Incontinence Flashcards
What anatomy is involved in continence?
bladder
urethra
pelvic floor muscles
nervous system
What type of system is the bladder?
Low pressure - High volume
Roughly what is the rate of bladder filling?
0.5-5ml/min = 30-300ml/hr
What is the capacity of the bladder?
600ml
At what volume does one desire to void?
250ml
How is continence maintained (very basically)?
urethral pressure is higher than bladder pressure
What occurs to allow micturition?
Relaxation of striated muscle around urethra and
pelvic floor muscle
and contraction of detrusor
What causes detrusor muscle to contract?
Bladder fills
signals parasympathetically to cause the
detrusor (smooth muscle) to contract
Where is the internal urethral sphincter (IUS) found?
junction of the urethra with the bladder
What makes up the IUS?
The detrusor, therefore its made of smooth muscle
What controls the IUS?
Autonomic NS (involuntary)
What urethral sphincter is the 1ry muscle for continence?
IUS
Where is the external urethral sphincter (EUS) located in males?
Inferior to the prostate
Where is the external urethral sphincter (EUS) located in females?
At the distal inferior end of the urethra
What type of muscle is the EUS?
Skeletal muscle
What is the problem with the EUS?
It is under voluntary control (as it is skeletal muscle) thus can relax when sneezing or coughing
Which area of the brain provides voluntary control of continence?
the frontal lobe (probably why pts with dementia are commonly incontinent)
Which part of the brain controls detrusor contraction and urethral relaxation?
the pontine micturition centre
Which part of the NS is responsible for micturition?
parasympathetic NS (for the involuntary side)
Which nerve is responsible for continence and what are its roots?
pudendal nerve
S2, 3, 4 (keep shit off the floor)
Where do the the parasympathetic nerves that control continence emerge form the spine?
The sacral plexus
Which subset of parasympathetic muscarinic receptor are responsible for bladder contraction?
M3
What nerves is bladder filling controlled by?
Sympathetic NS
Where do the sympathetic nerves relating to the bladder emerge and what do they do?
T11 - L2
Bladder neck contraction and
proximal urethral contraction
What muscle does the pudendal nerve innervate?
contraction of the external urethral sphincter
What does voiding depend on?
parasympathetic contraction of detrusor
Voluntrary relation of EUS
What are the types of incontinence?
Urge
Stress
Mixed (Urge + Stress)
Overflow (aka bladder outlet obstruction - BOO/ retention)
Fistulae
Functional (e.g. due to depression, dementia, etc)
What is the cause of urge incontinence?
Incontinence due to an overactive bladder
What are the symptoms of urge incontinence?
Incontience accompanied or preceded by urgency
What is the cause of stress incontinence?
Weakness of the urinary outlet
and resultant incontinence due to high abdo pressure
What is the cause of overflow incontinence?
A bladder that is overfull and overflows
What questionnaire is commonly used in incontinence?
Bladder Control Self Assessment Questionnaire (B-SAQ)
What should be undertaken in an older pt with continence problems?
Comprehensive geriatric assessment
How can continence symptoms be divided?
Storage
or
Voiding
List the storage symptoms
Nocturia
frequency
continual urine loss
urgency
List the voiding symptoms
Terminal dribbling
post-micturition dribble
hesitancy
incomplete emptying
intermittent stream
What symptoms relating to urination require urgent medical review?
Pain
Dysuria
Haematuria
Suspicion of prostate cancer
External vaginal prolapse
Which common substances exacerbate incontinence
alcohol
tobacco
caffeine
fluid intake
O/E you can test the nerve roots of the pudendal nerve, how?
S1 –> Sole of foot sensation
S3 –> Posterior aspect of thigh sensation
What can be used to grade the pelvic floor?
The oxford pelvic floor grading system (vaginal strength 0-5)
How can you test for stress incontinence?
Ask the pt to cough
whilst sitting and standing
How can investigations for urinary incontinence be split?
Simple
Specialist
What are the simple investigations for urinary incontinence?
Frequency/Volume charts
Blood tests
Imaging
Urinalysis
MC+S
Over how many days should a pt do Frequency/Volume charts?
3 days
What is recorded on a Frequency/Volume chart?
Intake
Urine passed
episodes of incontinence
What on a Frequency/Volume chart would suggest overactive bladder/ urge incontinence?
frequenct small volumes of urine
What on a Frequency/Volume chart would suggest nocturnal polyuria?
> 1/3 of the 24hr urine produced at night
What on a Frequency/Volume chart would suggest polyuria?
> 2500ml/day
What blood test can you do for urinary incontinence and what do they indicate?
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
What imaging can be used as simple incontinence Ix? (how important are they)
Post-void bladder scan - which is an essential first line Ix
What can urinalysis indicate as potential causes of urinalysis?
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
What are complex Ix’s of the lower urinary tract (LUT) referred to as?
urodynamics
What are the different types of urodynamics and which are the more complex ones?
They increase in complexity as you go down the list:
Uroflowmetry
Ultrasound cystodynamogram
Cystometry
Videourodynamics
Ambulatory urodynamics
What is uroflowmetry?
Urine flow rate and
volume
is measured using a flowmeter
How is uroflowmetry measured?
Patients are left in private to void normally
(either sitting or standing)
common flowmeter are in the form of rotating disks
How is the data is uroflowmetry output?
In graph form
What represents the total volume voided on the graph?
The are under the graph
What represents the maximum flow rate on the graph?
The highest point of the line
How is the average flow rate calculated in uroflowmetry?`
(volume voided/flow time)
What is a normal voided volume?
200ml
What is a normal flow time?
15-20 secs
What is maximum flow rate also noted as?
Qmax
What is Qmax usually?
> 20mls/sec
What happens to Qmax as one ages?
