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bHCE > Incontinence > Flashcards

Incontinence Flashcards

1
Q

What anatomy is involved in continence?

A

bladder

urethra

pelvic floor muscles

nervous system

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2
Q

What type of system is the bladder?

A

Low pressure - High volume

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3
Q

Roughly what is the rate of bladder filling?

A

0.5-5ml/min = 30-300ml/hr

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4
Q

What is the capacity of the bladder?

A

600ml

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5
Q

At what volume does one desire to void?

A

250ml

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6
Q

How is continence maintained (very basically)?

A

urethral pressure is higher than bladder pressure

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7
Q

What occurs to allow micturition?

A

Relaxation of striated muscle around urethra and

pelvic floor muscle

and contraction of detrusor

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8
Q

What causes detrusor muscle to contract?

A

Bladder fills

signals parasympathetically to cause the

detrusor (smooth muscle) to contract

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9
Q

Where is the internal urethral sphincter (IUS) found?

A

junction of the urethra with the bladder

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10
Q

What makes up the IUS?

A

The detrusor, therefore its made of smooth muscle

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11
Q

What controls the IUS?

A

Autonomic NS (involuntary)

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12
Q

What urethral sphincter is the 1ry muscle for continence?

A

IUS

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13
Q

Where is the external urethral sphincter (EUS) located in males?

A

Inferior to the prostate

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14
Q

Where is the external urethral sphincter (EUS) located in females?

A

At the distal inferior end of the urethra

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15
Q

What type of muscle is the EUS?

A

Skeletal muscle

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16
Q

What is the problem with the EUS?

A

It is under voluntary control (as it is skeletal muscle) thus can relax when sneezing or coughing

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17
Q

Which area of the brain provides voluntary control of continence?

A

the frontal lobe (probably why pts with dementia are commonly incontinent)

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18
Q

Which part of the brain controls detrusor contraction and urethral relaxation?

A

the pontine micturition centre

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19
Q

Which part of the NS is responsible for micturition?

A

parasympathetic NS (for the involuntary side)

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20
Q

Which nerve is responsible for continence and what are its roots?

A

pudendal nerve

S2, 3, 4 (keep shit off the floor)

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21
Q

Where do the the parasympathetic nerves that control continence emerge form the spine?

A

The sacral plexus

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22
Q

Which subset of parasympathetic muscarinic receptor are responsible for bladder contraction?

A

M3

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23
Q

What nerves is bladder filling controlled by?

A

Sympathetic NS

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24
Q

Where do the sympathetic nerves relating to the bladder emerge and what do they do?

A

T11 - L2

Bladder neck contraction and

proximal urethral contraction

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25
Q

What muscle does the pudendal nerve innervate?

A

contraction of the external urethral sphincter

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26
Q

What does voiding depend on?

A

parasympathetic contraction of detrusor

Voluntrary relation of EUS

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27
Q

What are the types of incontinence?

A

Urge

Stress

Mixed (Urge + Stress)

Overflow (aka bladder outlet obstruction - BOO/ retention)

Fistulae

Functional (e.g. due to depression, dementia, etc)

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28
Q

What is the cause of urge incontinence?

A

Incontinence due to an overactive bladder

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29
Q

What are the symptoms of urge incontinence?

A

Incontience accompanied or preceded by urgency

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30
Q

What is the cause of stress incontinence?

A

Weakness of the urinary outlet

and resultant incontinence due to high abdo pressure

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31
Q

What is the cause of overflow incontinence?

A

A bladder that is overfull and overflows

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32
Q

What questionnaire is commonly used in incontinence?

A

Bladder Control Self Assessment Questionnaire (B-SAQ)

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33
Q

What should be undertaken in an older pt with continence problems?

A

Comprehensive geriatric assessment

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34
Q

How can continence symptoms be divided?

A

Storage

or

Voiding

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35
Q

List the storage symptoms

A

Nocturia

frequency

continual urine loss

urgency

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36
Q

List the voiding symptoms

A

Terminal dribbling

post-micturition dribble

hesitancy

incomplete emptying

intermittent stream

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37
Q

What symptoms relating to urination require urgent medical review?

A

Pain

Dysuria

Haematuria

Suspicion of prostate cancer

External vaginal prolapse

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38
Q

Which common substances exacerbate incontinence

A

alcohol

tobacco

caffeine

fluid intake

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39
Q

O/E you can test the nerve roots of the pudendal nerve, how?

A

S1 –> Sole of foot sensation

S3 –> Posterior aspect of thigh sensation

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40
Q

What can be used to grade the pelvic floor?

A

The oxford pelvic floor grading system (vaginal strength 0-5)

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41
Q

How can you test for stress incontinence?

A

Ask the pt to cough

whilst sitting and standing

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42
Q

How can investigations for urinary incontinence be split?

A

Simple

Specialist

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43
Q

What are the simple investigations for urinary incontinence?

