Incontinence Flashcards
What is incontinence?
A condition where involuntary loss of urine is a social or hygenic problem and is objectively demonstrable.
What is the incidence of urinary incontinence in the adult population? How many people in total are affected in Australia?
Women = 1 in 4
Men = 1 in 8
4.8 million
What is continence important for?
- Self-esteem, function and independence
- Personal hygiene
- Ongoing PA
- Quality of life
- Decreased risk of falling
- Decreased personal and community cost of living
What percentage of incontinence sufferers can improve with conservative management?
75% can be cured or improve
What does incontinence cost the healthcare system?
$42.9 billion
What is the most common reason for nursing home admission?
Faecal incontinence
What factors can shift a client’s care options from community based care to residential care?
- Carer stress/ability to cope
- Dementia/cognitive function
- Functional ability and ADLs
- Incontinence
- Mobility
- Support networks
What is the prevalence of incontinence in the elderly in various settings?
High care homes: 77%
At home: 15-30%
In hospital: 20-30%
What are the six R’s of clinical effectiveness?
- Right person
- Right thing
- Right way
- Right place
- Right time
- Right results
What muscle is responsible for voluntary control of urethral and anal sphincter?
Pubococcygeus
What are the two muscle types in the pelvic floor and what are they responsible for?
- Slow twitch: hold pelvic organs in position, contracting when up and about
- Fast twitch: sustain short, sharp contraction
What does levator ani do during coughing?
Augments bladder neck support
What three nerves innervate the lower urinary tract?
- Pelvic parasympathetic nerves
- Lumbar sympathetic nerves
- Pudendal nerves
What are the causes of incontinence?
- Surgical
- Medical
- Biomechanical
- Environment
What factors can exacerbate incontinence?
- Diet: low fibre, caffeine, low fluid
- Lifestyle
- Obesity
- Smoking
- Lighting
- Distance to facilities
- Trip factor
What are the specific surgical causes of incontinence?
- Abdominal surgery
- Hernia repair
- Pelvic surgery
- Pelvic irradiation
- TURP/prostatectomy
- THR/NOF fracture
What are the reversible causes of incontinence?
- Delirium/dementia
- Infections
- Atrophic vaginitis
- Psychological causes
- Pharmaceutical agents
- Endocrine condition e.g. diabetes
- Restricted mobility
- Stool impaction
What are the medical causes of incontinence?
- Chronic bowel disease
- Chronic cough
- Dementia
- Diabetes
- Medications
- Neurological conditions
What are the biomechanical and environmental causes of incontinence?
- Acute or chronic LBP/SIJ
- COPD/smoker/hayfever
- History of falls
- Increasing age
- Obesity
- Decreased mobility, dexterity, eyesight, cognition
- Weakness
What are the seven types of incontinence?
- Stress
- Urge
- Over-active bladder syndrome
- Overflow
- Nocturia/nocturnal enuresis
- Functional incontinence
- Faecal incontinence
What is stress incontinence?
Involuntary loss urine (usually small amounts) with increased intra-abdominal pressure e.g. cough, laugh, exercise sport, changing position
What is urge incontinence?
Uncontrollable urge go to toilet Sensory = outside stimulus - urinate Motor = bladder muscle contracts for no reason (detrusor instability)
What is overflow incontinence?
Incomplete emptying bladder
Develop insidiously
Commonly with neurologic problems e.g. MS
Caused by trauma e.g. childbirth or obstruction (enlarged prostate)
What is nocturia?
Waking up go to toilet > 1 per night
Due to nocturnal frequency or nocturnal polyuria
Possible day problems
What is nocturnal enuresis?
Involuntary loss of urine during sleep
Due to medication, small bladder, decreased ADH & fluid intake
What is involved with an overactive bladder?
Combination urgency & frequency – Nocturia
+- wetting
Insidious onset
What is functional incontinence?
Cognitive impairment & or physical functioning or environmental barriers
Physically incapable reaching toilet in time, or cannot perceive need to void
Frequent frail aged
How is incontinence assessed?
- Normal clinical history
- Bladder diary
What general management options are there for incontinence?
- Empathy
- Improving environment
- Good bladder habits
What is considered normal bladder function?
- Number of voids: 4-6 (up to 8)
- Number of time to toilet during the night = 0-1 (2)
- Normal volume passed: 300-600ml
What is the aim of bladder training?
Decrease frequency of urination and increase quantity
What are good bladder habits?
- Good fluid intake, including limiting caffeine and alcohol
- Sufficient time for urination
- Avoid ‘just in case’ toileting
- Avoid constipation
What should physiotherapy intervention for incontinence include?
- Pelvic floor exercises
- Lower limb strength
- Upper limb function
- Appropriate aids
What is the aim of pharmacology in the treatment of incontinence?
- Increased bladder emptying
- Increased bladder storage
- Increased outlet resistance
- Decreased outlet resistance
What is faecal incontinence?
Involuntary loss of flatus, liquid or solid, stool that is a social or hygienic problem
What makes aspects ‘normal’ bowel?
- Regularity: 3 x day to 3 x a week
- Colour: brown
- Consistency: longer digestion = drier and harder
What are the causes of faecal incontinence?
- Constipation
- Related co-morbidities
- Functional FI
- Anorectal incontinence
- Loose stools/diarrhoea
- Rectal/colonic disease
What are the risk factors for faecal incontinence?
