incontinence Flashcards
why is incontinence important
common stigamatising disabling treatable often not treated well often becomes permanent if untreated
prevalence of urinary incontinence
3x more common in women prevalence in those living in institutions: - residential care - 25% - nursing home care - 40% - hospital care - 50-70%
causes of incontinence
extrinsic to the urinary system - environment, habit, physical fitness etc
intrinsic to the urinary system - problem w/ bladder or urinary outlet
often a bit of both
extrinsic causes of incontinence
physical state
co-morbidities: resp illness (SOB and limited mobility)
confusion: delirium/dementia (challenging to get to the bathroom)
drinking too much or at the wrong time - effort of getting up to drink, nocturnal incontinence if you are drinking lots before bed
medications e.g. diuretics
constipation
home and social circumstances
what does continence depend on
the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control
what are the 2 functions of the bladder
urine storage
voluntary voiding
types of muscle in the bladder
detrusor = smooth
internal urethral sphincter = smooth
external urethral sphincter = striated
how much urine can the bladder hold
400-600ml
storage function of the bladder
involves detrusor muscle relaxation w/ filling (<10CM pressure) to normal vol combined w/ sphincter contraction
voluntary voiding of the bladder
involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of the bladder
local innervation for continence and voiding
T10-L2 symp: beta adrenoreceptor, causes detrusor to relax
T10-S2 symp: alpha adrenoreceptor, causes contraction of neck of bladder and IUS
S2-4 parasymp: increases strength and frequency of contractions
S2-4 somatic: contraction of pelvic floor muscle (urogenital diaphragm) and EUS
CNS connections to bladder
centres within CNS inhibit parasymp tone - promote bladder relaxation and urine storage (normally this tone is constant unless unconscious/seizure etc)
sphincter closure is mediated by reflex increase in alpha adrenergic and somatic activity
intrinsic factors affecting incontinence
bladder
outlet
too weak/strong
what happens if the bladder outlet is too weak
stress incontinence
clinical features of stress incontinence
urine leak on movement, coughing, laughing, squatting etc
weak pelvic floor muscles
who gets stress incontinence
common in women w/ children, esp after menopause (loss of catabolic hormones which strengthen muscles)
treatment for stress incontinence
physiotherapy
oestrogen cream/pessary
duloxetine
surgical: TVT/colposuspension - 90% cure at 10yrs
start w/ non-pharmacological first and then work up
how does duloxetine work
SSRI
what are Kegel exercises
contraction and relaxation of pelvic floor muscles (3s each) for 10-15x, several times a day
helps strengthen pelvic floor muscles and improve incontinence
can use equipment alongside e.g. vaginal cones, biofeedback
what happens if the bladder outlet is too strong
urinary retention with overflow incontinence
features of urinary retention with overflow incontinence
poor urine flow
double voiding
hesitancy
post micturation dribbling
what can cause urinary retention with overflow incontinence and who gets it
blockage to urethra
older men w/ BPH
sometimes women w/ urethral strictures
treatment for urinary retention with overflow incontinence
alpha blocker (relaxes sphincter e.g. tamsulosin)
anti-androgen (shrinks prostate e.g. finasteride)
surgery (TURP)
may need catheterisation (suprapubic)
what happens if the bladder muscle is too strong
urge incontinence
features of urge incontinence
detrusor contracts at low volumes
sudden urge to pass urine immediately
patients often know every public toilet
what can cause urge incontinence
bladder stones
stroke
what can cause urge incontinence
bladder stones
stroke
treatment for urge incontinence
anti-muscarinic (relax detrusor) e.g. ocybutinin, tolterodine, solifenacin
bladder re-training sometimes helpful
side effects of anti-muscarinics
blurred vision
confusion
dry mouth - can worsen incontinence by drinking more
stop gastric and colonic peristalsis - constipation
postural instability and orthostatic hypotension
4 main drugs used for incontinence
anti-muscarinics - relax detrusor
beta-3 adrenoreceptor agonists (relax detrusor)
alpha blockers (relax sphincter, bladder neck)
anti-androgen drugs (shrink prostate)
examples of anti-muscarinics
oxybutinin
tolterodine
solifenacin
tropsium
examples of beta-3 adrenoreceptor agonists
miraBEgron
examples of alpha blockers
tamsulosin
terazosin
indoramin
examples of anti-androgen drugs
finasteride
dutasteride
what happens if you have an underactive bladder
neuropathic bladder
features of neuropathic bladder
‘rare’
2y to neurological disease, typically MS/stroke
also 2y to prolonged catheterisation
no awareness of bladder filling resulting in overflow incontinence
treatments for neuropathic bladder
medical treatments unsatisfactory
parasympathomimetics might help (pro-cholinergic)
- lots of side effects and quite toxic; reserved for younger pts in ITU rather than elderly
catheterisation is only effective treatment
scheme for assessing incontinence
hx - may need closed Qs
SHx - impact of incontinence, any extrinsic factors
intake chart and UO
general examination - rectal and vaginal
urinalysis and MSSU
bladder scan for residual vol
consider referral to incontinence clinic for further investigation in difficult cases
suggest lifestyle/behavioural changes and stopping unnecessary drugs
consider physio, medical treatment or surgical options
indications for referral to specialists for urinary incontinence
referral after failure of initial management
- max 3mths of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
when to refer to a specialist straight away for urinary incontinence
vesico-vaginal fistula
palpable bladder after micturition or confirmed large residual volume of urine after micturation
CNS disease
certain gynae conditions - fibroids, procidentia, rectocele, cystocele
severe BPH or prostatic carcinoma
pts who have had prev surgery for continence problems
others in whom a dagnosis hasn’t been made
indications for referral to specialist - faecal incontinence
after failure of initial management - constipation/diarrhoea with normal sphincter
referral necessary at onset: suspected sphincter damage, neurological disease
options for incontinence when everything else has failed
incontinence pads urosheaths intermittent catheterisation long term urinary catheter suprapubic catheter
