Incontinence

Question 1

Outline the neurologic control of micturition:

Answer 1

[See pic below]

SNS (T10-L2 via hypogastric nerve): bladder relaxation and internal sphincter contraction.

PNS (S2-4 via pelvic nerve): bladder contraction and internal sphincter relaxation.

The somatic (voluntary) system (via pudendal nerve): control of the external sphincter.

All three of these systems are part of reflex pathways and are under the influence of upper neurologic control (cerebrum and pons micturition center in the cerebellum).

Question 2

Common causes of TRANSIENT incontinence (potentially modifiable)

Answer 2

Mnemonic = DIAPPERS

D = Delirium

I = Infection, Irritants (eg. caffeine)

A = Atrophic vaginitis, Urethritis

P = Pharmaceuticals

P = Psychological

E = Excessive production

R = Restricted mobility

S = Stool impaction

Question 3

Stress incontinence: common causes

Answer 3

Muscle weakness

Post-TURP

Question 4

Urge incontinence: common causes?

Answer 4

Local (calculi, uterine prolapse)

Loss of frontal inhibitory centres

Question 5

Overflow incontience: common causes?

Answer 5

BPH and other outlet obstructions

Neuropathy (autonomic, sacral cord lesion)

Question 6

Assessent of incontinence (beyond Hx and examination)?

Answer 6

Bladder diary - times, volumes; include fluid intake where possible

UEC, calcium, glucose levels

MSU - infection, haematuria

Post-void residual volume

Urinary flow rate (easier to get than urodynamics - help distinguish obstructive from stress+urge)

Urodynamics

Question 7

Management of Urge Incontinence?

(also describe some of the SE of any pharmaceuticals used)

Answer 7

1. Badder retraining

(or timed tolieting in demented patients)

2. Pharmacotherapy:
   (a) oxybutinin -

** ASEs: dry mouth (MOST COMMON), urinary retention, constipation, confusion / delirium, hypotension.

(b) tolteridone -

** ASEs: dry mouth, constipation

(c) solifenacin -

** ASEs: dry mouth constipation

Question 8

Management of Stress Incontience?

Answer 8

1. Pelvic floor exercises
2. Oestrogen - creams, pessary
3. Surgery

Question 9

Management of Overflow Incontinence?

Answer 9

1. Surgery
2. IDC:
   (a) permanent
   (b) intermittent - eg. neurogenic bladders (more socially acceptable, less infections)
3. Alpha blockers (prazosin)

** ASEs: hypotension, drowsiness / delirium, dry mouth

Question 10

What is a normal post-void residual bladder volume?

Answer 10

Approx. 50mL or less

Question 11

Faecal incontinence: common causes?

Answer 11

• Overflow
• Neural damage (central / peripheral)
• Rectal capacity decreased (eg. scleroderma, etc)
• Liquid faeces (IBD, CRC, laxatives)
• Fistulas (eg. recto-vaginal)

Question 12

What are main rectal complaints in patients with scleroderma and what is the cause?

Answer 12

1. Faecal incontinence
   - diarrhoea
   - decreased rectal compliance
   - weakening of internal anal sphincter
   - rectal prolapse
2. Rectal prolapse
   - deposition of collagen in rectal wall –> weakens rectal submucosa

Question 13

what is the most common type of incontinence in the geriatric population?

Answer 13

apparently urge incontinence

Question 14

what is the treatment of cognitively normal 85 year old woman with leucs >100, rest <10

E. coli on growth?

Answer 14

despite demonstrating a specific infection this patient should still not be treated if completely asymptomatic.

it would become a lot less clear if her WCC was elevated