- Immobility
- Parkinson’s
- Diabetes mellitus
- Dementia
- Depression
What should the management of bowel incontinence involve?
- MDT
- Defecation techniques
- Biofeedback
- Pelvic floor muscle training
- Bowel habits, diet, fluid
What should the management of diarrhoea involve?
- GP/specialist review may be necessary
- Soluble fibre intake
- Fluid intake
- Decrease alcohol, caffeine and smoking
What treatment may be used for urinary tract infections?
- Antibiotics
- Decrease pelvic floor and anterior urethral colonisation
- Personal hygiene
What kinds of catheters can be used to manage urinary dysfunction?
- Suprapubic catheter (SPC)
- Indwelling catheter (IDC)
- Intermittent self-catheterisation (CISC)
What are the functions of the pelvic floor?
- Bladder inhibition
- Maintain anorectal angle
- Occlusive force to external urethral sphincter
- Pelvic organ support
- Rectal support during defecation
- Sexual function
What factors contribute to pelvic floor dysfunction?
- Type of connective tissue
- Pregnancy
- Menopause
- Medication
- Obesity
- Perineal trauma
- Urinary retention
What is pelvic organ prolapse (POP)?
Descent of pelvic organs towards introitus associated with vaginal wall & pelvic ligament weakness
What causes pelvic organ prolapse?
- Stretched pelvic fascia & ligaments
- Many large babies
- Patient with “cervix on view” at delivery = higher risk of future prolapse
- Constipation & chronic cough
- Heavy lifting
- Chronic low back pain/weak TA
How does pelvic pain behave/present?
- Aggravated by stress
- Mechanical component
- If spinal dysfunction present = may interact with myofascial dysfunction
- Visceral symptoms (diarrhoea, constipation, period pain)
What treatments exist for pelvic pain?
- Biofeedback & electrical stimulation
- Dilators
- Down training
- Exercises
- Lifestyle interventions
- Manual therapy
What is the incidence of incontinence in the younger population?
1 in 20
What are the three most common factors contributing to nursing home admission?
- Urinary incontinence
- Poor mobility
- Dementia
What percentage of pregnant women experience incontinence?
46%
What does the urinary tract system consist of?
- Kidneys
- Ureters
- Bladder
- Urethra
What is the muscle of the bladder?
Detrusor
What is the group of deep muscle layers of the pelvic floor called?
Levator ani
What are the three sections of the levator ani?
- Pubococcygeus
- Illiococcygeus
- Ischiococcygeus
What muscles are in the pelvis?
- Iliococcygeus
- Pubococcygeus
- Coccygeus
- Puborectalis
- Rectourethralis
- Piriformis
- Obturator internus
What are the three distinct bands of fibres found in the pubococcygeus muscle?
- The pubovaginalis
- The puborectalis
- The pubococcygeus proper
What is the role of sympathetic control of the bladder and what does it involve?
Allows the bladder to fill.
The release of NE relaxes the smooth muscles in the bladder wall and excites the smooth muscles in the sphincter valve.
What is the role of parasympathetic control of the bladder and what does it involve?
Empties the bladder.
The release of ACh relaxes the smooth muscles in the sphincter valve and excites the smooth muscles in the wall of the bladder, forcing the contents of the bladder out
What occurs during normal voiding mechanism?
- The brain sends nerve signals telling muscles to hold urine or let it out.
- Nerves send signals to the brain. telling the brain when the bladder is full or empty.
Where can communication breakdowns occur in the voiding mechanism?
- No message is sent by the brain (incontinence)
- Brain does not receive message of fullness (incontinence)
- Unable to void, remains in filling phase (retention)
- Senses fullness but cannot regulate (retention)
What are the barriers to seeking help for incontinence?
- Embarrassment
- Social stigma
- Inevitable, untreatable and a normal part of aging
- Language, level of education and cultural factors
- Lack of bathroom privacy
- Inadequate identification and assessment by health professionals
What are the risk factors for constipation?
- Polypharmacy
- Anticholinergic drugs
- Opiates
- Iron supplements
- Calcium channel antagonists
- NSAIDs
- Immobility
- Institutionalisation
- Parkinson’s disease
- Diabetes mellitus
- Low fluid intake
- Low dietary fibre
- Dementia
- Depression
What are the signs of a urinary tract infection?
- Increased body temperature
- Confusion
- Frequency of urination
- Stinging
What is chronic pelvic pain?
Chronic or recurrent pelvic pain that apparently has a gynaecological origin but for which no definitive cause is found
What issues are associated with persistent or recurrent episodic pelvic pain?
- Symptoms of LUT
- Sexual dysfunction
- Bowel dysfunction
- Gynaecological dysfunction
Causes of pelvic pain
- Overexertion of PFM
- ‘Wind-up’
- Hyperalgesia
- Central sensitisation
- Physical and sexual abuse
What components should be included in a PFM assesment?
- Observation
- Sensation and neural
- Palpation external and internal
- PFM contraction
- Spasm
- Relaxation
What treatment options are available for pelvic pain?
- Exercise
- Down training
- Manual therapy: myofascial and trigger points
- Biofeedback and electrical stimulation
- Dilators
What should the management of chronic pelvic pain involve?
- Full release
- Soft tissue mobilisation
- Biofeedback
- Feedback
- Heat/ultrasound
