incontinence

Question 1

In which group of patients is urinary incontinence most common?

Answer 1

It affects 1 in 30 people! Women are more affected than men, with 2 out of 5 women over the age of 60 having continence problems. A general rule is that urinary incontinence in men is less than half that of women

Question 2

How does the prevalence of urinary incontinence change with age?

Answer 2

urinary incontinence increases with age. Trends within prevalence data show that the median level of prevalence shows an: - increase in young adult life - a plateau in middle age - a steady increase in later life

Question 3

How does the prevalence of urinary incontinence vary between acute hospital beds, HCE beds, RHs and NHs?

Answer 3

Urinary incontinence (+/- faecal incontinence) affects just under 1/3 of patients in acute hospital beds. This figure is roughly the same for residential homes. Nursing homes and HCE beds have higher and roughly equal prevalences of urinary incontinence. The presence of faecal incontinence is roughly the same regardless of the location. The presence of catheters is roughly the same on HCE as acute medical beds despite the prevalence of urinary incontinence being much higher in older patients. This is probably due to the fact that catheterisation is required in the acute setting to monitor urine output, and the fact that Geriatricians are keen to avoid catheters if possible.

Question 4

What is a useful approach to asking a patient about incontinence?

Answer 4

Many older people do not want to discuss the issue of incontinence or feel embarrassed by it. A sensitive approach is therefore very helpful. This could simply be asking “Do you have any problems with your bladder or bowels?” or “Do you pass urine or faeces involuntarily?”

Question 5

What are lower urinary tract symptoms?

Answer 5

LUTS is the name given to symptoms associated with bladder and urethral problems that the International Continence Society has standardised.

Question 6

What is urgency?

Answer 6

This is a sudden, compelling desire to pass urine.

Question 7

Define hesitancy?

Answer 7

Define hesitancy?

Question 8

Nocturia

Answer 8

he need to pass urine during the night which awakens one from sleep.

Question 9

Urinary incontinence is

Answer 9

…the involuntary loss of urine

Question 10

The bladder contracts spontaneously during filling as the patient attempts to prevent micturition. This is…

Answer 10

The bladder contracts spontaneously during filling as the patient attempts to prevent micturition. This is…

Question 11

Nocturnal polyuria

Answer 11

passing > 1/3 of your urine volume during the night

Question 12

What is urge incontinence?

Answer 12

This is involuntary leakage of urine accompanied or preceded by urgency.

Question 13

Define overactive bladder?

Answer 13

This is a syndrome including urinary urgency +/- urge incontinence.

Question 14

Stress incontinence is…

Answer 14

…the involuntary leakage of urine caused by failure of the bladder outlet to remain closed when intra-abdominal pressure rises.

Question 15

What is the pathophysiology of incontinence?

Answer 15

1) weakness of the urinary outlet (stress incontinence) 2) failure of the bladder to store urine because of high bladder pressure (urge incontinence) 3) a combination of 1 and 2 4) a bladder that is overfull and overflows (bladder outlet obstruction) 5) abnormal communication of the urinary tract (fistula) 6) incontinence due to more general impairment (e.g. cognitive, functional, affective) (functional incontinence)

Question 16

trigone

Answer 16

a smooth triangular area on the inner surface of the bladder. The triangle is formed by 2 ureteral orifices and the internal urethral orifice.

Question 17

Where is the external urethral sphincter located?

Answer 17

The external urethral sphincter is located at the bladders distal inferior end in females and inferior to the prostate in males. It is made up of striated muscle and is therefore under voluntary control.

Question 18

What is the internal urethral sphincter?

Answer 18

The internal urethral sphincter is found at the junction between the bladder and the urethra. It is a continuation of the detrusor muscle and hence made of smooth muscle. It is only present in males.

Question 19

What controls bladder contraction?

Answer 19

Bladder contraction is mediated by the parasympathetic system. These parasympathetic fibres, along with those responsible for somatic control, originate from the sacral plexus (S2 to S4). Excitation of the parasympathetic nerves in response to bladder filling stimulates acetylcholine release which acts at M3 muscarinic receptors causing detrusor muscle contraction.

Question 20

What mediates bladder relaxation/ filling?

Answer 20

filling is mediated by the sympathetic system. Sympathetic nerves arise from T11 to L2 and innervate the smooth muscle of the bladder neck and proximal urethra causing contraction allowing the bladder to fill. Excitation of the pudendal nerve causes contraction of the external urethral sphincter, allowing voluntary control.

Question 21

What type of incontinence do alpha blockers cause?

Answer 21

Alpha blockers such as doxazosin block adrenergic stimulation of the external urethral sphincter, bladder neck and proximal urethra, resulting in decreased tone and consequent stress incontinence.

