Continence

Question 1

Define detrusor overactivity?

Answer 1

When the bladder contracts spontaneously during filling as the patient attempts to prevent micturition

Question 2

Define urge incontinence?

Answer 2

involutary leakage of urine accompanied/preceded by urgency

Question 3

Define nocturia?

Answer 3

The need to ppass urine during the night – awakens one from sleep

Question 4

Define overactive bladder

Answer 4

Syndrome including urgency +- urge incontinence

• Usually accompanied by urinary frequency (voiding 8 times or more in 24hours) and nocturia

Question 5

Define urinary frequency?

Answer 5

voiding 8times or more in 24hrs

Question 6

Define nocturnal polyuria?

Answer 6

Passing of >1/3 of your urine volume during the night

Question 7

Define stress incontinence?

Answer 7

Involuntary leakage of urine due to failure of bladder outlet to remain closed when intra-abdo pressure rises
can happen during physical exertion, when laughing, coughing, or, in severe cases, simply transferring from bed to chair

Question 8

Outline the process of micturition (voiding)

Answer 8

Voluntary relaxation of the striated muscle around the urethra; this reduces urethral pressure

this is followed by a corresponding increase in bladder pressure as a consequence of detrusor contraction (Pelvic nerve - ACh - M3 muscarinic receptors)

Question 9

Outline the bladder filling stage of micturition?

Answer 9

Sympathetic nerves arise from T11 to L2 and innervate the smooth muscle of the bladder neck and proximal urethra causing contraction

Excitation of the pudendal nerve causes contraction of the external urethral sphincter

Question 10

What is the Bladder Control Self Assessment Questionnaire (B-SAQ)used for?

Answer 10

Bladder Control Self Assessment Questionnaire (B-SAQ) – used to identify LUTS.

Question 11

Examination in someone with Incontinence?

Answer 11

• AMT
• Cardio (CCF), resp (chronic lung disease)
• Abdo
o Palpate for masses or enlarged kidneys.
o Palpate and percuss for a distended bladder.
o Digital Rectal Examination (DRE) should be performed in all patients to assess anal tone, presence of constipation or rectal mass and to assess prostate size in males.
• Vaginal (atrophy/prolapse, pelvic floor muscle (Oxofrd classification))
• Neuro (dorsiflexion of the toes (S3) and perineal sensation (L1-L2), sensation of the sole (S1) and posterior aspect of the thigh (S3))

Question 12

Neuro exam features when assessing incontinence?

Answer 12

dorsiflexion of the toes (S3) and perineal sensation (L1-L2), sensation of the sole (S1) and posterior aspect of the thigh (S3)

Question 13

Investigations for incontinence?

Answer 13

Simple: Frequency/volume charts (over 3d peiod), urinalysis, bloods (FBC (infection), U+Es, Glucose, calcium (rule out hypercalcaemia which can cause constipation and confusion)
imaging: 1st line: post-void bladder scan

Question 14

Describe imaging that can be used for imcontinence

Answer 14

Imaging:
1st line: post-void bladder scan – rule out chronic urine retention
 USS abdo - if renal failure to evaluate kidney size and look for signs of obstructive uropathy
 CT urography (if ?renal stones)
 CT abdo (exclude abdominal or pelvic masses)

Question 15

Imaging of choice for renal failure?

Answer 15

 USS abdo - if renal failure to evaluate kidney size and look for signs of obstructive uropathy

Question 16

Imaging of choice for ?renal stones?

Answer 16

CT urography

Question 17

Use of uroflowmetry?

Answer 17

help with determining a provisional diagnosis especially if bladder outlet obstruction

Question 18

Uroflowmetry in person with ooveractove bladder?

Answer 18

 Decreased time to maximum flow is suggestive of overactive bladder – also get smaller volumes voided

Question 19

Reversible causes of incontinence

Answer 19

Delirium
Infection (UTI)
Atrophy (vaginal)
Pharmacological
Psychiatric (inc. depression)
Excess urine output (DM, excess fluid intake)
Restricted mobility
Stool impaction 

DIAPPERS

Question 20

Stress incontinence RFs?

Answer 20

• Women more likely to develop SUI – weaker bladder outlet (shorter urethra and lack of prostate), childbirth (increased risk if forceps delivery), obesity
surgery - TURP
• Age, neuro disease, UTI, post-menopausal, post-hysterectomy, bladder outlet obstruction

Question 21

Causes of overactive bladder?

Answer 21

• Idiopathic – most common
• Neurogenic – associated with neurological conditions e.g. multiple sclerosis, parkinsonism, stroke or spinal cord injury
• Infective – urinary tract infection
• Bladder outlet obstruction

Question 22

Causes of bladder outlet obstruction?

