Continence Flashcards by Chloe Mackle

What is the prevalence of incontinence?

34% in women
20-30% in young adults
30-40% in middle age
30-50% in older adults

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Incontinence is a major cause of morbidity, what is it linked with?

Functional decline
Hospitalisation
Nursing home placement
Death

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What is the prevalence of urinary incontinence in nursing homes?

70%

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What percentage of people with dementia in institutional care are affected by incontinence?

84%

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Why might the numbers of people with incontinence be inaccurate?

People can be embarrassed and unwilling to present to their doctor for help, so not everyone with incontinence will be known

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What are the classifications of urinary incontinence?

Stress incontinence
Urge incontinence (overactive bladder)
Overflow incontinence
Mixed incontinence

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What is urinary incontinence?

Unintentional passing of urine

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What is bladder control dependent on?

Functioning bladder 
Functioning sphincters 
Cognition 
Mobility 
Dexterity 
Environment

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What is the musculature of the bladder/urinary tract?

Detrusor muscle - smooth muscle, involuntary
Internal urethral sphincter - smooth muscle, involuntary
External urethral sphincter - striated muscle, voluntary

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What is the parasympathetic innervation of the bladder?

Muscarinic receptors
S2-S4
Cause detrusor muscle contraction

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What is the sympathetic innervation of the bladder?

T10-L2, beta-2 adrenoceptors
Cause detrusor muscle relaxation

T10-S2, alpha adrenoceptors
Cause internal sphincter contraction

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How does reflex urination occur (spontaneous)?

Stretch receptors in wall of bladder stimulated by expanding bladder
Feedback to spinal cord
Parasympathetic nerves stimulated
Detrusor muscle contracts

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When does the internal urethral sphincter usually open?

When bladder is half full

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How is urination controlled by higher centres?

Pontine micturition centre - blocks the parasympathetic actions and leads to detrusor relaxation, and so storage of urine
Frontal cortex exerts overall control, allowing voluntary voiding of urine

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What is the typical presentation of stress incontinence?

Urine typically leaks with increased abdominal pressure e.g. laughing, coughing, sneezing, standing up

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What are typically weak in stress incontinence?

Outlet from the bladder - weak external sphincter and weak pelvic floor muscles

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In what sex is stress incontinence more common?

Women, particularly those who have had children and after menopause

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What is the typical presentation of urge incontinence?

Incontinence associated with the sudden urge to pass urine which cannot be delayed
Frequency a common symptoms
Nocturnal incontinence common

What happens to the detrusor muscle in urge incontinence?

Detrusor muscle instability leading to bladder overactivity

When does the bladder contract in urge incontinence?

With low urine volumes

What is urge incontinence due to?

Upper motor neurone lesion or detrusor muscle disorder

What is the typical presentation of overflow incontinence?

Urine is retained in the bladder with subsequent overflow
Hesitancy
Reduced stream
Post-micturition dribbling

What is often the cause of overflow incontinence?

Bladder outlet obstruction e.g. prostatic hypertrophy, tumour

What is important in the history of a patient with incontinence?

Type of incontinence (allows you to direct the management)
Any contributing factors, intrinsic and extrinsic
How the symptoms affect the patient
Drug history e.g. anticholinergics, diuretics, alpha-adrenergic blockers

For how long should a bladder diary be taken in an incontinent patient?

For 3 days, over working and non-working days, or over various days in patients who are not working Volume of fluid taken in Volume of urine excreted Any episodes of incontinence

What examination may be necessary in a patient with incontinence?

``` Abdominal Vaginal Rectal Determine strength of pelvic floor muscles Assess for constipation Assess for prolapse Assess size of prostate ```

What investigations, other than history and physical examination, might be necessary in a patient with incontinence?

Urinalysis MSSU Bladder scan - check residual volume, pre and post-void Urodynamics - cystometry, uroflowmetry

What is the general management of incontinence?

``` Weight control Fluid control - volume and type Reduce bladder irritants e.g. caffeine, fruit juice, alcohol Pelvic floor exercises Bladder retraining ```

When should pads be used?

Should not be used as a treatment, but may have a place as a coping strategy

What pelvic floor exercises should be recommended for stress incontinence treatment?

Minimum of 8 contractions, 3 times a day | Fast (1 second) and slow (10 second) contractions

How long should pelvic floor exercises for stress incontinence be done?

Will take 3 months to work initially but should be continued lifelong

What can be used as aids in pelvic floor exercises?

Biofeedback Vaginal cones Electrical stimulation (where patient cannot actively contract pelvic floor muscles)

What surgery can be done for stress incontinence treatment?

Colposuspension | TVT tape

What is the first line treatment for urge and mixed incontinence?

Bladder retraining programme | Prompted, regular toileting

How long should a bladder retraining programme for urge incontinence be done for?

Minimum of 6 weeks

What medications can be used to treat urge incontinence?

Anticholinergics e.g. oxybutynin, tolderodine, solifenacin | Beta-3 adrenoceptor agonist e.g. mirabegron

What are the potential side effects of anticholinergics?

``` Cognitive impairment Dry mouth Constipation Blurred vision Postural hypotension Drowsiness Urinary retention ```

What specific treatments are there for urge incontinence?

``` Bladder retraining programme Prompted, regular toileting Medications Botulinum toxin Sacral nerve stimulation ```

How does botulinum toxin help urge incontinence?

Relaxes detrusor muscle

What are the specific treatments for overflow incontinence?

Relieve the obstruction Relax the sphincter Bypass the obstruction

What can be done to relieve an obstruction causing overflow incontinence?

Anti-androgen to shrink prostate e.g. finasteride | TURP

What can be given to relax the sphincter in overflow incontinence?

Alpha-blocker e.g. tamsulosin, doxazocin

When should urinary catheters be used?

As a last resort Criteria; Symptomatic urinary retention Bladder outflow tract obstruction, otherwise unable to clear Undue stress caused by alternative management in the elderly, frail or dying

What is preferred, in terms of catheterisation, especially with urge incontinence?

Intermittent self-catheterisation