Continence (Faecal/urinary) Flashcards
Describe the urinary flow rate in men and women?
- Men
- 20-25ml/s
- Women
- 25-30ml/s
Describe the capacity of the bladder?
- 300-550ml
- The bladder signals for the person . to micturate at around 400ml
Describe the regulation of micturition?
- Parasympathetic stimulation from pelvic nerve (S2-4) causes detrusor muscle to contract which increases the intra-vesicular pressure
- Pontine micturition centre inhibit Onuf’s nucleus which reduces sympathetic stimulation
- Conscious relaxation of the external urethral sphincter allows urine to pass
Describe the differences in the end part of micturition between men and women?
- Female
- Assisted by gravity
- Men
- Bulbospongiosus contractions expel the urine
What is urinary incontinence?
- Any involuntary leakage of urine
- More common in women
Risk factors for urinary incontinence?
- Childbirth, hysterectomy
- Obesity, recurrent UTI
- Smoking, caffeine
Describe the pathophysiology of urinary incontinence?
- As urine accumulates the bladder, the sphincter tone gradually increases
- But there is no changes in vesical pressure, detrusor pressure or intra-abdominal pressure
- Normally during micturition, the intravesicular pressure increases as a result of detrusor contraction and the sphincter relaxes, allowing urine to flow
Describe Stress incontinence?
- Passive bladder pressure exceeds the urethral pressure
- Due to poor pelvis floor support or a weak urethral sphincter
- Incontinence during coughing, sneezing and exertion
- Women, esp after childbirth, and sometimes men after prostate surgery
Describe Urge incontinence?
- Due to detrusor over activity
- Increased bladder pressure which overcomes the urethral sphincter
- May also be driven by hypersensivite bladder from UTI or bladder stone
Causes of Urge incontinence / detrusor overactivity?
- Idiopathic
- Neurological conditions
- Spina bifida
- Multiple sclerosis
Describe continual urinary incontinence?
- Suggestive of fistula between bladder and vagina (vesicovaginal)
- Can occur with:
- Gynaecological surgery or malignancy
- Post-radiotherapy
- Prolonged obstructed labour
Describe Overflow incontinence?
- Occurs when the bladder becomes chronically overdistended
- Can lead to AKI (high-pressure chronic urinary retention)
Causes of overflow incontinence?
- Bladder neck obstruction
- Bengin prostatic enlargement
- Failure of detrusor muscle (atonic bladder)
- Damage of pelvic nerves
Describe Functional incontinence?
When they know they need to go to the toilet but can’t get there in time
Describe passive urinary incontinence?
- Physically they could control the bladder
- But cognition impairs their ability to do so
- Micturition is learned behaviour
Management for functional and passive urinary incontinence?
- Physiotherapy / occupational therapy
- Timed holding of urine
- Pads
Describe post-micturition dribble?
- Due to a small . amount of urine being trapped in the U-bend of the bulbar urethra
- It then leaks out when the patient moves
- More pronounced if urethral diverticulum or stricture
- Can occur in women with a urethral diverticulum
What can a post-micturition dribble mimic in women?
Stress incontinence
Name some of the clinical features of urinary incontinence?
- Encouraged to keep a voiding diary
- Volume, frequency, associated features
- Neurological assessment
- Rectal examination
- Assess prostate and for faecal impaction
- Geniital examination
- Men: phimosis, paraphimosis
- Women: vaginal mucosal atrophy, cystoceles
Describe some investigations into urinary incontinence?
- Urinalysis and culture
- Ultrasound abdomen
- May show retained urine with overflow incontinence (>100mL post micturition)
- CT scan and cystoscopy
- Patients with continual incontinence who are suspected of having a fistula
Describe the management of stress urinary incontience?
Physiotherapy
Describe the management of urge urinary incontience?
- Bladder retraining
- Teaching patients to hold more urine voluntarility in the bladder
- Assisted with anticholinergic medication
Describe the management of urinary incontience secondary to fistula formation?
Surgery
Describe the management of overflow urinary incontience due to bladder obstruction?
- Surgically OR
- Long term catheterisation (intermittet/continuous)
Describe the management of urinary incontience due to neurological diseases?
Intermittent self catheterisation .
How does urinary incontience usually come to attention in the elderly?
When it causes a social or hygiene problem
Describe the assessment and management of urinary incontinence in old age?
Describe normal faecal continence?
- Depends on:
- Maintenance of anorectal angle
- Tonic contraction of the external anal sphincters
- On defacation, there is relaxation of the anorectal muscles, increased intra-abdominal pressure from the Valsalva manoeuvre, contraction of abdominal muscles and relaxation of the anal sphincters
Name some causes of faecal incontinence?
- Childbirth, hysterectomy
- Diarrhoea/constipation
- Faecal impaction
- Haemorrhoids, rectal prolapse, Crohns disease
- Cauda equina, dementia
High risk patients for faecal incontinence?
- Frail older people
- Women after childbirth
- Thoses with severe cognitive impairment
Investigations for faecal incontinence?
- History & examination
- Assess stools using Bristol stool chart
- Endoanal ultrasound
- Defines integrity of the anal sphincters
- MR proctography
Describe the management of faecal incontinence?
- Diarrhoea
- Loperamide, codeine phosphate
- Proper diet and fluid intake
- Pelvis floor exercises
- Bowel retraining techniques
- Surgery for sphincter defects
Describe the surgical approach to anal sphincter repairs?
- Sacral nerve stimulation
- View to insert permanent stimulator
- If unsuccessful:
- Insert artificial anal sphincter
