Continence Flashcards
What is incontinence linked with?
Functional decline
Nursing home placement
Death
Socially and psychologically challenging
Definition of incontinence
Unintentional passing of urine
Types of incontinence
Stress incontinence
Urge incontinence (overactive bladder)
Overflow incontinence
What is mixed incontinence?
Stress incontinence and urge incontinence
Bladder control is dependent on….
Functioning bladder Functioning sphincters cognition mobility dexterity
Bladder changes with age
Vaginal atrophy Decreased bladder capacity Increased residual volume Prostate hypertrophy Increased urine production at night
Reversible factors possibly related to incontinence
Polydipsia Medications UTI Prolapse Delirium
Co morbidities associated with incontinence
Decreased mobility BOO Constipation Stroke Spinal cord pathology Cognitive impairment
Functions of the bladder
Urine storing - detrusor muscle relaxation - sphincter contraction Voluntary voiding - relaxation of external sphincter - involuntary relaxation of internal sphincter - contraction of bladder
Involuntary muscles of the bladder
Detrusor (smooth muscle)
Internal urethral sphincter (smooth muscle)
Voluntary muscles of the bladder
External urethral sphincter (voluntary)
Innervation of the bladder
parasympathetic
- S2-S4 = detrusor muscle contraction = urine
Sympathetic
- T10-L2 = detrusor muscle relaxation
- T10 - S2 = internal sphincter contraction
Motor/somatic
- S2-4 external sphincter contraction
Control of urination
Can have voluntary control over stretch reflex mechanism
- pontine micturition centre (blocks parasympathetic actions)
- frontal cortex exerts overall control
- caudal part of spinal cord
Causes of overflow incontinence
Urethral blockage OR
bladder unable to empty properly
Pathology of stress incontinence
Relaxed pelvic floor
Increased intraabdominal pressure
Causes of urge incontinence
Bladder oversensitivity from infection
Neurological disorders e.g. strokes
Bladder stones
Triggers of stress incontinence
Increased intra abdominal pressures
- coughing
- sneezing
- laughing
- standing up
Stress incontinence is common in who?
Women
- have had children
- after menopause
What is urge incontinence?
Incontinence associated with the sudden urge to pass urine (and cannot be delayed)
Symptoms of overflow incontinence
Hesitancy
Reduced stream/poor urine flow
post micturition dribbling
Double voiding
Two types of urinary system disease
Bladder outlet over activity
Bladder outlet under activity
Extrinsic causes of incontinence
Physical state and co morbidities Decreased mobility Confusion (delirium/dementia) Drinking too much/at wrong time Diuretics Constipation Home / social circumstances
Intrinsic causes of incontinence
Bladder outlet
- too weak = stress incontinence
- too strong = urinary retention + over flow incontinence
Bladder muscle
- too strong = urge incontinence
- too weak = neuropathic bladder
Investigations of incontinence
Abdominal exam PV - strength of pelvic floor muscles - vaginal redness/dryness - Prolapse PR - anal one (neuropathic problems) - constipation Urinalysis / MSSU Bladder scan (residual volume post void) Urodynamics - cystometry - uroflowmetry
Management of incontinence
Weight control fluid control reduce bladder irritants Pelvic floor training exercises Bladder retaining Pads/urinals Surgery - colposupension - TVT tape
Bladder irritants
Caffeine
Fruit juice
Alcohol
Stop unnecessary drugs
AIDs for pelvic floor muscle exercises
Biofeedback
Vaginal cones (adding extra weight)
electrical stimulation
Specific treatment for urge incontinence
Bladder retaining programme Prompted, regular toileting Anticholinergics Beta-3-adrenoreceptor agonist Botulinium toxin Sacral nerve stimulation
Specific treatment for overflow incontinence
Relieve the obstruction
- prostatic hypertrophy/tumour
- anti-androgen
- TURP
- Relax sphincter
- alpha blocker
- bypass obstruction (catheter)
What do antimuscarinics do?
Relax detrusor
What do beta-3-receptor agonists do?
Relax detrusor
What do alpha blockers do?
Relax sphincter, bladder neck
What do anti androgen drugs do?
Shrink the prostate
What is neuropathic bladder secondary to?
Neurological disease e.g. MS or stroke
Prolonged catheterisation
What does a neuropathic bladder result in?
No awareness of bladder filing resulting in overflow incontinence
Only effective treatment for neuropathic bladder
Catheterisation
Criteria for urinary catheters
Symptomatic urinary retention
BOO, otherwise unable to clear
Undue stress caused by alternative management in elderly/frail/dying
Indications for incontinence referral to specialist
Failure of initial management (max 3 months)
Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume
Disease of CNS
Certain gynae conditions e.g. fibroids, rectocele
Severe benign prostatic hypertrophy or prostatic carcinoma
Previous surgery for continence problems
Diagnosis not been made
Faecal incontinence
Measures to promote independence if all else fails
Incontinence pads Urosheaths Intermittent catheterisation Long term urinary catheter Suprapubic catheter
