Continence Flashcards
Physiology of maintaining continence
co-ordinated interaction of the bladder, urethra, pelvic floor muscles and the nervous system
The bladder is low pressure-high volume system. The pressure increases slowly as the bladder fills (rate 0.5-5ml/hr).
Desire to void at 250ml.
Capacity ca. 600ml
As long as urethral pressure exceeds bladder pressure, there is continence-
Physiology of micturition
o The voluntary relaxation of the striated muscle around the urethra: this reduces urethral pressure
o This is followed by a corresponding increase in bladder pressure a a consequence of detrusor contraction (pontine micturition centre)
Bladder contraction is mediated by parasympathetic fibres (originate sacral plexus S2-S4)
Types of incontinence
Urge
Stress
Functional
Mixed
Reflex
Faecal
Overflow
Describe urge incontinence
detrusor overactivity
Urge with or without involuntary leakage
Usually there is frequency and nocturia
Describe stress incontinence
involuntary leakage of urine during increased abdominal pressure in the absence of detrusor muscle contraction
Describe overflow incontinence
Urinary incontinence associated with chronic retention of urine. 2 main causes:
Detrusor failure (neurological, medication induced, DM, spinal surgery)
Obstruction: BPH, bladder stones, tumour, urethral stricture
What is functional incontinence
Not normally incontinent, but due to external factors.
Often in hospital.
Immobility
Sedation
Cognitive impairment
Aetiology of Functional incontinence
DIAPPERS
Delirium Infection Atrophy (vaginal) Pharmacology Psychological Excess urine output (polyuria) Restricted mobility Stool impaction (constipation)
How does giving birth have an effect on continence?
Increases risk of incontinence:
Lowest-to-greatest:
C-section
Vaginal delivery
Forceps delivery
Combo of ligament and nerve damage
RF for urinary incontinence
Female (shorter - thus weaker - urethra)
-labour
Surgery (transurethral resection of prostate)
Age Neurological disease UTI Post-menopause Post-hysterectomy Bladder outlet obstruction
Causes of overactive bladder (urge incontinence)
Idiopathic (most common)
Neurogenic (MS, Parkinsonism, strome)
UTI
Causes of bladder outlet obstruction
Stricture STDs Trauma Calculi BPH Cancer of prostate or bladder Carcinoma of cervix or colon
Medications that can cause incontinence
Cholinesterase inhibitors (increased contraction)
ACE inhibitors (chronic cough - worsen SUI) Opioids (constipation) Alpha-adrenoreceptor blockers: relax bladder outlet
Haloperidol (anticholinergic - retention)
Calcium channel blockers (decrease smooth muscle contractility)
Lorazepam (awareness)
Incontinence Red Flags (refer to urology/urogynaecology)
Pain on micturition
Haematuria
Prolapse beyond introitus
Suspicious of prostate cancer
Examinations in incontinence
AMT (if concerns with cognition)
Abdomen - masses, enlarged kidneys, distended bladder
DRE in all patients (tone, constipation, rectal mass, assess prostate size in M)
Pelvis (vaginal atrophy or prolapse)
Ask patient to cough or strain for stress incontinence
Cardiorespiratory (chronic lung)
Bladder scan - post-void scan
Neuro to rule out cauda equina syndrome: dorsiflexion of toes (S3), perineal sensation (L1-2), sensation of sole (S1), and posterior aspect of thigh (S3)
Investigations for incontinence
Frequency/volume charts: diary over 3 days (fluid intake, volume of urine, episodes of incontinence)
Urinalysis
Blood tests (FBC, U and Es, Glucose, Calcium - hypercalcaemia can cause constipation and confusion)
Imaging
What is nocturnal polyuria
> 1/3 of the 24hr urine is produced at night
What is polyuria
> 2500ml urine/24hr
What imaging may be done in incontinence
1st line:
Post-void bladder scan to rule out chronic retention
USS abdo - requested if renal failure to evaluate kidney size and look for obstructive uropathy.
CT urography is renal stones are suspected
CT abdo if abdo or pelvic masses are suspected
What is uroflowmetry?
Measures urine flow rates (non-invasive). Useful to diagnose bladder outlet obstruction.
Normal volumes:
Total voided volume >200ml
Flow time 15-20secs
Smooth parabolic curve
What is normal value for post-void bladder volume?
50-100ml
Above that is retention
Consequences of incontinence
Pressure ulcers (and moisture) Falls Depression Impaired quality of life Admission to care homes Skin infection Isolation
Management of stress incontinence
PELVIC FLOOR EXERCISES
Patient education: smoking, weight reduction, constipation management, alcohol and caffeine
Surgical
minimally invasive day-case procedure: mid-urethral sling insertion
MDT in stress incontinence
Community continence advisor or physiotherapist
-may assess and give advice at home
Pudendal nerve stimulation for building up muscle strenght if initially weak
Vaginal cones - designed to improve awareness of pelvic musculature (tone is needed to keep it in place)
management of overactive bladder (detrusor) = urge incontinence
Bladder training Prompted voiding (need to be mobile) Timed voiding (fixed interval toileting)
Patient education: reduced fluid intake, especially in evening
Reduce caffeine and alcohol
Weight reduction
Manage constipation
Surgical:
Sacral nerve stimulation
medical management of overactive bladder
Anti-muscarinic is the mainstay: oxybutynin, tolteridone
Beta-3-adrenoceptor agonists (Mirabegron). If Antimuscarininc CI or untolerated. relaxes bladder. Contraindicated in cardiovascular disease, because causes HTN
Intravaginal oestrogens - recommended for vaginal atrophy and symptoms of overactive bladder
Botulinum toxin - injected into detrusor muscle via cystoscopy (inhibits NT release thereby decreasing contractility)
Sid effects of antimuscarinics (oxybutynin, tolteridone)
Dry mouth Blurred vision Constipation Cognitive impairment Urinary retention
MDT team in overactive bladder
Community continence advisor - asses at home and advice
Behavioral therapy - involve bladder retraining - a patient increase the interval between first desire to void and actual voiding (1st line in combo with pelvic floor exercises, for at least 6 weeks)
management of bladder outlet obstruction
Patient education
Medical: 2 options for BPH.
- Alpha adrenoceptor antagonist. eg. Doxazocin. Reduce smooth muscle tone of prostate.
- 5 alpha-reductase inhibitors. Finasteride. Reduce prostate volume by blocking conversion of testosterone to dihydrotestosterone
Surgical - depends on cause. Transurethral prostatectomy can be considered if BPH
MDT
