Incontinence Flashcards
Overactive bladder (OAB)
a) What does it involve?
b) vs. Detrusor overactivity
a) Urinary urgency +/- urge incontinence. Often associated with frequency and nocturia
b) Spontaneous bladder contraction during filling (may be a cause of OAB)
Types of incontinence:
a) Urge
b) Stress
c) Mixed
d) Functional
e) Double
a) Failure of the bladder to store urine because of high bladder pressure. May be associated with overflow.
b) Weakness of the urinary outlet, often arises during raised intra-abdominal pressure
c) Combination of urge + stress
d) Doesn’t get to the toilet in time (cognitive, immobile)
e) Of urine and faeces
Control of micturition
a) Voiding
b) Storage
c) Voluntary control
d) What muscle is most important in women maintaining continence?
a) Pontine micturition centre in midbrain, parasympathetic activity (S2 - S4) on the M3 muscarinic ACh receptors causing detrusor contraction and voiding
b) Sympathetic (T11 - L2) activity contract the internal urethral sphincter to cause filling
c) External urethral sphincter under cortical control - signal to Onuf’s nucleus (sacral) which relays to pudendal nerve (S2 - S4) and causes contraction of striated muscle in EUS and pelvic floor
d) Periurethral striatal muscle in the pelvic floor (often damaged as a consequence of instrumentation during vaginal childbirth)
What type of incontinence is commonly caused by:
a) Dementia
b) Alpha-adrenergic blockers (e.g. doxasozin)
c) Muscarinic antagonists (anticholinergics)
d) Prostatectomy
e) Neurogenic bladder (due to CNS/PNS damage)
f) Constipation
a) Functional
b) Stress - blocks alpha adrenergic stimulation of the external urethral sphincter, resulting in decreased tone and consequent stress incontinence
c) Overflow - e.g. amitryptilline, oxybutynin. The latter is used to treat urge incontinence/OAB but may lead to retention and overflow
d) Stress - prostate is important in retaining continence in men due to obstruction of bladder outlet.
e) Overflow - may be spastic or flaccid. Leads to retention and overflow dribbling
f) Overflow - treat with disimpaction and laxatives
Incontinence screening
a) Questionnaire - what does it assess?
a) Bladder Control Self Assessment Questionnaire (B-SAQ) - assesses symptoms (urgency, frequency, nocturia, incontinence) and how much it bothers patients
b)
Symptoms:
a) Of voiding
b) Of storage
a) Hesitancy, intermittent stream, incomplete emptying, terminal dribbling
b) Urgency, frequency, nocturia, incontinence
Assessing incontinence:
a) History - symptoms? what components may need adding? Social history?
b) Examination
c) Assessment of pelvic floor strength in women
a) Symptoms of storage and voiding, and also other urinary Sx: pain, dysuria and haematuria.
Systemic: fever, weight loss, back pain, bowel function. Added components: Sexual, Obs/Gynae.
SHx: smoking, alcohol, caffeine, ADLs
b) Cognitive (AMT/MMSE), Neuro (gait, perineal sensation, leg weakness), Abdo (DRE for impaction/ prostate Ca, masses, full bladder, enlarged kidneys), pelvic (female - assess for vaginal atrophy/prolapse and assess pelvic floor strength)
c) Oxford Grading System (vaginal palpation):
0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good (with lift) and 5 = strong
Incontinence:
a) Causes
b) Reversible causes (DIAPPERS)
c) Complications
a) Chronic cough, obstetric history, neurological disease (stroke, PD, MS, spinal cord), dementia, diabetes, UTI, Heart failure (BNP levels and medications - diuretics and ACE, cough)
b) Delirium, Infection, Atrophy (vaginal), Pharmacological (alpha-blockers, anticholinergics, diuretics, oestrogens, ACE inhibitors), Psych (depression, anxiety, dementia), Excess UO (diabetes, CCF), Restricted mobility (functional), Stool impaction (assess via DRE)
c) Care home admission, depression, infections, falls, pressure ulcers, impaired QoL
Investigating incontinence: simple 1st line
a) Urine-related (2)
b) Bloods
c) Imaging
a) - Frequency/volume chart: Ask the patient to complete a diary over a three day period that records fluid intake, volume of urine passed and episodes of incontinence.
- Urinalysis: glucose (diabetes), protein (kidney),
leucocytes and nitrites (UTI), blood (UTI, renal stones or urinary tract malignancy) +/- MSU for M, C and S
b) Bloods: FBC (infection, malignancy), UEs (renal, metabolic), Glucose (diabetes), Calcium (malignancy; hypercalcaemia can cause constipation and confusion)
c) Imaging: Post void bladder USS (rule out chronic retention of urine)
Investigating incontinence: 2nd line (if indicated)
a) More complex bladder studies, AKA…? - examples
b) If haematuria - ?
c) True intravesical pressure is the intravesical pressure minus the…?
d) Imaging
a) Urodynamics (e.g. uroflowmetry, cystometry)
b) Cystoscopy to rule out bladder cancer
c) Intra-abdominal pressure (measured using rectal pressure as a surrogate)
d) Renal stones - CT urography, Abdo masses - CT abdo
Frequency/volume charts:
a) OAB
b) Nocturnal polyuria define
c) Polyuria define
d) Fluid intake issues
e) Urge incontinence
a) Frequent small volumes of urine
b) > 1/3 of the 24 hour urine is produced at night
c) > 2500 ml urine / day
d) Excessive intake of fluid or increased fluid intake in the evening – this could lead to increased frequency
e) Frequent small volumes of urine (as with OAB), AND episodes of incontinence
Uroflowmetry:
a) Plots ___ rate (ml/s) against time (s)
b) Area under curve = ?
c) Test combining uroflowmetry with pre- and post-void bladder scan
a) Flow rate vs. time
b) Urine volume voided
c) Ultrasound Cystodynamogram
Interpreting uroflowmetry results:
a) Exaggerated flow rate and decreased time to maximal flow
b) Prolonged flow time and reduced flow rate
c) Intermittent flow
a) Detrusor overactivity
b) Bladder outlet obstruction
c) Straining
Faecal incontinence:
a) In post-op patient - possible cause?
b) Management of impaction
c) What blood tests may find cause for constipation?
a) Overflow from impaction, due to opiates and poor fluid intake
b) Disimpact with PR and suppositories/enemas (may need surgical evacuation), then oral laxatives, encourage good fluid intake and mobilisation
c) Calcium and TFTs
Managing urinary incontinence:
a) Treat reversible causes (DIAPPERS)
a) Delirium, Infection, Atrophy (vaginal), Pharmacological (alpha-blockers, anticholinergics, diuretics, oestrogens, ACE inhibitors), Psych (depression, anxiety, dementia), Excess UO (diabetes, CCF), Restricted mobility (functional), Stool impaction (assess via DRE)
b)
