Continence

Question 1

What is required to maintain continence

Answer 1

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.

Question 2

What are the risk factors for male urinary incontinence?

Answer 2

Constipation 
Prostate enlargement 
Infections 
Functional impairment 
Cognitive impairment 
Prostatectomy

Question 3

How should male urinary incontinence be investigated?

Answer 3

DRE – prostate
Urine Dip
Post void bladder scan for residual volume
Urinary flow rates if neurological causes suspected

Question 4

What is involved in a complete continence assessment of either gender?

Answer 4

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?

Question 5

What general advice can be given for urinary incontinence?

Answer 5

First line general management advice
Switching to decaffeinated drinks, good bowel habit, improving oral intake, regular toileting, pelvic floor exercises and bladder retraining.

Question 6

What temporary management can be used for urinary incontinence?

Answer 6

Temporarily manage with containment devices

Question 7

How is stress urinary incontinence managed?

Answer 7

Stress incontinence – pelvic floor exercises, intramural bulking agents

Question 8

How should urinary incontinence post prostatectomy be managed?

Answer 8

If postprostatectomy then pelvic floor exercises

Question 9

How is mixed urinary incontinence managed?

Answer 9

Mixed incontinence – pelvic floor exercises, antimuscarinics (avoid oxybutynin due to effect on cognition), treating constipation and retention

Question 10

How is urinary incontinence influenced by cognitive function best managed?

Answer 10

If cognitive dysfunction induced incontinence, then follow a timed toilet programme

Question 11

What are the male catheter options in urinary incontinence?

Answer 11

Male catheter options in incontinence
Indwelling (urethral)
Suprapubic – lower rates of UTIs and urine bypassing

Question 12

What are the indications for an indwelling catheter?

Answer 12

Chronic retention 
Skin wounds 
Contamination with urine 
Distress and disruption caused by incontinence 
Unable to perform self-catheterisation

Question 13

Why are anticholinergics a last resort in urinary incontinence?

Answer 13

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.

Question 14

What drug classes are used in urinary incontinence?

Answer 14

Anticholinergics
Beta 3 adrenergic agonists
Alpha 1 receptors antagonists

Question 15

Name some antimuscarinic drugs used in urinary incontinence, describe what exactly they improve and their common side effects

Answer 15

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

Question 16

Which beta 3 adrenergic agonist is used in urinary incontinence, when is it used and what are the side effects?

Answer 16

Mirabegon

Used if antimuscarinics are contraindicated or clinically ineffective

Tachycardia
CI in severe hypertension
Caution if renal/hepatic impairment

Question 17

Name the 3 alpha 1 receptor antagonists used in urinary incontinence, when are they used and what are each of their respective side effects?

Answer 17

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

Question 18

Is faecal incontinence ever normal?

Answer 18

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.

Question 19

What can influence faecal incontinence as we age?

Answer 19

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.

Question 20

What direct causes are there for faecal incontinence

Answer 20

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.

Question 21

What investigations should be done on someone with faecal incontinence?

Answer 21

• 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.

Question 22

What social and psychological factors should be considered for faecal incontinence?

Answer 22

Diet – optimised depending on stool consistency
Access – to toilet and easily removable clothing
Continence products
Psychological and emotional support

Question 23

What general management advice should be offered for faecal incontinence?

Answer 23

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

Question 24

How should loose stool incontinence be managed?

Answer 24

Regular antidiarrheal, loperamide (augments anal sphincter and reduced motility and secretions, codeine if Loperamide not tolerated)

Question 25

How is constipation/overflow incontinence managed?

Answer 25

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

Question 26

How should faecal incontinence related to cognitive/behavioural dysfunction be managed?

Answer 26

Regular toileting

Good diet

Question 27

How should faecal incontinence related to sphincter dysfunction be managed?

Answer 27

Pelvic floor exercises

TCA – amitriptyline

Question 28

How should faecal incontinence related to spinal cord or neurogenic bladder be managed?

Answer 28

Routine even if this mean manual evacuation or digital anorectal stimulation
Sacral nerve stimulation

Question 29

Name some anti-motility diarrhoea medication, give its mechanism and side effects/CI.

Answer 29

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

Question 30

What is mebeverine used for?

Answer 30

Reduced colonic hypermobility relieving spasm. Useful when combined with bulk forming agents

Question 31

Name a bulk type constipation medication, describe its mechanism and some side effects/CI

Answer 31

Fybogel
Insoluble and non-absorbable substances which distend the gut and draw water in

Flatulence

Contraindications – adhesions/ulceration

Question 32

Describe the mechanism of enemas

Answer 32

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

Question 33

Name the osmotic type constipation medications, describe its mechanism and some CI

Answer 33

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

Question 34

Name the irritant/stimulant type constipation medications, describe its mechanism and side effect/CI

Answer 34

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

Question 35

How is overactive bladder managed in men?

Answer 35

Conservative measures including moderating fluids
Bladder retraining
Antimuscarinics such as oxybutynin, tolterodine and darifenacin
Mirabegron if first line drugs fail

Question 36

What management and advice can be given regarding nocturia for men?

Answer 36

Moderate fluid intake at nigh
Furosemide 40mgin later afternoon
Desmopressin