It decreases by about 8mls/sec
What is ultrasound cystodynamogram?
combines flowmetry with pre and post void bladder scanning
What is cystometry?
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.
How is true intravesicular pressure calculated in cystometry?
true intravesicular pressure = intravesicular pressure – rectal pressure
What is videourodynamics
Combination of cystometry and radiographic screening
so that both pressure and visual information is obtained
What is ambulatory urodynamics?
Essentailly cystometry, but you let the bladder fill naturally. and the patient walks around with continence pads on
What are the major REVERSIBLE causes of incontinence?
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
Other than just being confused what can link delirium to incontinence?
UTI can cause both and thus may be the underlying cause of incontinence
How does UTI cause incontinence?
It irritates the bladder causing it to be overactive
How is vaginal atrophy treated?
Trial of intravaginal oestrogen.
What psychological things can cause incontinence?
Depression
Dementia
What are common cause of excess urine output/
DM
Overdrinking
How should you test for stool impaction and how often?
Via DRE
perform on all patients with incontinence who have yet to be diagnosed
What are main the risk factors for stress incontinence and explain why?
Female - lack of prostate + shorter urethra
Multiparity - due to ligament + nerve damage
Obesity - increased IAP
Surgery
What type of surgery most often causes stress incontinence?
Transurethral resection of prostarte (TURP)
What are main the risk factors for urge incontinence and give examples?
Idiopathic – most common
Neurogenic – e.g. MS, parkinsonism, stroke
Infective – UTI
Which type of incontinence is caused by bladder outlet obstruction (BOO)?
all of them
but most commonly overflow incontinence
What causes overflow incontinence?
bladder outlet obstruction (BOO)
What are common causes of BOO?
Benign prostate hypertrophy (BPH)
Carcinoma (of prostate, bladder, cervix, colon)
STI, more commonly in women
Which medications can cause incontinence?
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
How do α-adrenoreceptor blockers cause urinary incontinence?
relax bladder outlet
+ may worsen Stress Urinary Incontinence
How do α-adrenoreceptor agonists cause urinary incontinence?
urinary retention
+ thus may lead to overflow
How do antipsychotics cause incontinence?
anticholinergic and may cause retention
and could this lead to overflow incontinence
How do Ca2+ channel blockers cause incontinence?
decrease smooth muscle contractility
How do opiods cause urinary incontinence?
constipation causes overflow incontinence
How do ACEi’s cause urinary incontinence?
can cause chronic cough and may worsen stress incontinence
How do hypnotics cause urinary incontinence?
reduce awareness of need to urinate
What are broad areas of management of incontinence?
1) MDT + non-pharmacological
2) Patient education
3) Medical management
4) Surgical management
What are community continence advisors?
Essentially continence OT’s
What are the methods used for MDT + non-pharmcological Mx of stress incontinence?
Community continence advisor assessment at home
Physio - for pelvic floor muscles
Pedendal nerve stimulation
Vaginal cones
What are some common causes of pelvic floor muscle weakness?
Childbirth
Obesity
Post-pelvic surgery
Post-menopause
How does a vaginal cone work?
Woman has to “work” to keep cone in
and thus increases pelvic floor strength
What patient education should be given to a patient with stress incontinence?
Smoking cessation
weight reduction
managing constipation
reducing alcohol + caffeine
Which medication is NO LONGER recommended by NICE as a treatment for stress incontinence
Duloxetine (the SNRI) as there is poor evidence for it efficacy
For how long should pt’s with urge incontinence be offered non-surgical/non-pharmacological before moving onto other types of treatment?
6 weeks
What is the MDT + non-pharmacological Mx for pts with urge incontinence?
Community continence advisor assessment of home
Behavioural therapy (wait longer between urge to void and voiding)
Pelvic floor exercises
What patient education should be given to a patient with urge incontinence?
Reduce fluid intake (none after 8pm)
Reduce caffeine + alcohol
What is the medical management for urge incontinence?
Antimuscarinic drugs: (mainstay of treatment)
β-3 agonists
Intravaginal eostrogens
Botox of detrusor to paralyse muscle to stop contraction
How do antimuscarinic drugs (muscarinic receptor antagonists) work with regards to urge incontinence?
Act on the M3 receptors
on the detrusor muscle
to reduce contraction.
What antimuscarinic drugs are use first line for urge incontinence?
Oxybutynin (but not to be used in older adults with frailty)
Tolteridone
Darifenacin
Give an example of a β-3 agonist used in urge incontinence?
Mirabegron
When is a β-3 agonist used in urge incontinence?
When fist line antimuscarinics have failed
How do β-3 agonists work with regards to urge incontinence?
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
When do NICE recommend the use of intravaginal oestrogens in urge incontinence?
Women with vaginal atrophy and urge incontinence
What MDT + non-pharmacological treatments should be used for overflow incontinence (a.k.a. BOO)?
Same as for urge incontinence
(Community continence advisor assessment of home
Behavioural therapy (wait longer between urge to void and voiding)
Pelvic floor exercises)
Which types of incontinence often co-excist?
Urge and Overflow incontinence
What patient education should be given for overflow incontinence?
Same as for urge incontinence
(Reduce fluid intake (none after 8pm)
Reduce caffeine + alcohol)
What is the medical management for overflow incontinence?
Mainly the management for BPH which is:
α blockers
5-α reductase inhibitors
How do α blockers help in BPH and give an example?
They reduce the smooth muscle tone of the prostate
e.g. doxazocin
How do 5-α reductase inhibitors work in BPH?
reduce prostate volume
by blocking the conversion of testosterone to
dihydrotestosterone
What are possible surgical interventions of overflow incontinence?
obviously it will depend on the cause.
If caused by BPH then can consider a:
TURP
