Incontinence Flashcards
What is urinary incontinence?
- 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
Why care about UI?
- Significant impact on quality of life
- Increases dependence on care-givers
- Increases rate of serious medical conditions
- Increases risk for falls
Is UI more common in males or females?
Females!
How the lower urinary tract changes as you age
- 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)
Bladder innervation
3 parts
- parasympathetic from sacral nerve
- Sympathetic- further up in the spinal cord
- Pudendal- voluntary
Types of Incontinence
- 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
Overactive Bladder
- A syndrome of urinary urgency WITH or WITHOUT incontinence, which is often accompanied by nocturia and urinary frequency.
Common causes of OAB in the elderly
- Meds
- Delirium
- Prostatectomy
- Excessive fluid intake
- Atrophic vaginitis
- Constipation
- UTI
- Glycosuria
First steps of OAB management
- Ask
- Review meds
- Screen for fall risks
- Screen for cognitive decline
- Screen for constipation
- Screen for UTI
Asking patients about incontinence increases reporting by _______
20%
Meds that frequently cause OAB/incontinence
- Loop diuretics
- Antipsychotics
- TCAs
- Alpha-blockers
- CCBs
- ACEI
- Gabapentin
Why does constipation cause Incontinence
- Blocks parasympathetic nerves and applies pressure on the bladder
Screening for UTI- high risk things in elderly
- Low estrogen
- Comorbidities
- Low immunity
- Low urinary defenses
- Limited fluid intake
- Catheters
- Dementia
- Constipation
- Poor mobility
Things to Look for in regards to incontinence during the history
- onset, duration, frequency
- Type
- quality of life
- Drinking habits
- Smoking and alcohol
- Medical history
- Gyne history
- Surgical history
Red flags for Incontinence
Abrupt onset, pelvic pain, hematuria
Stress test
- 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
Post Void Residual Test
- Measures the amt of urine left in the bladder after voiding
- Obtained via straight catheter or US scan
- If over 200 ml- positive
Urodynamic tests
- Uroflowmetry
- Cystometric testing
- Leak point pressure measurement
- Electromyography
- Video urodynamic tests
Treatment goal
-To relieve the most bothersome aspect(s)
Stepped management strategy
- Lifestyle changes
- Behavioral therapy
- Medications
- Anti-incontinence rings and pessaries
- Surgery
Life style changes
- 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
Behavioral Therapy
- Bladder diary
- Bladder training
- Pelvic floor exercises
- Biofeedback
Medications to use
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
Mirabegron
- New treatment for overactive bladder and urge UI
- Targets beta3 pathway relaxing bladder spasms
- Increased risk of hypertension
Anti-incontinence rings and pessaries
- Been around 4000 years
- Used for stress/mixed UI
- Pessaries may make stress UI worse
- Hard to retain if weak perineum
- Varied results
Surgery
- Only for selective cases
- Very simple procedures
- For stress UI
- – bulking agents
- – Sling surgery
For Urge UI
- – Bladder pacemaker
- – Botox injections
How does bulking agents help?
- injects more “mass into the sphincters” so they plug better
Sling Surgery
- Only for stress UI
- Similar to Bulking agents, but more effective
Botox injections
- 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
Bladder Pacemaker
- Sacral nerve stimulation
- Similar to cardiac pacemaker
