Continence Flashcards
What is required to maintain continence
Continence
Factors involved in maintaining continence
• Recognise the need to go to the toilet
• Identify an appropriate place and time to go to the toilet
• Reach the place identified
• Hold on until that place is reached
• Pass urine/faeces.
What are the risk factors for male urinary incontinence?
Constipation Prostate enlargement Infections Functional impairment Cognitive impairment Prostatectomy
How should male urinary incontinence be investigated?
DRE – prostate
Urine Dip
Post void bladder scan for residual volume
Urinary flow rates if neurological causes suspected
What is involved in a complete continence assessment of either gender?
Review bladder and bowel diary and post micturition bladder scan
Abdominal examination and check for constipation
Urinalysis note mid-stream urine sample is most useful (not urine dip as this can easily be contaminated) and assessment of clinical symptoms of a UTI
Prostate assessment including PR for both sexes
Hydration
Blood glucose
Drug review – diuretic use?
What general advice can be given for urinary incontinence?
First line general management advice
Switching to decaffeinated drinks, good bowel habit, improving oral intake, regular toileting, pelvic floor exercises and bladder retraining.
What temporary management can be used for urinary incontinence?
Temporarily manage with containment devices
How is stress urinary incontinence managed?
Stress incontinence – pelvic floor exercises, intramural bulking agents
How should urinary incontinence post prostatectomy be managed?
If postprostatectomy then pelvic floor exercises
How is mixed urinary incontinence managed?
Mixed incontinence – pelvic floor exercises, antimuscarinics (avoid oxybutynin due to effect on cognition), treating constipation and retention
How is urinary incontinence influenced by cognitive function best managed?
If cognitive dysfunction induced incontinence, then follow a timed toilet programme
What are the male catheter options in urinary incontinence?
Male catheter options in incontinence
Indwelling (urethral)
Suprapubic – lower rates of UTIs and urine bypassing
What are the indications for an indwelling catheter?
Chronic retention Skin wounds Contamination with urine Distress and disruption caused by incontinence Unable to perform self-catheterisation
Why are anticholinergics a last resort in urinary incontinence?
Remember that anticholinergics are not good in older people and oxybutynin whilst good for younger patients is not good for older people. Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.
What drug classes are used in urinary incontinence?
Anticholinergics
Beta 3 adrenergic agonists
Alpha 1 receptors antagonists
Name some antimuscarinic drugs used in urinary incontinence, describe what exactly they improve and their common side effects
Tolteradine, Solifenacin, Oxybutynin
and Trospium
Improves frequency and urgency
SE include dry mucosal membranes, constipation, tachycardia, abdominal pain, urinary retention, oedema, weight gain, glaucoma precipitation.
Oxybutinin particularly causes cognition decline
Which beta 3 adrenergic agonist is used in urinary incontinence, when is it used and what are the side effects?
Mirabegon
Used if antimuscarinics are contraindicated or clinically ineffective
Tachycardia
CI in severe hypertension
Caution if renal/hepatic impairment
Name the 3 alpha 1 receptor antagonists used in urinary incontinence, when are they used and what are each of their respective side effects?
Tamsulosin - Dizziness and sexual dysfunction
CI in postural hypotension
Doxazosin - Heart problems, dry mouth, GI upset, cough, coryza and headache
CI in postural hypotension
Finasteride - Sexual dysfunction
Used in Benign Prostatic Hyperplasia
Is faecal incontinence ever normal?
This is always abnormal and almost always curable and it is abnormal for there to be faeces in the rectum at any time unless passing stool.
What can influence faecal incontinence as we age?
As the body ages the rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chronic constipation. Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.
What direct causes are there for faecal incontinence
The most common cause of faecal incontinence is faecal impaction with overflow diarrhoea. This accounts for 50% of faecal incontinence.
The second most common cause is neurogenic dysfunction
Other causes – structural anorectal abnormalities such as sphincter trauma, alterations in stool consistency such as infection and IBD, and cognitive/behavioural dysfunction.