A

Frequency/Volume charts

Blood tests

Imaging

Urinalysis

MC+S

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44
Q

Over how many days should a pt do Frequency/Volume charts?

A

3 days

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45
Q

What is recorded on a Frequency/Volume chart?

A

Intake

Urine passed

episodes of incontinence

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46
Q

What on a Frequency/Volume chart would suggest overactive bladder/ urge incontinence?

A

frequenct small volumes of urine

47
Q

What on a Frequency/Volume chart would suggest nocturnal polyuria?

A

> 1/3 of the 24hr urine produced at night

48
Q

What on a Frequency/Volume chart would suggest polyuria?

A

> 2500ml/day

49
Q

What blood test can you do for urinary incontinence and what do they indicate?

A

Full Blood Count – leucocytosis may indicate infection

U&Es – to determine renal function and electrolytes

Glucose – to rule out diabetes

Calcium – useful to rule out hypercalcaemia which can cause constipation and confusion

50
Q

What imaging can be used as simple incontinence Ix? (how important are they)

A

Post-void bladder scan - which is an essential first line Ix

51
Q

What can urinalysis indicate as potential causes of urinalysis?

A

glucose – suggests diabetes

protein – suggests a primary kidney pathology

leucocytes and nitrites – may suggest urinary tract infection

blood – suggests renal stones or urinary tract malignancy

52
Q

What are complex Ix’s of the lower urinary tract (LUT) referred to as?

A

urodynamics

53
Q

What are the different types of urodynamics and which are the more complex ones?

A

They increase in complexity as you go down the list:

Uroflowmetry

Ultrasound cystodynamogram

Cystometry

Videourodynamics

Ambulatory urodynamics

54
Q

What is uroflowmetry?

A

Urine flow rate and

volume

is measured using a flowmeter

55
Q

How is uroflowmetry measured?

A

Patients are left in private to void normally

(either sitting or standing)

common flowmeter are in the form of rotating disks

56
Q

How is the data is uroflowmetry output?

A

In graph form

57
Q

What represents the total volume voided on the graph?

A

The are under the graph

58
Q

What represents the maximum flow rate on the graph?

A

The highest point of the line

59
Q

How is the average flow rate calculated in uroflowmetry?`

A

(volume voided/flow time)

60
Q

What is a normal voided volume?

A

200ml

61
Q

What is a normal flow time?

A

15-20 secs

62
Q

What is maximum flow rate also noted as?

A

Qmax

63
Q

What is Qmax usually?

A

> 20mls/sec

64
Q

What happens to Qmax as one ages?

A

It decreases by about 8mls/sec

65
Q

What is ultrasound cystodynamogram?

A

combines flowmetry with pre and post void bladder scanning

66
Q

What is cystometry?

A

The bladder is filled with saline at room temperature

via a small bore urethral catheter which is passed along

with a pressure transducer.

A further pressure transducer is placed in the rectum.

Pressure recordings are measured as the bladder is filled.

67
Q

How is true intravesicular pressure calculated in cystometry?

A

true intravesicular pressure = intravesicular pressure – rectal pressure

68
Q

What is videourodynamics

A

Combination of cystometry and radiographic screening

so that both pressure and visual information is obtained

69
Q

What is ambulatory urodynamics?

A

Essentailly cystometry, but you let the bladder fill naturally. and the patient walks around with continence pads on

70
Q

What are the major REVERSIBLE causes of incontinence?

A 
D elirium
I nfection 
A trophy (vaginal)
P harmacological 
P sychological
E xcess urine output (e.g. DM of increased intake
R estricted mobility
S tool impaction
71
Q

Other than just being confused what can link delirium to incontinence?

A

UTI can cause both and thus may be the underlying cause of incontinence

72
Q

How does UTI cause incontinence?

A

It irritates the bladder causing it to be overactive

73
Q

How is vaginal atrophy treated?

A

Trial of intravaginal oestrogen.

74
Q

What psychological things can cause incontinence?

A

Depression

Dementia

75
Q

What are common cause of excess urine output/

A

DM

Overdrinking

76
Q

How should you test for stool impaction and how often?

A

Via DRE

perform on all patients with incontinence who have yet to be diagnosed

77
Q

What are main the risk factors for stress incontinence and explain why?

A

Female - lack of prostate + shorter urethra

Multiparity - due to ligament + nerve damage

Obesity - increased IAP

Surgery

78
Q

What type of surgery most often causes stress incontinence?

A

Transurethral resection of prostarte (TURP)

79
Q

What are main the risk factors for urge incontinence and give examples?

A

Idiopathic – most common

Neurogenic – e.g. MS, parkinsonism, stroke

Infective – UTI

80
Q

Which type of incontinence is caused by bladder outlet obstruction (BOO)?

A

all of them

but most commonly overflow incontinence

81
Q

What causes overflow incontinence?

A

bladder outlet obstruction (BOO)

82
Q

What are common causes of BOO?

A

Benign prostate hypertrophy (BPH)

Carcinoma (of prostate, bladder, cervix, colon)

STI, more commonly in women

83
Q

Which medications can cause incontinence?

