Incontinence

Question 1

what is the prevalence of urinary incontinence?

Answer 1

• 3x more common in women
• residential care: 25%
• nursing home care: 40%
• hospital care: 50-70%

Question 2

what are some extrinsic factors which can cause incontinence?

Answer 2

• physical state and co-morbidities
• reduced mobility
• confusion (delirium or dementia)
• drinking too much or at the wrong time
• medications, e.g. diuretics
• constipation
• home circumstances
• social circumstances

Question 3

describe the local innervation of the bladder and how it relates to its function

Answer 3

• (T10-L2), sympathetic: B-adrenoceptor causes detrusor muscle to relax.
• (T10-S2), sympathetic: a-adrenoceptor causes contraction of neck of bladders, and internal urethral sphincter
• (S2-4), parasympathetic: increases strength and frequency of contractions
• (S2-4), somatic: contraction of pelvic floor muscles (urogenital diaphragm) and external urethral sphincter.

Question 4

describe the CNS connections involved with maintaining urinary continence

Answer 4

• centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.
• sphinvcter closure is mediated by reflex increase in alpha-adrenergic and somatic activity.
• the pontine micturition centre normally exerts a ‘storage program’ of neural connections until a voluntary switch to a voiding program occurs.
• other areas involved: frontal cortex, caudal part of spinal cord.

Question 5

what are some intrinsic factors that can cause incontinence?

-

Answer 5

• bladder outlet too weak, weak pelvic floor muscles > stress incontinence
• bladder outlet ‘too strong’ > urinary retention with overflow incontinence, caused bt blockage to urethra usually older men with BPH
• bladder muscle ‘too strong’ > urge incontinence, can be caused by bladder stones or stroke
• underactive bladder > neuropathic bladder, secondary to neurological disease, typically MS or stoke, also secondary to prolonged catheter

Question 6

stress incontinence characteristic features

Answer 6

• urine leak on movement, coughing, laughing, squatting etc.
• weak pelvic floor muscles
• common in women with children, especially after menopause

Question 7

stress incontinence treatment

Answer 7

• physio (kegel exercises), oestrogen cream and duloxetine
• surgical: TVT/colposuspension 90% cure at 10 years

Question 8

urinary retention with overflow incontinence characteristics and treatment

Answer 8

• poor urine flow, double voiding, hesitancy, post-micturition dribblin
• blockage to urethra
• older men with BPH
• treat with alpha-blocker (relaxes sphincter e.g. tamsulosin) or anti-androgen (shrinks prostate e.g. finasteride) or surgery (TURP)
• may need catheterisation, often suprapubic

Question 9

urge incontinence characteristic features and treatment

Answer 9

• detrusor contracts at low volumes
• sudden urge to pass urine immediately
• patients often know every public toilet
• can be caused by bladder stones or stroke
• treat with anti-muscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin
• bladder re-training sometimes helpful

Question 10

list the main drugs used to treat incontinence?

Answer 10

• antimuscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin, trospium
• beta-3 adrenoceptor agonists (relax detrusor) e.g. mirabegron
• alpha-blockers (relax sphincter, bladder neck) e.g. tamsulosin, terazosin, indoramin
• anti-androgen drugs (shrink prostate) e.g. finasteride, dutasteride

Question 11

indications for referral to specialists regarding urinary incontinence

Answer 11

• referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)

Question 12

indications for immediate referral to specialist regarding urinary incontinence

Answer 12

• vesico-vaginal fistula
• palpable bladder after micturition or confirmed large residual volume of urine after micturition
• disease of the CNS
• certain gynae conditions e.g. fibroids, procidentia, rectocele, cystocele
• severe BPH or prostatic carcinoma
• patients who have had previous surgery for continence problems
• others in whom a diagnosis has not been made

Question 13

indications for referral to specialists in the case of faecal incontinence

Answer 13

• referral after failure of initial management e.g. constipation or diarrhoea with normal sphincter
• immediate referral if suspected sphincter damage or neurological disease

Question 14

if all else fails, what management options are available for incontinence?

Answer 14

• incontinence pads
• urosheaths
• intermittent catheterisation
• long-term urinary catheter
• suprapubic catheter