Incontinence Flashcards
What is the epidemiology of incontinence (3)
1 in 30 worldwide
40% women >60
50% in care
What is the main muscle affected in stress incontinence?
Periurethral striated muscle
- Normally allows for voluntary interruption of abdo pressure to prevent leakage
- Most commonly affected mm in instrumental childbirth
Why are women more prone to stress incontinence? (2)
Bladder outlet weaker due to shorter urethra/no prostate
Childbirth esp forceps → lig/nn damage
What are some other RFs for stress incontinence (8) (other than being a woman)
Obesity (strain/pelvic floor weaker)
Age
Post menopausal
Surgery
Post hysterectomy
UTI
Bladder outlet obstrn (e.g. prostate)
Neuro disease
What is urge incontinence?
What is the basic physiology behind it?
Involuntary urine leakage w. sense of urgency
Detrusor instability/ Hyperreflexia → invol contraction
What are some causes of urge incontinence? (4)
Idiopathic - commonest
Infective - UTI
Neuro - MS/Parksinsons/Stroke/SC injury
Bladder outlet obstrn (e.g. prostate)
What are the diff types of incontinence (7)
Stress Urge Mixed (urgency/exertion) Functional (mobility reaching toilet in time) Overflow (freq/noct/retention) Detrusor overactivity Overactive bladder
What elements of incontinence may be present in prostatism (3)
Urinary retention + Overflow
Outlet obstrn
Retention has irritant effects → detrusor instability
What nerve fibres/roots are involved in micturition?
Describe the interface b/wn parasymp/symp control in micturition
Parasymp + pudendal nn (somatic) = S2-4
Sympathetic = T11-L2
Sympathetic neck contraction → allows filling
Voiding depends of parasymp - opening bladder neck
FOLLOWED BY
Voluntary EUS relaxation
List some causes of bladder outlet obstrn (11)
Benign prostate hypertrophy (BPH)
Prostate cancer
Phimosis
Stricture (male predom)
Cervical cancer
Bladder cancer Colon cancer Calculi STDs Trauma Blood clot
What is Overactive Bladder? (OAB)
Syndrome of urgency ± urge incontinence
Usually + frequency/nocturia
Assoc w. detrusor overactivity
What is the epidemiology of BPH in men?
40% >60s + 75% >80s
List some organic causes for transient incontinence
DIAPERS
Delirium Infection Atropic (vag/urethritis) Pharm Excess urine Restricted mobility Stool impaction
List some medication RFs for urinary incontinence (OD AAAACCH) + why
Opiates
Diuretics
Alpha-adreno blockers
Alpha agonists
ACEis
Antipsychotics
Cholinesterase inhibs
Ca chan blockers
Hypnotics
What are some of the urinary storage Sx that should be asked for in the Hx (6)
+ Voiding Sx (5)
Storage Sx: Continual urine loss Frequency micturition (≥8/d) Nocturia (≥3/night) Urge incontinence Stress incontinence
Voiding Sx: Hesitancy Intermittent stream Incomplete emptying Terminal dribbling Post-micturition dribble
What co-morbiditities should be asked about in the PMH in incontinence (9)
Dementia
Stroke
MS
PD
CCF
Chronic lung disease
DM
MSk disease
Pelvic surg/OG Hx
What should be included O/E in incontinence (6)
Cognition
Neuro: dorsiflexion + sensation posterior thigh (S3) + sensation sole (S1)
Abdo: kidneys/distended bladder
DRE: prostate / constipation
Pelvic: prolapse / cough
Cardioresp: CCF / chronic lung disease
What Ix may be done in incontinence (10)
Urinary diary (3d) - intake/vol passed/incontinent eps Urinalysis (Glucose/Prot/L+Ns/Blood/MC+S)
Bloods: U&Es FBC (leucocytosis - infection) Glucose Calcium (hypercalcaemia → constipation/confusion)
Imaging:
Post-void bladder scan (1st line- rule out chronic retention)
Only if indicated:
USS Abdo - obstr uropathy/renal failure
CT Abdo - masses
CT urography - stones
IV urogram - stones (CT urography more commonly done)
What info may be given from a urinary diary?
Polyuria (>2500ml/d)
Nocturia (1/3rd urine at night)
Frequent small vols = overactive (+ if with incont = urge)
What specialist urology tests may be used in incontinence (5)
Uroflowmetry USS Cystodynamogram (flowmetry + pre/post-void scan) Cystometry (if still uncertain after flowmetry ± USS)
Videourodynamics - saline fill bladder, pressure transducers (urethra/rectum)
Ambulatory urodynamics - same but less artificial, transducers + electronic continence pads
What is always 1st line RE: Management in incontinence?
What red flags may → secondary referral? (4)
1st line always: Pt education / MDT (Non-Pharm therapy)
Red flags: Haematuria Painful micturition Prolapse beyond introitus Suspect prostate cancer
What elements of pt education should be covered in the management of ALL types of incontinence (5)
Smoking
Alcohol/Caffeine
Reduce fluid intake (esp after 8pm)
Wt reduction
Manage constipation
Describe the MDT/Medical/Surgical management of Stress Incontinence (4:1:3)
MDT:
Community continence advisor (assess pt in home)
Physio - pelvic floor
Pudendal nn stimulation (device; strength altered)
Vaginal cones (improve mm awareness)
Medical - SNRIs limited evidence, none recommended
Surg:
TVT / Colposuspension / Periurethral bulking agents
Describe the MDT/Medical/Surgical management of Overactive Bladder (3:4:1)
MDT (must trial ≥6wks):
Community continence advisor
Physio
Behavioural Therapy - bladder retraining
Medical:
Antimuscarinics
Beta3 agonists - if probs with antimuscarinics
Intravaginal oestrogens (if vag atrophy + OAB Sx)
Botox
Surg: Sacral nn stimulation
Describe the MDT/Medical/Surgical management of Bladder Outlet Obstrn (3:3:1)
MDT:
Community continence advisor
Physio
Behavioural therapy - bladder retraining
Medical:
Alpha-antagonists (doxazocin)
Alpha reductase inhibitors (block testost. conversion)
OAB drugs (antimuscarinics/b3 agonists)
Surgical:
Transurethral prostatectomy
What are the SEs of anti-muscarinics (6)
Cognitive impairment/hallucinations Blurred vision Dry mouth Tachycardia Nausea/constipation Urinary retention