Question 22

A patient presents with symptoms of urgency associated with occasional incontinence. Their bladder function is normal between times. What is the most likely diagnosis?

Answer 22

This is classic of overactive bladder

Question 23

A patient is started on amitriptylline for depression. They develop incontinence following this. What is the most likely cause of their incontinence?

Answer 23

Amitriptylline is a TCA and has anti-muscarinic side effects. Detrusor contraction is maintained by parasympathetic muscarinic fibres, which are inhibited by anti-muscarinic agents. As a result, patients tend to retain urine and develop overflow incontinence.

Question 24

What screening tools can be used to assess incontinence issues in older people?

Answer 24

All elderly patients should be asked about bladder and bowel problems. If they report a problem then a more objective assessment is required. The B-SAQ (Bladder Control Self Assessment Questionnaire) is a useful questionnaire that patients can fill out. It gives both a “symptom score” which confirms the presence of a urinary problem and a “bother score” which assesses how much their symptoms affect the patient.

Question 25

What are storage symptoms?

Answer 25

Nocturia Continual urine loss Frequency of micturition Urgency Urge incontinence Stress incontinence

Question 26

Name some voiding symptoms?

Answer 26

Incomplete emptying Hesitancy Intermittent stream Post micturition dribble Terminal dribbling

Question 27

What are some co-morbid conditions that can lead to incontinence?

Answer 27

Dementia PD Stroke MS CCF Musculoskeletal disease

Question 28

important consequences of incontinence?

Answer 28

Isolation
 Depression 
Falls
 Skin infection Admission to care homes
 Reduced quality of life

Question 29

Examination in a patient with incontinence?

Answer 29

1) Cognition: - AMT if concerns regarding cognitive impairment 2) Neurological: - look for clues and assess gait - check dorsiflexion of the toes (S3) and perineal sensation (L1-2) and sensation over the posterior aspect of the thigh (S3) 3) Abdomen: - palpate for enlarged kidneys - palpate abdomen for distended bladder - DRE for anal tone 4) Pelvis: - inspect for vaginal atrophy or prolapse - assess pelvic floor muscle strength (e.g. Oxford classification) 5) Cardiorespiratory: - signs of chronic lung disease or CCF

Question 30

investigations should be performed on a patient presenting with incontinence

Answer 30

1) Frequency/ volume charts: - ask a patient to keep a diary over 3 days recording fluid intake, volume of urine passed and episodes of incontinence 2) Urinalysis: - check for glucose (diabetes), protein (renal pathology), leucocytes and nitrates (infection), haematuria (stones or malignancy) - MC&S 3) Bloods: - FBC, leucocytosis may indicate infection - U&Es, determine renal function - Glucose, rule out diabetes - Calcium, rule out hypercalcaemia which can cause constipation and confusion 4) Imaging

Question 31

What imaging modalities can be used to help investigate incontinence?

Answer 31

A post void bladder scan is an essential first line investigation and should be performed to rule out chronic retention of urine. Other imaging modalities are not routinely indicated unless there are specific indications: - USS abdo: requested if renal failure to evaluate kidney size and look for signs of obstructive uropathy - CT urography: requested if considering renal stones - CT abdo: to exclude abdominal or pelvic masses if these are suspected - Intravenous urogram: useful if renal stones are suspected, but most centres use CT urography now

Question 32

What should be ruled out prior to referral for more complex investigations in incontinence?

Answer 32

UTI

Question 33

What trends are useful to look out for in frequency volume charts?

Answer 33

1) Frequent small volumes of urine - suggests OVERACTIVE BLADDER 2) >1/3 of total urine volume voided at night - suggests NOCTURNAL POLYURIA 3) >2500ml urine/day - indicates POLYURIA 4) Excessive intake of fluid or increased fluid intake in the evening - could lead to increased frequency

Question 34

What is uroflowmetry?

Answer 34

Of the specialist investigations that patients with incontinence can be referred for, this is perhaps one of the more simple ones. It basically measures urine flow rate.

Question 35

Name some transient, reversible causes of incontinence?

Answer 35

These can be remembered by the mnemonic “DIAPPERS”: - Delirium: patients with acute confusional state often develop urinary incontinence - Infection: urinary tract infection can cause bladder irritation - Atrophy: vaginal atrophy is associated with urinary incontinence - Pharmacological - Psychological: several psychiatric diagnoses can lead to incontinence including depression and dementia - Excess urine output: e.g. diabetes or excess fluid intake - Restricted mobility - Stool impaction: essential to rule out constipation as a cause of urinary incontinence, don’t forget a DRE

Question 36

Why are women more at risk of stress incontinence?

Answer 36

Women are more likely to develop stress incontinence for several reasons: - bladder outlet is weaker due to short urethra and lack of prostate - childbirth increases the risk of developing urinary incontinence - obesity can contribute