Continence ☺️

Question 1

How would you take a continence history

Answer 1

Acute/chronic?
Duration?
Urinary/fecal
Characteristics?
Continence/food/fluid diary
-potential diuretics
Exacerbating/relieving factors

PMH, PSH
-chronic cough?
-abdo/GU surgery
Obs/gynae 
DHx
Risk factors
-obesity, smoking

Question 2

How would you screen for continence

Answer 2

Urgency
Regular trips
Incontinence/UTIs/urinary catheters
Nocturia
Exercise, sneeze, cough

Drugs/dementia
Rectal exam
Image bladder (after peeing, amount of retention)
PV
Send urine sample (NOT A DIPSTICK) if they have urinary symptoms

Question 3

Stress urinary incontinence

• what is it?
• what are the risk factors
• how would you manage this

Answer 3

Leaking without significant urgency
Weakness pelvic muscles, sphincters
-abdominal pressure is greater than sphincter and pelvic pressure

Obese
Vaginal delivery/prostate/pelvic surgery
Post menopause => generalised atrophy
ACEi => chronic cough

BE REALISTIC!
Treat causes and optimise lifestyle factors
-better cough management?
-weight loss?
Fluid management
-timing of diuretics/meds, fluids taken?
Pelvic floor exercises, bladder training
Surgery/pessaries

Question 4

Urge urinary incontinence

• what is it?
• what are the risk factors
• how would you manage this

Answer 4

Sudden urge to pee due to detrusor instability

Alcohol/food
Constipation => stool compresses bladder, reduce volume
Age
Structural - stones, cancer, infection
Neurological (SC or cortical issues) - PD, MS

BE REALISTIC
Treat causes and optimise lifestyle factors
-functional review, stop oxybutinin
-address constipation
Bladder training
Double voiding => empty bladder further 

Be careful with anticholinergics (solifenacin), B3 agonists (mirabegron) unless they have neuro issues
-increase risk of falls
Botox, nerve surgery => can make problem worse

Question 5

What are some common anticholinergics

What are the SEs

Answer 5

Oxybutinin
Tolterodine
Solifencacin
Donepezil

Falls
Cognitive impairment
Dry mouth
Constipation

Question 6

What are some common B3 agonists

What are the SEs?

Answer 6

Mirabegron

HTN

Question 7

How can severe cognitive impairment affect continence

Answer 7

Loss of voluntary control over excretion => reflex mediated

• dementia
• trauma, stroke, neuro disability

BE REALISTIC
Modify any reversible causes
Toileting regime if possible => bowel management
Support with continence products, skin/pressure care

Question 8

How could you assess and manage urinary incontinence?

Answer 8

Any prolapse?
Any retention, overflow incontinence?
Estrogen cream to soothe dryness from atrophy
Stopping Ach medications

Question 9

How could you asses and manage fecal incontinence

Answer 9

Any impaction with PR or AXR
Bulking agents (ispaghula)
Assess for medical causes
-CCB, Ca, Fe

Question 10

How might you manage incontinence in people who have lost capcity

Answer 10

Close bowel monitoring
Regular toileting regime and prompting
Skin and pressure care

Question 11

Why is constipation common in PD

• why is constipation a huge issue
• what can cause this
• how would you manage this?

Answer 11

Lewy body formation in gut

Cause of significant morbidity, mortality
Impacts on wellbeing and urinary continence

Ageing with reduced gut activity and poor mobility
Drugs, neurological conditions

Lifestyle, dietary factors
Laxatives, suppositories or enemas, manual evacuation
-prucalopride

Question 12

What drugs cause constipation

Answer 12

Opioids

Fe, Ca, Al

Bb, CCB, anticholinergics, antipsychotics

Question 13

Why are the pros and cons of a urinary catheter?

When would you use one

Answer 13

Monitor fluid output
Relieve urinary retention

Source of trauma, pain and infection

• Severe critical illness where active monitoring will change management (sepsis)
• Painful urinary retention, obstruction
• Severe skin damage/pressure sores with incontinence and immobility
• patient preference

Question 14

Who would need long term catheters

-how would you monitor this

Answer 14

BPH
-failed TWOC many times/unsuitable for prostate surgery

Neuro => stroke, PD, MS

Anatomical => local cancer, significant surgery

Plan around catheter care to stop infection/blockage
Change every 8-12wks
Review need

Question 15

Describe the nervous control of micturition in males

• PNS
• SNS
• Somatic

Answer 15

PNS => spinal sacral nerve => pelvic nerve => M3 Ach receptors on detrusor

SNS => paraaortic ganglia => hypogastric nerve

• B3 relaxes detrusor
• A1 constricts internal spincter

Somatic pudendal nerve
-N Ach constricts external sphincter