A

CHAD takes heroin

Cholinesterase inhibitors

Ca2+ channel blockers

Hyponotics e.g. lorazepam

α-adrenoreceptor blockers

α adrenoreceptor agonist

Antipsychotics e.g. Haloperidol

ACEi

Diuretics

Opioids

84
Q

How do α-adrenoreceptor blockers cause urinary incontinence?

A

relax bladder outlet

+ may worsen Stress Urinary Incontinence

85
Q

How do α-adrenoreceptor agonists cause urinary incontinence?

A

urinary retention

+ thus may lead to overflow

86
Q

How do antipsychotics cause incontinence?

A

anticholinergic and may cause retention

and could this lead to overflow incontinence

87
Q

How do Ca2+ channel blockers cause incontinence?

A

decrease smooth muscle contractility

88
Q

How do opiods cause urinary incontinence?

A

constipation causes overflow incontinence

89
Q

How do ACEi’s cause urinary incontinence?

A

can cause chronic cough and may worsen stress incontinence

90
Q

How do hypnotics cause urinary incontinence?

A

reduce awareness of need to urinate

91
Q

What are broad areas of management of incontinence?

A

1) MDT + non-pharmacological
2) Patient education
3) Medical management
4) Surgical management

92
Q

What are community continence advisors?

A

Essentially continence OT’s

93
Q

What are the methods used for MDT + non-pharmcological Mx of stress incontinence?

A

Community continence advisor assessment at home

Physio - for pelvic floor muscles

Pedendal nerve stimulation

Vaginal cones

94
Q

What are some common causes of pelvic floor muscle weakness?

A

Childbirth

Obesity

Post-pelvic surgery

Post-menopause

95
Q

How does a vaginal cone work?

A

Woman has to “work” to keep cone in

and thus increases pelvic floor strength

96
Q

What patient education should be given to a patient with stress incontinence?

A

Smoking cessation

weight reduction

managing constipation

reducing alcohol + caffeine

97
Q

Which medication is NO LONGER recommended by NICE as a treatment for stress incontinence

A

Duloxetine (the SNRI) as there is poor evidence for it efficacy

98
Q

For how long should pt’s with urge incontinence be offered non-surgical/non-pharmacological before moving onto other types of treatment?

A

6 weeks

99
Q

What is the MDT + non-pharmacological Mx for pts with urge incontinence?

A

Community continence advisor assessment of home

Behavioural therapy (wait longer between urge to void and voiding)

Pelvic floor exercises

100
Q

What patient education should be given to a patient with urge incontinence?

A

Reduce fluid intake (none after 8pm)

Reduce caffeine + alcohol

101
Q

What is the medical management for urge incontinence?

A

Antimuscarinic drugs: (mainstay of treatment)

β-3 agonists

Intravaginal eostrogens

Botox of detrusor to paralyse muscle to stop contraction

102
Q

How do antimuscarinic drugs (muscarinic receptor antagonists) work with regards to urge incontinence?

A

Act on the M3 receptors

on the detrusor muscle

to reduce contraction.

103
Q

What antimuscarinic drugs are use first line for urge incontinence?

A

Oxybutynin (but not to be used in older adults with frailty)

Tolteridone

Darifenacin

104
Q

Give an example of a β-3 agonist used in urge incontinence?

A

Mirabegron

105
Q

When is a β-3 agonist used in urge incontinence?

A

When fist line antimuscarinics have failed

106
Q

How do β-3 agonists work with regards to urge incontinence?

A

They work as Beta-3-adrenoceptors cause the bladder to relax (i.e. not contract)

which helps it to fill and also to store urine

107
Q

When do NICE recommend the use of intravaginal oestrogens in urge incontinence?

A

Women with vaginal atrophy and urge incontinence

108
Q

What MDT + non-pharmacological treatments should be used for overflow incontinence (a.k.a. BOO)?

A

Same as for urge incontinence

(Community continence advisor assessment of home

Behavioural therapy (wait longer between urge to void and voiding)

Pelvic floor exercises)

109
Q

Which types of incontinence often co-excist?

A

Urge and Overflow incontinence

110
Q

What patient education should be given for overflow incontinence?

A

Same as for urge incontinence
(Reduce fluid intake (none after 8pm)

Reduce caffeine + alcohol)

111
Q

What is the medical management for overflow incontinence?

A

Mainly the management for BPH which is:

α blockers

5-α reductase inhibitors

112
Q

How do α blockers help in BPH and give an example?

A

They reduce the smooth muscle tone of the prostate

e.g. doxazocin

113
Q

How do 5-α reductase inhibitors work in BPH?

A

reduce prostate volume

by blocking the conversion of testosterone to

dihydrotestosterone

114
Q

What are possible surgical interventions of overflow incontinence?

A

obviously it will depend on the cause.

If caused by BPH then can consider a:

TURP

bHCE (18 decks)

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