Answer 22

Phimosis, Stricture (male preponderance)
Sexually transmitted diseases (particularly in women)
Trauma, Blood clot, Calculi
Benign prostate hypertrophy (BPH), Cancer of prostate or bladder, Carcinoma of cervix or colon

Question 23

Pharmacological causes of UI?

Answer 23

• Cholinesterase inhibitors
• Antipsychotics
• CCB
• ACEi
• Diuretics
• alpha blockers
• hypnotics (eg. Lorazepam)
• Opioids

Question 24

Mechanism of cholinesterase inhibitor –> UI?

Answer 24

Increases bladder contraction (increased ACh acting on M3 receptors)

Question 25

Antipsychotics mechanism of UI?

Answer 25

anticholinergic leading to retention

Question 26

CCB mechanism of UI?

Answer 26

decreases smooth muscle contractility

Question 27

alpha blockers mecahnism of UI?

Answer 27

alpha 1 receptors on the internal uretheral sphincter. therfore alpha blockers relax bladder outlet which may worsen SUI

Question 28

Red flag symptoms in UI?

Answer 28

haematuria, pain on micturition, prolapse beyond the introitus, ?prostate ca.

Question 29

Mx of SUI?

Answer 29

MDT: Community continence advisor (assess patients in their own home and give advice and equipment) and physiotherapists (pelvic floor excercises)
pudendal nere stimulation
vaginal cones

patient education: Smoking cessation, Weight reduction, Managing constipation, Reducing alcohol and caffeine

Medical: Duloxetine (SNRI) – no longer recommended by NICE

Surgical: Mid-urethral sling insertion , colposuspension, injection of bulking agents

Question 30

Use of mid-uretheral slling?

Answer 30

(tension free vaginal tape, or TVT for short) provides support under the urethra

Question 31

Use of colposuspension?

Answer 31

useful if a patient has an associated cystocele

Question 32

Use of bulking agents in SUI?

Answer 32

if patient not suitable for TVT or major surgery

Question 33

Causes of weak pelvic floor?

Answer 33

Childbirth, Obesity, Chronic cough, Post pelvic surgery, Post-menopausal

Question 34

OAB non-surgical/non-pharma Mx?

Answer 34

All patients should have a trial of non-surgical/non-pharmacological options for at least 6 weeks in the first instance.

• Patient education: Reduce fluid intake, especially in the evening (advise no drinks after 8pm), Reduce caffeine and alcohol intake, Weight reduction, Manage constipation
• MDT: Community continence advisor, Behavioural therapy (bladder retraining – increase the interval between first desire to void and actual voiding (1st line with pelvic floor exercises for a min. of 6wks)

Question 35

OAB pharma and surgical Mx?

Answer 35

Antimuscarinic drugs – eg. oxybutynin, tolteridone, darifenacin, trospium, solifenacin and propiverine
 Oxybutynin, tolteridone and darifenacin are 1st line
 SEs: Brain (cognitive impairment, hallucinations), Eyes (blurred vision), Salivary glands (Dry mouth), Tachycardia, Nausea, constipation, Urinary retention

o Intravaginal oestrogen (if vaginal atrophy)
o Botulinum toxin injected into the detrusor muscle via cystoscopy
o Mirabegnon – if antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects.

Surgical: Sacral nerve stimulation, Augmentation cystoplasty

Question 36

Types of catheter and uses?

Answer 36

Low-friction intermittent catheter – least-likely to result in recurrent infection.

Silastic urethral catheter - biodegrade more slowly and therefore can remain in situ longer than latex ones

Suprapubic catheter – associated with a lower incidence of infection than urethral ones

Urethral catheter with flip-flow valve – Increases likelihood of successful restoration of continence following trial without catheter compared to catheter with bags
• A flip-flow valve is placed on the end of a urethral catheter in place of a catheter. It allows the bladder to fill and empty in a cycle, rather than urine draining directly into a bag

Question 37

PPx of faecal incontinence in older people? Most common causes?

Answer 37

rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chronic constipation

faecal impaction with overflow diarrhoea.
• 2nd most common – neurogenic dysfunction

Question 38

Presentation of Impaction with overflow incontinence?

Answer 38

• smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation

Question 39

Consitpation fatal complications?

Answer 39

stercoral perforation and ischaemic bowel in those chronically constipated.

Question 40

Chronic diarrhoea Tx?

Answer 40

• Exclude underlying causes with bowel imaging, stool culture, medication review
• Advise regular toileting and dietary review
• Low dose loperamide - constipating and enema regiemes can be used if this does not work.