Incontinence 2 Flashcards
What are the normal values in uroflowmetry?
Total voided volume >200ml Flow time 15-20secs Qmax >20mls/sec- reduces with age Smooth parabolic curve Volume voided- >150ml need to be voided for accurate interpretation
What diseases can incontinence be a consequence of?
Chronic Lung Disease Diabetes Mellitus Congestive Heart Failure Stroke Parkinson’s disease Musculoskeletal disease Dementia Multiple sclerosis
What can incontinence lead to?
Pressure ulcers Falls Depression Impaired quality of life Admission to care homes Skin infection Isolation
What is the non-medical management for stress incontinence?
Pelvic floor exercises Patient Education: Smoking cessation Weight reduction Managing constipation Reducing alcohol & caffeine Pudendal nerve stimulation Vaginal cones- improve awareness of pelvic musculature
What is the medical management for stress incontinence?
Duloxetine (SNRI) has some limited evidence to improve stress incontinence, but no longer recommended by NICE- still used off licence
What is the surgical management for stress incontinence?
Minimally invasive day case procedures are most common- mid-urethral sling insertion (TVT) supports under the urethra
Colposuspension- more invasive operation, but useful in associated cystocele
Injecting bulking agents (silicone) into the urethra can also be performed although success rates are much lower
What is the non-medical management for an overactive bladder?
Bladder training (1st line therapy in combination with pelvic floor exercises for a min of 6 weeks) Prompted voiding- need to be mobile Timed voiding- fixed interval toileting Reduce fluid intake, especially in the evening Reduce caffeine and alcohol intake Weight reduction Manage constipation
What is the surgical management for an overactive bladder?
Sacral nerve stimulation
Augmentation cystoplasty- rarely used now
What is the medical management for an overactive bladder?
Anti-muscarinic- mainstay of treatment, act on M3 receptors on detrusor muscles to reduce contraction eg. Oxybutynin, Solifenacin, Tolteridone and Darifenacin SE – dry mouth, constipation, blurred vision, cognitive impairment, urinary retention
Beta-3-adrenoreceptor agonists (Mirabegron) used if contraindication or intolerable side effects to anti-muscarinic cause bladder relaxation, which helps to fill and also store urine CI in severe cardiovascular disease as causes hypertension
Intravaginal oestrogens- recommended for vaginal atrophy and symptoms of overactive bladder
Botulinum toxin- injected into detrusor muscles via cystoscopy, inhibits neurotransmitter release thereby decreasing contractility
What is the management for bladder outlet obstruction?
Surgical- referral to urology or urogynaecology- a transurethral prostatectomy (TURP) can be considered in cases of BPH
Medical (BPH)-
Alpha adrenoreceptor antagonists eg. Doxazocin- these drugs reduce the smooth muscle tone of the prostate
5 alpha reductase inhibitors eg. Finasteride-these drugs reduce prostate volume by blocking the conversion of testosterone to dihydrotestosterone
Which medications can cause the different types of urinary incontinence?
Alcohol- polyuria, frequency, delirium
ACE inhibitor- cough and stress incontinence
Anticholinergic- urinary retention and overflow
Diuretic- polyuria, frequency, urgency
Opiate- delirium, sedation, constipation and urinary retention
TCA- urinary retentions and overflow
What are the causes of stress incontinence?
- Instrumentation during childbirth and/or pelvic floor damage
- Vaginal prolapse
- Post-prostatectomy in men
What is the management of stress incontinence?
- Lifestyle measures (smoking cessation, weight loss, reduced caffeine intake)
- Pelvic floor exercises
- Medication – duloxetine (SNRI)
- Surgery – mid-urethral sling insertion (tension free vaginal tape)
What are the causes of an overactive bladder?
- Idiopathic – most common
- Neurogenic – associated with neurological conditions, e.g. multiple sclerosis, Parkinsonism, stroke or spinal injury
- Infective – urinary tract infection
- Bladder outlet obstruction
What is the management for an overactive bladder?
- Lifestyle measures (weight loss, reduced caffeine intake, monitor timings of drinks and maintain regular bowel habit)
- Behavioural – bladder retraining
- Pelvic floor exercises
- Medications – anticholinergics (e.g. tolteridone); B3 adrenoreceptor agonists (e.g. mirabegron)
- Intravaginal oestrogens
- Intradetrusor botox injections
- Sacral nerve stimulation
What are the side effects of oxybitynin?
Anti-muscarinic
Common: confusion
Caution: pregnancy, breast feeding, hepatic/renal impairment
What are the side effects of tolterodine?
Anti-muscarinic
Common: Bronchitis, chest pain, fatigue, paraesthesia, peripheral oedema, sinusitis, vertigo, weight gain.
Caution: history in QT interval prolongation
What are the side effects go darifenacin?
Anti-muscarinic
Uncommon: cough, dyspnoea, hypertension, impotence, insomnia, oedema, rhinitis, ulcerative stomatitis, vaginitis, weakness
What are the side effects of solifenacin?
Anti-muscarinic
Uncommon: Gastro-oesophageal reflux, , oedema, dysphonia, hyperkalaemia, muscle weakness, reduced appetite, Torsade de pointes.
Caution: neurogenic bladder disorder, susceptibility of QT interval prolongation
What are the side effects of trospium?
Rare: Asthenia, chest pain, dyspnoea, arthralgia, myalgia
Caution: pregnancy, breast feeding, hepatic impairment, renal impairment
What are the side effects of fesoterodine?
Anti-muscarinic
Very common: insomnia
Uncommon: cough, nasal dryness, pharyngolaryngeal pain, vertigo
What are the side effects of mirabegron?
Beta-adrenoceptor agonist
Common: tachycardia, UTI
Uncommon: AF, dyspepsia, gastritis, hypertension, joint swelling, palpitations, pruritis, rash, vulvovaginal infection, vulvovaginal pruritis
Caution: susceptibility to QT intervak prolongation
Contra-indicated: severe hypertension
What are other key points for an incontinence history?
Use and number of incontiennce pads LUTS presence of neurologic disease History of pelvic surgery or radiotherapy Obstetric history Bowel and sexual function Medication history Impact on quality of life
What are pelvic floor muscle exercises?
Used for stress incontinence
Kegel exercises
Requires 2-5 sets of pelvic muscle contractions done several times each day
Feedback from client:
Vaginal palpation
Biofeedback devices (identify pelvic floor activation)
Vaginal cones
