Incontinence Flashcards
What major complication of incontinence are we so concerned about in the elderly?
FALLS
patients rushing to reach the toilet on time, and problematic if pt PU before reaching the toilet
how does prevalence of incontinence vary between men and women?
prevalence in men usually half that in women
examples of LUTS?
frequency
urgency
nocturia-need to pass urine during the night which wakens one from sleep and is an independent RF for falls
incontinence
define overactive bladder
syndrome including urinary urgency with or without urge incontinence, which is usually accompanied by frequency (voiding 8 or more times/24hr) and nocturia
can be associated with detrusor overactivity.
what is stress incontinence?
involuntary leakage of urine caused by failure for bladder outlet to remain closed during rises in intra-abdominal pressure
how is a diagnosis of detrusor overactivity confirmed?
requires urodynamic studies
what diagnosis does the following correspond to: spontaneous bladder contraction during filling as pt attempts to prevent micturition?
detrusor overactivity
what is nocturnal polyuria?
passing more than 1/3 of your urine volume during the night
can be identified by viewing frequency volume charts
types of urinary incontinence?
stress-result of weakness of the urinary outlet so fails to remain closed during rises in intra-abdo pressure e.g. coughing, laughing
urge-high bladder pressure causes bladder to fail in storing urine
overflow-bladder overfull due to bladder outlet obstruction e.g. BPH, so overflows
mixed-combination of stress and urge
functional-incontinence due to more general impairment e.g. cognitive-e.g. pt with dementia who has frontal cortex dysfunction so makes no attempt to move to the toilet before micturition, functional, affective, pt unable to get to the bathroom on time.
fistulae e.g. in crohns
what is necessary for the process of micturition?
there must be voluntary relaxation of the striated muscle around the urethra to reduce urethral pressure (pelvic floor muscles already not functioning adequately in stress incontinence) AND
corresponding increase in bladder pressure due to detrusor contraction-M3 muscarinic receptors stimulated by PNS
normal bladder capacity, and what volume causes a desire to void?
around 600ml
desire to void usually felt at around 250ml
primary muscle for inhibiting the release of urine?
internal urethral sphincter-smooth muscle, continuation of detrusor muscle, under autonomic (involuntary) control
how is detrusor contraction coordinated with urethral relaxation to allow micturition to take place?
by the pontine micturition centre in the midbrain
overview of how micturition is stimulated following bladder filling?
filling causes detrusor muscle of the bladder to stretch-increased signals sent to the sacral region, which then causes PNS stimulation of the detrusor via the pelvic nerves (S2-S4) to contract. stretching bladder also causes increased signals to be sent up to the brain, where the pontine micturition centre coordinates detrusor contraction with urethral relaxation-brain decreases APs in somatic motor neurones to the external urethral sphincter (pudendal nerve S2-S4).
if voiding not desired, inhibitor signals sent from the brain to the detrusor muscle (hypogastric nerve T10-L2 SNS).
most common cause of stress incontinence in men?
prostate damage, usually post-op following prostatectomy
structure most important for stopping stress incontinence in women?
peri-urethral striated muscle
useful questions for assessing urinary incontinence?
any problems with your bladder or bowels?
do you ever leak urine?
do you find it difficult to hold urine when you feel the urge to go?
do you have a problem with going to the toilet too often to pass urine during the day?
do you have to wake from sleep at night to pass urine?
storage symptoms?
frequency of micturition urgency of micturition continual urine loss nocturia urge incontinence stress incontinence
voiding symptoms?
terminal dribble
hesitancy
intermittent stream
incomplete emptying
what should be asked about in the social history which can exacerbate incontinence?
smoking
alcohol
caffeine
fluid intake
complications of incontinence for the patient?
social isolation admission to care home falls pressure ulcers skin infection impaired QOL depression
what co-morbidities might incontinence be a consequence of?
dementia-frontal lobe dysfunction-pt doesn’t make attempt to go to the toilet before micturition, plus lack of function of the micturition inhibitory centre.
MSK disease-pt unable to mobilise well enough to access the toilet
chronic lung disease
CCF-causes surges in BNP, commonly assoc. with nocturia, plux tx diuretics-exacerbate all types of incontinence, +ACEIs-bradykinin induced cough exacerbates incontinence.
MS
stroke
DM
parkinson’s disease
what examination must NOT be missed in assessing pt with urinary incontinence?
DRE:
assess anal tone
constipation, rectal mass
prostate size and consistency
simple investigations for the assessment of incontinence?
