Continence Flashcards
What is the prevalence of incontinence?
34% in women
20-30% in young adults
30-40% in middle age
30-50% in older adults
Incontinence is a major cause of morbidity, what is it linked with?
Functional decline
Hospitalisation
Nursing home placement
Death
What is the prevalence of urinary incontinence in nursing homes?
70%
What percentage of people with dementia in institutional care are affected by incontinence?
84%
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
What are the classifications of urinary incontinence?
Stress incontinence
Urge incontinence (overactive bladder)
Overflow incontinence
Mixed incontinence
What is urinary incontinence?
Unintentional passing of urine
What is bladder control dependent on?
Functioning bladder Functioning sphincters Cognition Mobility Dexterity Environment
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
What is the parasympathetic innervation of the bladder?
Muscarinic receptors
S2-S4
Cause detrusor muscle contraction
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
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
When does the internal urethral sphincter usually open?
When bladder is half full
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
What is the typical presentation of stress incontinence?
Urine typically leaks with increased abdominal pressure e.g. laughing, coughing, sneezing, standing up
What are typically weak in stress incontinence?
Outlet from the bladder - weak external sphincter and weak pelvic floor muscles
In what sex is stress incontinence more common?
Women, particularly those who have had children and after menopause
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