What investigations should be done on someone with faecal incontinence?
- A PR is absolutely mandatory in the assessment of faecal incontinence and the rectum, the prostate, anal tone and sensation should all be assessed as well as a visual inspection around the anus.
- Do not assume that a patient who is opening their bowels is not impacted; smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation should raise the suspicion of impaction with overflow.
- Impaction can be higher up than the rectum in some cases and a high degree of suspicion should be had if the clinical picture fits, but the rectum is empty.
- Behind every full rectum is often a full bladder and if a patient is found to have urinary retention then they MUST have a PR to assess for an impacted rectum and/or a large prostate if male.
What social and psychological factors should be considered for faecal incontinence?
Diet – optimised depending on stool consistency
Access – to toilet and easily removable clothing
Continence products
Psychological and emotional support
What general management advice should be offered for faecal incontinence?
Pharmacy review and avoid straining
Diet – keep a diary and have a high fibre diet
Bowel habit – try to empty after meal in private comfortable toilets
Continence products – disposable pads, anal plugs, skin care advice and odour control
How should loose stool incontinence be managed?
Regular antidiarrheal, loperamide (augments anal sphincter and reduced motility and secretions, codeine if Loperamide not tolerated)
How is constipation/overflow incontinence managed?
Should be utilising enemas for rectal loading and stool softeners and stimulants. If stool is hard then stimulants will not help as the stool requires softening.
Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.
Manual evacuation is done in difficult cases and the risk of perforation is outweighed by the positive impact on patient symptoms and wellbeing.
Stool softeners such as Docusate are useful
How should faecal incontinence related to cognitive/behavioural dysfunction be managed?
Regular toileting
Good diet
How should faecal incontinence related to sphincter dysfunction be managed?
Pelvic floor exercises
TCA – amitriptyline
How should faecal incontinence related to spinal cord or neurogenic bladder be managed?
Routine even if this mean manual evacuation or digital anorectal stimulation
Sacral nerve stimulation
Name some anti-motility diarrhoea medication, give its mechanism and side effects/CI.
Anti-motility drugs Loperamide (Imodium)
Codeine
Opiate analogue 40 times more potent than morphine.
Reduce bowel motility increasing time for fluid to reabsorb, also increases anal tone and reduces sensory defecation reflex
Avoid in IBD due to toxic megacolon
What is mebeverine used for?
Reduced colonic hypermobility relieving spasm. Useful when combined with bulk forming agents
Name a bulk type constipation medication, describe its mechanism and some side effects/CI
Fybogel
Insoluble and non-absorbable substances which distend the gut and draw water in
Flatulence
Contraindications – adhesions/ulceration
Describe the mechanism of enemas
Magnesium and sodium salts
Cause water retention in small/large bowel to increase peristalsis
Act quickly and are severe so used in resistant constipation or to clear bowel before surgery/radiological procedure
Name the osmotic type constipation medications, describe its mechanism and some CI
Lactulose, Macrogols and Phosphate Enemas
Disaccharide that cannot be hydrolysed and so fermentation occurs producing lactic acid which has an osmotic effect
Caution with intestinal obstruction
Name the irritant/stimulant type constipation medications, describe its mechanism and side effect/CI
Senna and Danthron
Excitation of sensory nerve endings leading to water and electrolyte retention and thus peristalsis
Repeated use – colonic atony and hypokalaemia
Abdominal cramps
Abuse - melanosis coli
Used for rapid treatment for faecal impaction and surgical prep
Contraindicated in intestinal obstruction
How is overactive bladder managed in men?
Conservative measures including moderating fluids
Bladder retraining
Antimuscarinics such as oxybutynin, tolterodine and darifenacin
Mirabegron if first line drugs fail
What management and advice can be given regarding nocturia for men?
Moderate fluid intake at nigh
Furosemide 40mgin later afternoon
Desmopressin
