Continence Flashcards
In what populations is incontinence most likely?
Three times more likely to affect females than males
Two peaks in age- post-menopause and elderly
What is the goal of management of incontinence?
Identify cause of incontinence and treat it
What are the two broad categories of causes of incontinence?
Extrinsic- environmental, habit and physical fitness
Intrinsic- problem with the urinary system
Often both present
What are some extrinsic causes of incontinence?
- Physical state and co-morbidities
- Reduced mobility
- Confusion
- Drinking too much or at the wrong time
- Medications
- Constipation
- Home circumstances
- Social circumstances
What are the intrinsic causes of incontinence?
Intrinsic factors contributing to incontinence can be to do with the bladder or the outlet being too weak or too strong
When does stress incontinence occur?
When the bladder outlet is too weak
What are the characteristics of stress incontinence?
- Urine leak on movement, coughing, laughing, squatting, etc.
- Weak pelvic floor muscles
- Common in women with children, especially after menopause
How is stress incontinence treated?
Treatments of stress incontinence include physiotherapy, oestrogen cream and duloxetine. Surgical treatment is also possible with TVT/colposuspension.
When does urinary retention with overflow incontinence occur?
When the bladder outlet is too strong
What are the characteristics of urinary retention with overflow incontinence?
- Poor urine flow, double voiding,
- Hesitancy, post micturition dribbling
- Blockage to urethra
- Older men with BPH
- Only type of incontinence more common in males
How is urinary retention with overflow incontinence treated?
Treatment can be done with alpha blockers, anti-androgens or surgical TURP.
Catheterisation may be required, often done suprapubically.
When does urge incontinence occur?
When the bladder muscles are too strong
What are the characteristics of urge incontinence?
- Detrusor contracts at low volumes
- Sudden urge to pass urine immediately
- Patients often know every public toilet
- Can be caused by bladder stones or stroke
How is urge incontinence treated?
Treatment can be done with anti-muscarinics, to relax the detrusor, with bladder retraining sometimes being necessary.
How is bladder retraining done?
Bladder retraining involves getting the patient to void every 90-120mins, regardless of urge to void.
When does a neuropathic bladder occur?
When the bladder muscle is underactive
What are the characteristics of a neuropathic bladder?
- Rare
- Secondary to neurological disease, typically multiple sclerosis or stroke
- Can also be secondary to prolonged cathetarisation
- No awareness of bladder filling resulting in overflow incontinence
How is the neuropathic bladder treated?
Medical treatments are usually unsatisfactory but parasympathomimetics may help
Catheterisation is the only effective treatment
What type of incontinence occurs when the bladder muscle is overactive?
Urge incontinence
What type of incontinence occurs when the bladder muscle is under active?
Neuropathic bladder
What type of incontinence occurs when the bladder outlet is too weak?
Stress incontinence
What type of incontinence occurs when the bladder outlet is too strong?
Urinary retention with overflow incontinence
What are some examples of anti-muscarinic drugs?
Oxybutinin
Tolterodine
Solifenacin
Trospium
What affect do anti-muscarinics have in incontinence?
Relaxes the detrusor
What is an example of a β3-adrenoreceptor?
Mirabergon
What affect do β3-adrenoreceptors have in incontinence?
Relaxes the detrusor
What are some examples of α-blockers?
Tamsulosin
Terazosin
Indoramin
What affects do α-blockers have in incontinence?
Relaxes sphincter and bladder neck
What are some examples of anti-androgen drugs?
Finasteride
Dutasteride
What are the affects of anti-androgen drugs in incontinence?
Shrinks the prostate
What steps should be included in assessment of incontinence?
- Careful history with emphasis on social history to assess impact of incontinence and identify extrinsic factors
- Intake chart and urine output diaries
- General examination plus vaginal and rectal examinations
- Urinalysis and MSSU
- Bladder scan to assess residual volume
- Consider referral to incontinence clinic in difficult cases
- Suggest lifestyle/medication changes
- Consider physiotherapy, medical or surgery therapies
When should patients be referred to an incontinence specialist?
In cases of persistent urinary incontinence, patients should be referred to a specialist after failure of initial management- maximum three months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
What patients should be referred to an incontinence specialist when presenting?
Patients with the following:
- Vesico-vaginal fistula
- Palpable bladder after micturition or confirmed large residual volume of urine after micturition
- Disease of the CNS
- Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
- Severe benign prostatic hypertrophy or prostatic carcinoma
- Patients who have had previous surgery for continence problems
- Others in whom a diagnosis has not been made
When should referral to a specialist be done in cases of faecal incontinence?
Indications for specialist referral in faecal incontinence are:
Failure of initial management
Suspected sphincter damage
Neurological disease
What options are available when management of incontinence fails?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
