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HCOLL > Continence > Flashcards

Continence Flashcards

1
Q

Physiology of maintaining continence

A

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-

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2
Q

Physiology of micturition

A

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)

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3
Q

Types of incontinence

A

Urge
Stress
Functional
Mixed

Reflex
Faecal
Overflow

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4
Q

Describe urge incontinence

A

detrusor overactivity

Urge with or without involuntary leakage

Usually there is frequency and nocturia

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5
Q

Describe stress incontinence

A

involuntary leakage of urine during increased abdominal pressure in the absence of detrusor muscle contraction

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6
Q

Describe overflow incontinence

A

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

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7
Q

What is functional incontinence

A

Not normally incontinent, but due to external factors.
Often in hospital.

Immobility
Sedation
Cognitive impairment

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8
Q

Aetiology of Functional incontinence

A

DIAPPERS

Delirium
Infection
Atrophy (vaginal)
Pharmacology
Psychological
Excess urine output (polyuria)
Restricted mobility
Stool impaction (constipation)
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9
Q

How does giving birth have an effect on continence?

A

Increases risk of incontinence:

Lowest-to-greatest:
C-section
Vaginal delivery
Forceps delivery

Combo of ligament and nerve damage

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10
Q

RF for urinary incontinence

A

Female (shorter - thus weaker - urethra)
-labour

Surgery (transurethral resection of prostate)

Age
Neurological disease
UTI
Post-menopause
Post-hysterectomy
Bladder outlet obstruction
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11
Q

Causes of overactive bladder (urge incontinence)

A

Idiopathic (most common)
Neurogenic (MS, Parkinsonism, strome)

UTI

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12
Q

Causes of bladder outlet obstruction

A 
Stricture
STDs
Trauma
Calculi
BPH
Cancer of prostate or bladder
Carcinoma of cervix or colon
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13
Q

Medications that can cause incontinence

A

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)

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14
Q

Incontinence Red Flags (refer to urology/urogynaecology)

A

Pain on micturition
Haematuria
Prolapse beyond introitus
Suspicious of prostate cancer

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15
Q

Examinations in incontinence

A

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)

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16
Q

Investigations for incontinence

A

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

17
Q

What is nocturnal polyuria

A

> 1/3 of the 24hr urine is produced at night

18
Q

What is polyuria

A

> 2500ml urine/24hr

19
Q

What imaging may be done in incontinence

A

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

20
Q

What is uroflowmetry?

A

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

21
Q

What is normal value for post-void bladder volume?

A

50-100ml

Above that is retention

22
Q

Consequences of incontinence

A 
Pressure ulcers (and moisture)
Falls
Depression
Impaired quality of life
Admission to care homes
Skin infection
Isolation
23
Q

Management of stress incontinence

A

PELVIC FLOOR EXERCISES

Patient education: smoking, weight reduction, constipation management, alcohol and caffeine

Surgical
minimally invasive day-case procedure: mid-urethral sling insertion

24
Q

MDT in stress incontinence

A

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)

25
Q

management of overactive bladder (detrusor) = urge incontinence

A 
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

26
Q

medical management of overactive bladder

A

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)

27
Q

Sid effects of antimuscarinics (oxybutynin, tolteridone)

A 
Dry mouth
Blurred vision
Constipation
Cognitive impairment
Urinary retention
28
Q

MDT team in overactive bladder

A

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)

29
Q

management of bladder outlet obstruction

A

Patient education

Medical: 2 options for BPH.

  1. Alpha adrenoceptor antagonist. eg. Doxazocin. Reduce smooth muscle tone of prostate.
  2. 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

HCOLL (11 decks)

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