Incontinence

Question 1

What is urinary incontinence?

Answer 1

• Unwanted leakage of urine
• Among 10 most common conditions
• Leading cause for admission to nursing homes
• Underdiagnosed- 1/2 of people with it never bring it up

Question 2

Why care about UI?

Answer 2

• Significant impact on quality of life
• Increases dependence on care-givers
• Increases rate of serious medical conditions
• Increases risk for falls

Question 3

Is UI more common in males or females?

Answer 3

Females!

Question 4

How the lower urinary tract changes as you age

Answer 4

• Decreased bladder contractility
• Increased inhibited bladder contractions
• Diurnal urine output shifted later in the day
• Decreased bladder capacity
• Increased post void residual
• Decreased urethral closure pressure
• Vaginal mucosal atrophy (women)
• Benign prostatic hyperplasia (men)

Question 5

Bladder innervation

Answer 5

3 parts

• parasympathetic from sacral nerve
• Sympathetic- further up in the spinal cord
• Pudendal- voluntary

Question 6

Types of Incontinence

Answer 6

• Overflow- blockage in the bladder- fills up and can’t empty itself- will be leakage when it gets too big
• Stress- increase in intraabdominal pressure- makes little leaks- any time they cough/sneeze/laugh they pee
• Urge - no leaking- just get the sense of urgency before it is all the way full

Mixed- stress and urge

Question 7

Overactive Bladder

Answer 7

• A syndrome of urinary urgency WITH or WITHOUT incontinence, which is often accompanied by nocturia and urinary frequency.

Question 8

Common causes of OAB in the elderly

Answer 8

• Meds
• Delirium
• Prostatectomy
• Excessive fluid intake
• Atrophic vaginitis
• Constipation
• UTI
• Glycosuria

Question 9

First steps of OAB management

Answer 9

• Ask
• Review meds
• Screen for fall risks
• Screen for cognitive decline
• Screen for constipation
• Screen for UTI

Question 10

Asking patients about incontinence increases reporting by _______

Answer 10

20%

Question 11

Meds that frequently cause OAB/incontinence

Answer 11

• Loop diuretics
• Antipsychotics
• TCAs
• Alpha-blockers
• CCBs
• ACEI
• Gabapentin

Question 12

Why does constipation cause Incontinence

Answer 12

• Blocks parasympathetic nerves and applies pressure on the bladder

Question 13

Screening for UTI- high risk things in elderly

Answer 13

• Low estrogen
• Comorbidities
• Low immunity
• Low urinary defenses
• Limited fluid intake
• Catheters
• Dementia
• Constipation
• Poor mobility

Question 14

Things to Look for in regards to incontinence during the history

Answer 14

• onset, duration, frequency
• Type
• quality of life
• Drinking habits
• Smoking and alcohol
• Medical history
• Gyne history
• Surgical history

Question 15

Red flags for Incontinence

Answer 15

Abrupt onset, pelvic pain, hematuria

Question 16

Stress test

Answer 16

• patient supine on table with full bladder
• Gauze pad in front of perineum
• Have them cough- then if they leak then its stress incontinence
• then place fingers on either side of the urethra and elevate it and cough again- if the elevation of the urethra stops the leakage, that confirms the stress incontinence

Question 17

Post Void Residual Test

Answer 17

• Measures the amt of urine left in the bladder after voiding
• Obtained via straight catheter or US scan
• If over 200 ml- positive

Question 18

Urodynamic tests

Answer 18

• Uroflowmetry
• Cystometric testing
• Leak point pressure measurement
• Electromyography
• Video urodynamic tests

Question 19

Treatment goal

Answer 19

-To relieve the most bothersome aspect(s)

Stepped management strategy

• Lifestyle changes
• Behavioral therapy
• Medications
• Anti-incontinence rings and pessaries
• Surgery

Question 20

Life style changes

Answer 20

• Address underlying illnesses
• Correct functional impairment
• Stop medication that contribute to UI
• Weight loss
• Avoid caffeine and alcohol
• Tobacco cessation in smokers with a stress UI

Question 21

Behavioral Therapy

Answer 21

• Bladder diary
• Bladder training
• Pelvic floor exercises
• Biofeedback

Question 22

Medications to use

Answer 22

Anticholinergics!

• annoying side effects- dry mouth, constipation
• Increased toxicity in elderly
• Low efficacy in clinical trials
• High non-adherence
• Use if behavioral therapy fails but monitor carefully

Question 23

Mirabegron

Answer 23

• New treatment for overactive bladder and urge UI
• Targets beta3 pathway relaxing bladder spasms
• Increased risk of hypertension

Question 24

Anti-incontinence rings and pessaries

Answer 24

• Been around 4000 years
• Used for stress/mixed UI
• Pessaries may make stress UI worse
• Hard to retain if weak perineum
• Varied results

Question 25

Surgery

Answer 25

• Only for selective cases
• Very simple procedures
• For stress UI
• – bulking agents
• – Sling surgery

For Urge UI

• – Bladder pacemaker
• – Botox injections

Question 26

How does bulking agents help?

Answer 26

• injects more “mass into the sphincters” so they plug better

Question 27

Sling Surgery

Answer 27

• Only for stress UI

- Similar to Bulking agents, but more effective

Question 28

Botox injections

Answer 28

• Targets bladder spasms
• Very expensive though
• paralyze the bladder wall so it does not respond to the stimulus anymore and the urgency can go away

Question 29

Bladder Pacemaker

Answer 29

• Sacral nerve stimulation

- Similar to cardiac pacemaker