Infection especially UTI
- Atrophy – vaginal
- Pharmacological
- Psychological – delirium, depression
- Excess urine output – excess intake, DM etc.
- Restricted mobility
- Stool impaction – constipation
What are the systemic causes of continence problems?
- Multiple sclerosis
- Stroke
- Dementia
- Congestive Heart Failure
- Parkinson’s
- Diabetes
- Musculoskeletal disease (mobility)
- Chronic lung disease
What are the consequences of continence problems?
- Decreased QofL
- Skin infection
- Falls
- Isolation
- Care home admission
- Depression
- Pressure ulcers
What are the most common causes of incontinence in men/women?
damaged periurethral striate muscle in women
prostatic hypertrophy in men
How should bladder outlet obstruction be managed?
1 - lifestyle
2 - MDT
3 - medical
4 - surgical
Lifestyle • Reduce evening fluid intake • Less caffeine, alcohol • Weight reduction • Manage constipation
MDT
• Continence advice
• Behavioural therapy – bladder retraining
• Pelvic floor exercises
Medical
• Doxazosin for BPH, or finasteride
• May need to treat OAB at same time
Surgical
• Depends on cause, most likely TURP if BPH etc.
What are the possible causes of faecal incontinence?
- Faecal loading
- Diarrhoea i.e. infectious, IBS, IBD i.e. Crohn’s, UC.
- Lower GI cancer?
- Rectal prolapse, 3rd degree haemorrhoids
- Acute anal sphincter injury
- Neuro i.e. acute disc prolapse, cauda equina syndrome
What are the management options?
lots
- Encourage good fluid intake
- Ensure good nutrient intake and balanced diet
- Consider a food and fluid diary
- Do an anogenital examination
- Screen for malnutrition
- Encourage good bowel habits
- May require surgery i.e. stoma
What is the first line medication for constipation?
sodium docusate - stool softener and stimulant
What other meds can be used to manage constipation?
- Lactulose = stool softener
- Senna = osmotic laxative
- Glycerin suppositories to soften stools
- Microlax enemas to move soft stools
- Phosphate enemas if the stool is high up
