Incontinence

Question 1

What is urinary INCONTINENCE?

Answer 1

the complaint of involuntary loss of urine

Question 2

PRECIPITANTS/treatable causes of urinary incontinence? (DIAPPERS)

Answer 2

D: delirium
I: infection (urinary)
A: atrophic urethritis & vaginitis
P: pharmaceuticals
P: psychiatric disorders (esp depression)
E: excessive urine output (eg: from heart failure or hyperglycaemia)
R: restricted mobility
S: stool impaction

Question 3

TYPES of incontinence?

Answer 3

1) URGE
•detrusor overactivity
• decreased bladder wall compliance

2) STRESS
• pelvic floor weakness
• urethra hyper mobility
• intrinsic sphincter deficiency/weakness

3) MIXED
- combo of STRESS + URGE (only)

4) OVERFLOW
- usually caused by outflow obstruction (e.g.: BPH)
- poor detrusor contractility (e.g.: overdistention of bladder

5) CONTINUOUS
- anatomical (due to fistula, ectopic ureter

6) FUNCTIONAL
- due to cognition of physical basis

Question 4

Causes of acute urinary incontinence?

Answer 4

The mnemonic is DRIP
D
• Delirium (can occur in any acute illness)
• Drugs, e.g. anticholinergics, psychotropics, diuretics, alcohol, narcotics, sedatives, antihypertensives

R
• Restricted mobility, e.g. OA of hip, postural hypotension, gait disorders, restraint
• Retention of urine with overflow, e.g. from drugs or prostatic hypertrophy

I
• Infection or inflammation in the GUT or systemically
• Illness (any acute disorder)
• Impaction (faecal material presses on urethra and obstructs it)
• Injury to brain (e.g. stroke)

P
• Polyuria, e.g. DM or CHF

Question 5

Pathophysiology of LUT

Answer 5

• Poor storage function
1. Detrusor overactivity, poor compliance – ‘urge’ incontinence
2. Reduced sphincter function – ‘stress’ incontinence
• Poor emptying
1. Outflow obstruction, poor detrusor contractility – ‘overflow’
2. ‘Continuous’ – extra urethral
3. ‘Functional’ – impaired, mobility, dexterity, cognition, psychiatric

Question 6

Causes of URINARY INCONTINENCE → URGE

Answer 6

idiopathic
bladder outflow obstruction (prostatic, urethral)
bladder stone
tumour
neurogenic: MS, stroke, parkinson’s, dementia, SCI, CP, spina bifida

Question 7

Causes of URINARY INCONTINENCE → OVERFLOW

Answer 7

Obstruction - prostatic, urethral

Question 8

DEFINE: URGE incontinence

+ clinical features

Answer 8

involuntary loss of urine accompanied or immediately preceded by urgency

frequently associated w Sx of overactive bladder (urinary frequency & nocturne)

CLINICAL FEATURES
• M:F 
• ↑↑ urgency &  ↑ frequency
• large volume leakage
• small volume voids
• triggers: running water (fountains, washing up, showering etc), behaviours e.g.: key in door, sex
• normal PVR

Question 9

DEFINE: STRESS incontinence

+ clinical features

Answer 9

involuntary leakage on “stress” - any cause of increased abdominal pressure (e.g.: exertion, sneezing, coughing)

usually due to weakness of pelvic floor muscles & fascial support

• often as result of childbirth, ageing & straining
• weakness/damage of the urethral sphincter following surgery, trauma or sacral cord disease

CLINICAL FEATURES
• F > M - post-childbirth + post-menopausal
• Triggers: any cause of ↑ intra-abdo pressure - coughing, sneezing, laughing, exercise
• small volume losses
• normal voids
• normal PVR
• prev Hx pelvic surgery

Question 10

DEFINE: MIXED incontinence

Answer 10

STRESS + URGE:involuntary leakage of urine assoc w urgency, exertion, effort, sneezing or coughing

NB: most common type of incontinence in women > 60 yo

Question 11

DEFINE: urinary retention (chronic)

causes

Answer 11

inability to empty bladder/urinate

Occurs secondary to either:

1) Outflow obstruction
- most common cause = urethral obstruction from BPH ∴ M>F
- urethral strictures, stones, bladder tumours
- also detrusor dysynergia (in supra-spinal cord disease e.g.: MS, parkinson’s)

2) Acontractile detrusor
- common causes = autonomic neuropathy (e.g.: diabetic)
- sacral cord/spinal nerve pathology
- post surgical or traumatic pelvic nerve damage
- after prolonged bladder distention 2 to obstruction

NB: bladder is an unreliable witness - symptoms don’t always correlate with underlying pathology

Question 12

Causes of FUNCTIONAL INCONTINENCE

Answer 12

1. Factors not directly related to the bladder that may contribute, or be the primary cause of urinary incontinence
2. Physical
   a. Poor mobility + transfers
   b. Reduced dexterity leading to slow disrobing
   c. Sensory eg. visual impairment
3. Cognitive factors
   a. Delirium
   b. Dementia
   c. LOC
4. Environmental factors
   a. Access to toilets
   Physical restraints – cot sides, IV lines, monitoring equipment