-frequency-volume charts-ask pt to complete diary over 3 day period that records fluid intake, volume of urine passed and episodes of incontinence
-urinalysis-dipstick-glucose, proteinuria-primary kidney pathology, nitrites+leucocytes-infection, haematuria
plus M, C+S
-bloods-FBC, U+Es, Ca2+-hypercalcaemia can cause constipation and confusion, glucose
-imaging-post void bladder scan-rule out chronic urinary retention
others depending on specific indications:
USS Abdo if CKD-evaluate kidney size and look for signs of obstructive uropathy
CT urography-renal stones
CT abdo
IV urogram
what trend from a frequency volume chart is suggestive of an overactive bladder?
frequent small volumes of urine being passed
what is uroflowmetry?
an example of a urodynamic study, which measures the urinary flow rate, and is useful for diagnosing bladder outlet obstruction e.g. BPH
usually pt left to void in private and the commode has a rotating disc-inertia increased as urine falls onto it, which can be measured by the computer and translated into a flow rate.
normal results: total voided volume more than 200ml, flow time 15-20s, Qmax more than 20mls/s, smooth parabolic curve.
uroflowmetry trace for a pt with bladder outflow obstruction?
prolonged flow rate with low Qmax
most important imaging investigation for urinary incontinence?
post void bladder scan
what is cystometry?
bladder pressure studies:
bladder filled with saline at room temp via small bore urethral catheter passed along with a pressure transducer, and further pressure transducer placed in rectum. pressure recordings measured as bladder filled.
combined with radiographic imaging=videourodynamics
how is true intravesical pressure measured with pressure urodynamics?
intravesical pressure minus intra abdominal pressure/rectal pressure (measured via rectal transducer)
uroflowmetry features of an overactive bladder?
decreased time to maximum flow, increased max flow rate and decreased max flow
define polyuria
more than 2.5L urine passed/24hrs
what might cause stress incontinence in men?
prostatectomy
prostate essential to bladder outlet integrity in men
transient reversible causes of urinary incontinence?
DIAPPERS: delirium infection atrophy-vaginal-trial topical oestrogens pharmacological psychological-dementia, delirium excess urine-DM, DI, psychogenic polydipsia reduced mobility stool impaction (constipation)-do DRE!
RFs for stress incontinence?
females: outlet already weaker due to shorter urethra and absence of prostate, childbirth-nerve and ligament damage, obesity-increased strain and weakening of pelvic floor
surgery: hysterectomy, TURP
increasing age
neurological disease
urinary infection
post menopausal-oestrogen loss
bladder outlet obstruction
causes of overactive bladder (urge incontinence)?
idiopathic
neurogenic-MS, stroke or SC injury, parkinsonism
infective-UTI
bladder outlet obstruction
causes of bladder outlet obstruction?
BPH malignancy-prostate or bladder, or carcinoma of the cervix or colon calculi blood clot trauma STDs, part. in women phimosis stricture (male preponderance)
why might BPH be a contributer to urge incontinence?
BPH causes bladder outlet obstruction and can cause overflow incontinence, but over time, there is a strain on the bladder which causes residual urine to be left which irritates the bladder and can cause detrusor overactivity.
drugs which may cause/worsen urinary incontinence?
anticholinergics-cause urinary retention
opioids-cause urinary retention by causing constipation
cholinesterase inhibitors-increase bladder contraction-increased ACh acting on M3
ACEI-bradykinin induced cough
alpha blockers-relax bladder outlet
alpha agonists-urinary retention
hypnotics-reduced awareness of need to urinate
haloperidol-anticholinergic, may cause retention
Ca2+ channel blockers-decrease smooth muscle contractility
pt education to manage stress incontinence?
smoking cessation
reduce alcohol and caffeine
lose weight
manage constipation-increase fibre in diet
non-pharmacological management of stress incontinence?
pelvic floor exercises-advice can be given by physiotherapists and continence advisors
pudendal nerve stimulation if initial pelvic floor muscle contraction weak
vaginal cones-must contract pelvic floor muscles to keep cone in place
medical and surgical management of stress incontinence?
duloxetine-SNRI, thought to increase urethral sphincter tone during bladder filling
surgical: mid-urethral sling insertion (tension free vaginal tape) provides support under urethra
colposuspension-much more invasive
injection of bulking agents into the urethra e.g. silicone
pt education to manage an overactive bladder (urge incontinence)?
reduce fluid intake, especially in the evening
reduce alcohol and caffeine
lose weight
manage constipation
non-pharmacological management of an overactive bladder?
pt education e.g. reduce fluid intake
community continence advisor-can assess pt in own home and give advice
behavioural therapy-bladder retraining-this should be 1st line for at least 6 wks alongside pelvic floor muscle exercises. bladder retraining involves increasing the time between 1st desire to void and voiding.
complementary therapy
medical and surgical management of overactive bladder?
antimuscarinics e.g. oxybutynin
vaginal oestrogens for those with vaginal atrophy
botulinum toxin injected via cystoscopy to inhibit NT release hence decrease contractility
surgical: sacral nerve stimulation
urinary catheter least associated with infection?
low friction intermittent catheter
what 2 diagnoses is the failure to produce urine indicative of?
acute urinary retention or AKI
need catheter insertion
