Incontinence Flashcards
What is the function of the bladder and urethra?
- Function – urine storage (holds 500ml, at 250ml start to feel it then at 400ml becomes urgent) and voluntary voiding (involves relation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder)
What is the capacity of the bladder?
(holds 500ml, at 250ml start to feel it then at 400ml becomes urgent)
What muscles are involved in micturition and what innervation are they under?
- Anatomy – detrusor and internal urethral sphincter is smooth muscle under control of parasympathetic nervous system, external urethral sphincter is striated muscle (only bit we have control over)
Describe the innervation of the urinary tract and the action of each?
- S2-S4, parasympathetic
- Increases strength and frequency of contraction
- T10-L2, sympathetic
- B adrenoreceptor causes detrusor to relax
- T10-S2, sympathetic
- A adrenoreceptor causes contraction of neck of bladder and internal urethral sphincter
- S2-S4, somatic
- Contraction of pelvic floor muscle (urogenital diaphragm) and external sphincter
Describe the aetiology of incontinence?
- Extrinsic to urinary system
- Physical state and co-morbidities, reduced mobility, confusion, drinking too much at wrong time, medications, constipation, home and social circumstances
- Intrinsic to urinary system
- Problem with bladder or urinary output, occurs due to being too strong or weak
Describe the epidemiology of incontinence (common/rare, age, gender)?
- Common
- Prevalence increases with age
- 3x more common in woman
What is the general management of urinary incontinence?
- Identify and treat cause
What are possible complications of incontinence?
- Becomes permanent if not treated early
- Social aspects such as limiting activates
- Mental health – embarrassment
What are the different kinds of urinary incontinence?
- Stress incontinence
- Urinary retention with overflow incontinence
- Urge incontinence
- Neuropathic bladder
What is teh aetiology of stress incontinence?
- Bladder outlet too weak
- Weak pelvic floor muscles
Describe the epidemiology of stress incontinence (gender)?
- Common in woman with children, especially after menopause
What are clinical features of stress incontinence?
- Physiotherapy – 1st line
- Pelvic floor exercises
- Vaginal cone
- Medical – 2nd line
- Oestrogen cream
- Duloxetine
- Surgical – 3rd line
- TVT/colposuspension
What is the aetiology of urinary retention with overflow incontinence?
- Bladder outlet “too strong”
- Blockage to urethra
Describe the epidemiology of urinary retention with overflow incontinence (gender, age)?
- M>F (only incontinence where this is the case)
- Common in older men
What are the risk factors for urinary retention with overflow incontinence?
- Older men with BPH
What are the clinical features of urinary retention with overflow incontinence?
- Poor urine flow, double voiding, hesitancy, post micturition dribbling
Describe the management for urinary retention with overflow incontinence?
- Medical
- Alpha blocker
- Drugs – tamsulosin
- Effect - Relaxes sphincter
- Or anti-androgen
- Drug - finasteride
- Effect – shrinks prostate
- Alpha blocker
- Surgical
- TURP
What are the effects of alpha-blockers on the urinary tract?
- Drugs – tamsulosin
- Effect - Relaxes sphincter
What are the effects of anti-androgen?
- Drug - finasteride
- Effect – shrinks prostate
What is the aetiology of urge incontinence?
- Bladder muscle too strong
- Neurological problems
- Bladder stones
Describe the pathophysiolofy of urge incontinence?
- Detrusor contracts at low volumes
What are the clinical features of urge incontinence?
- Sudden urge to pass urine immediately
Describe the management for urge incontinence?
- Medical
- Anti-muscarinic
- Drugs – oxybutynin, tolterodine, solifenacin
- Effect – relax detrusor
- Anti-muscarinic
- Non-pharmacological
- Bladder re-training (sit on toilet once every hour/2 hours to desensitise bladder)
What are the effects of anti-muscurinics?
- Drugs – oxybutynin, tolterodine, solifenacin
- Effect – relax detrusor
What is the aetiology for neuropathic bladder?
- Secondary to neurological disease, typically MS or stroke
- Also secondary to prolonged cathetarisation
Describe the epidemiology of neuropathic bladder (common/rare)?
Rare
What are clinical features of neuropathic bladder?
- No awareness of bladder filling resulting in overflow incontinence
Describe the management of neuropathic bladder?
- Medical treatments
- Unsatisfactory but parasympathomimetics might help – such as acetylcholine, however are very toxic
- Catheterisation only effective treatment
What are the main drugs used in the management of incontinence?
- Antimuscarinincs
- Drugs – oxybutynin, tolterodine, solifenacine, trospium
- Effect – relax detrusor
- Beta-3 adrenoceptor agonists
- Drugs – mirabegron
- Effect – relax detrusor
- Alpha-blockers
- Drugs – tamsulosin, terazosin, indoramin
- Effect – relax sphincter and bladder neck
- Anti-androgens
- Drugs – finasteride, dutasteride
- Effect – shrink prostate
What is involved in assessing incontinence?
- History
- Good social history for extrinsic factors
- Examination
- General, rectal and vaginal
- Investigations
- Intake chart and urine output diaries
- Urinalysis and MSSU
- Bladder scan for residual volume
What are indications for specialist referal for urinary incontinence?
- Failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining or medication)
- Or straight away for some reasons
- Vesico-vaginal fistula
- Palpable bladder after micturition
- Disease of CNS
- Gynaecological conditions
- Fibroids, procidentia, rectocele, cystocele
- Severe BPH or prostatic carcinoma
- Previous surgery for incontinence
What are indications for referral of faecal incontinence?
- Failure of initial management
- At onset
- Suspected sphincter damage
- Neurological disease
What are management options for incontinence if all else fails?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
