Incontinence Flashcards
What is urinary incontinence?
Unintentional passing of urine
What are the consequences of urinary incontinence?
Hygiene problems Skin damage Socially restricting Affects self-esteem Reduces quality of life
Why are women more often affected by urinary incontinence?
Because they are often affected weakening of pelvic floor and sphincter muscles due to childbirth
What are the risk factors of urinary incontinence?
Multiparity Hysterectomy Obesity Bowel dysfunction Menopause Dietary factors: caffeine, alcohol Drugs: diuretics
What is the muscle found in the wall of the bladder?
Detrusor muscle
Which type of muscle makes up the:
- internal urethral sphincter
- external urethral sphincter?
Internal: smooth
External: skeletal
Which branch of the nervous system controls micturition?
Autonomic: parasympathetic + sympathetic
What is the role of the parasympathetic nerves in micturition?
What neurotransmitters do they use?
Drive detrusor contraction
So drives urination
Cholinergic
What is the role of the sympathetic nerves in micturition?
What neurotransmitters do they use?
Inhibits contraction of detrusor
So prevents urination
Noradrenergic
What types of incontinence are there? Briefly say what they are.
Stress: sphincter weakness
Urge: overactive bladder
Mixed stress + urge
Overflow
Functional
What is stress incontinence?
Sphincter weakness that causes small leakages of urine when intra-abdominal pressure rises
This happens when laughing, coughing, exercising
The urethra becomes hypermobile
What causes stress incontinence?
Primary:
- neurogenic problems
- congenital (rare)
Secondary:
- pelvic floor damage to nerves + fascial support
What is meant by the urethra becoming ‘hypermobile’?
When the urethra sags and ends up below the pelvic floor, meaning the sphincters are unable to control urine outflow
Management of stress incontinence?
Reduce caffeine and alcohol intake
Pelvic floor re-education + physio
Duloxetine: a drug that is not great
Surgical methods
What type of drug is duloxetine?
A serotonin-noradrenaline reuptake inhibitor
Treats stress incontinence
Many side effects and not much benefit
What surgical methods can be used to treat stress incontinence?
A sling:
- a hammock underneath the urethra to provide support and prevent hypermobility
- TOT and TVT slings
Colposuspension:
- stitches to support bladder neck
Injectable drugs:
- to make bladder neck stronger
Artificial urinary sphincter
What are TOT and TVT slings?
What is meant by autologous in this context?
Used to treat stress incontinence
TOT: Trans-obturator tape sling
TVT: tension-free vaginal tape sling
Autologous = when the tape is made out of the person’s own tissue
Describe an artificial urinary sphincter?
A cuff fits around the urethra and can be inflated to close off the urethra
The cuff is inflated with fluid stored in a balloon placed under the abdominal muscles
The pump is placed in the scrotum for men and in the lower abdominal muscles for women
What is urge incontinence?
What are the features of it?
Urgent need to void and sometimes urine leakage or complete emptying of bladder before you can get to a toilet
Enuresis: bed wetting
Incontinence with the sound of running water
What causes urge incontinence?
Detrusor muscle over-activity due to:
- detrusor instability
- brain damage
Overactive bladder
Vaginitis, urethritis
UTI
What is detrusor instability and what causes it?
Detrusor muscle contracts when it shouldn’t
Local irritation of the bladder such as infection, trauma, inflammation
What types of brain damage causes detrusor instability?
Dementia
Stroke
Parkinson’s
Investigation of urge incontinence?
Ultrasound of bladder to exclude urinary retention
Management of urge incontinence?
Treat cause if able to: i.e. infection
Behavioural therapy:
- limit fluid intake
- mind over bladder
Pelvic floor exercises
Electrical stimulation
Drugs
Botox
Bladder augmentation
What drugs are used to treat urge incontinence?
Anti-cholinergic agents:
- oxybutynin
Beta-3-agonist: mirabegron
How do anti-cholinergic agents work to treat urge incontinence?
Because the parasympathetic nervous system, which drives detrusor contraction, are cholinergic
Anti-cholinergic drugs prevent excessive and unwanted contraction of detrusor muscle
Describe how Botox is used to treat urge incontinence?
What are the risks?
Botox is a neurotoxin that paralyses muscles
Inject into bladder to paralyse it
Sometimes paralysis of bladder can cause retention of urine, because muscles don’t expel urine
What is bladder augmentation?
Two types:
Detrusor myectomy: removing part or all of the muscle layer surrounding the bladder
Cystoplasty: insert a patch of small bowel into the bladder wall
Both of these treatments aim to prevent the bladder contracting as forcefully
What is overflow incontinence?
When the bladder is unable to void completely so urine builds up causing the bladder to be overfilled
Overfilling leads to leakage of urine
What causes overflow incontinence?
Obstruction of urine outflow:
- stricture
- enlarged prostate
- stones
Detrusor weakness
- MS
- cauda equina damage
Are males or females more commonly affected by overflow incontinence?
Males, because they get obstruction more by things like stones, prostate enlargement
Management of overflow incontinence?
Treat whatever is causing the obstruction
Otherwise, catheterisation
What is functional incontinence?
The person is aware of the need to urinate, but for physical or mental reasons they are unable to get to a toilet
How can you treat functional incontinence?
Use of a commode, or pads
Ease of access to toilet
In spastic spinal cord injuries, what is the effect on the bladder?
Still have bladder contraction reflexes
So the bladder contracts involuntarily
Causing voiding at inappropriate times
In flaccid spinal cord injuries, what is the effect on the bladder?
No bladder reflexes
Bladder fills until it overflows
Causing overflow and stress incontinence
What is the difference between a flaccid and spastic spinal cord injury (briefly, in terms of reflexes)?
Spastic = you still have reflexes but they are not from the brain
Flaccid = reflexes are lost
What is an ‘unsafe bladder’?
One that puts kidneys at risk, for example a reflux of urine into the kidneys
What two options do you have to treat a person who incontinent as a result of a spastic spinal cord injury?
They will have a reflex bladder
So you can either:
- Harness the reflexes and collect the urine using a catheter bag or penile sheath
- Supress the reflexes and make it areflexic, empty regularly with a catheter
What is a penile sheath?
A condom-like sheath that fits over the penis ad collects the urine in a bag attached to the leg
What type of patients are best suited to penile sheaths?
Men with urge or stress incontinence, uncontrolled leakage of urine
Men with good mental ability and dexterity
Men with no damaged skin on the penis
What are the problems that penile sheaths can cause?
Infections
Damage to skin on penis
What is a catheter?
A tube inserted into the bladder that drains urine out of the bladder
What are the two main types of catheter?
Intermittent self catheterisation: inserted only to empty the bladder then they are taken out
Indwelling: remain in the bladder continuously
What type of patients are best suited to intermittent self catheterisation (ISC)?
People with overflow incontinence who need to empty their bladders to prevent overfilling
People with good mental ability and dexterity
Not good for patients with stress or urge incontinence because the catheter is most often not in, so intermittent leaking won’t be prevented
Good as it means patients don’t have to carry a bag on them, they are just the same as normal except when they go to the toilet
What types of indwelling catheters are there?
Urethral: go into the bladder via the urethra
Supra-pubic: go into the bladder via an incision in the abdominal wall
What type of patients are best suited to indwelling urethral catheters?
People will areflexic bladders which continually leak
People with urinary retention
People who are not capable of ISC due to mental or physical impairment
What type of patients are best suited to indwelling suprapubic catheterisation?
People who are likely to need a catheter for a long time or for life
People with damaged urethra
People who are at high risk of UTI
