Incontinence Flashcards
What stimulates voiding
Parasympathetic S2-S4
Muscarinic receptors
Contract detrusor muscle
Pelvic nerves
What causes detrusor muscle relaxation (storage)
Sympathetic B-adrenoreceptor have constant inhibitory affect on bladder contraction allowing storage
Hypogastric - T10-L2
What causes internal sphincter contraction (storage)
Sympathetic a-adrenoreceptor
Hypogastric - T10-L2
What allows voluntary motor control over urination
Pudendal S2-S4 control external sphincter contraction and pelvic floor
How does urination occur
Stretch receptors detect filling
Go to spinal cord
Stimulate para and detrusor contracts
How do you have voluntary control over urination
Pontine micturition centre can block para until voluntary switch to voiding occurs
Frontal cortex has overall control
What are age related causes of incontinence
Increased residual volume + decreased capacity
Vaginal atrophy
Prostate hypertrophy
What co-morbidities cause incontinence
Bladder outlet obstruction
Stroke
Spinal cord pathology
Cognitive
What are environmental causes
Assistance Mobility Toilet on different level Home / social Increased water intake
What are reversible causes of incontinence
Polydipsia Medication - diuretics Delerium Prolapse UTI Constipation
What are the types of incontinence
Stress
Urge / overactive bladder
Retention with overflow
Underactive
What is stress incontinence
Leakage on increased intra-abdominal pressure
Pressure > urethral pressure holding sphincter
Weak outlet
What causes SUI
Intra abdominal > urethral pressure
Weak external sphincter / pelvic floor
Hammox laxity stimulating stretch receptors
RF Women with children Post-menopause Obesity Smoking Chronic cough Prostate or pelvic surgery
What causes urge incontinence / overactive bladder (incontinence immediately proceeded by urgency)
Detrusor instability / overactivity
Overactive bladder even if low volume
Bladder stones / cancer
Stroke / neuro
What are the symptoms of urge incontinence / overactive bladder
Frequency
Nocturnal incontinence
Urgency
Patient knows every toilet or never leaves house
What causes retention with overflow
Obstruction - tumour / BPH / urethral stricture / anti-cholinergic
What are the symptoms of overflow
Hesitancy Reduced stream Dribbling Double void Palpable bladder Blockage at urethra
How do you investigate incontinence
History inc social + extrinsic factors
Urine dipstick / MSSU = 1st line to exclude infection
Bladder diary - intake and outtake
Examination - abdominal / PV / PR
Post void residual assessment if can’t void / overflow - bladder scan
Urodynamics if surgery contemplated
Refer to specialist
What do you look for in examination
Anal tone - neuropathic Strength of pelvic floor Constipation as RF for incontinence Prolapse Vaginal atrophy - oestrogen cream may help
When do you refer to a specialist
Failure of initial management
Faecal incontinence
When do you refer at onset
Vesico-vaginal fistula Palpable bladder after micturition CNS disease Severe BPH Previous Rx Fibroids Prolapse - rectocele / cystocele
What is general management of incontinence
Weight control Fluid control Stop unnecessary drugs Reduce irritants - caffeine / alcohol / drugs Make toilet accessible
What do you do if all management fails
Incontinence pads
Urosheath
Catherisation
What is 1st line in SUI
PFMT
Biofeedback to tell if working
What are other Rx for SUI
Duloxitine / Yentreve
Oestrogen cream
Surgery - TVT 1st line or colposuspension
Risk of bladder perforation, vascular injury, erosion of TVT leading to UTI
How is 1st line for urge
Bladder retraining programme + prompted regular toilet
What is drug treatment for urge
Anticholinergics / anti-muscarinics to relax detrusor - Oxybutynin - Mirebegron if >75 Botulinum toxin Sacral nerve stimulation TCA
What are SE of anti-cholinergic
Cognitive
Postural hypo as cholinergic cause dilatation
Retention
Constipation
Eye issues as receptors in eyes cause constriction
Dry mouth
CI
- BPH
- Narrow angle glaucoma
- Myasthenia grans
How do you treat overflow
Relieve obstruction - anti-androgen / TURP for prostate
A-blocker - relax sphincter
When do you use a catheter
Last resort
Symptomatic urinary retention
Bladder obstruction that cannot be cleared
Undue stress
What are main drugs used to treat incontinece
Anti-muscarinic - relax detrusor
B-adrenoreceptor agonist - relax detrusor
Alpha blocker - relax sphincter
Anti-androgen
What causes an underactive bladder
Neurological disease - MS / stroke
Prolonged catheter as muscle atrophy
What are the symptoms of underactive bladder
No awareness of filling
Results in overflow incontinence
How do you treat underactive bladder
Parasympa mimetic might help
Only treatment is catheter
What are the RF for SUI
Age Parity = main RF Menopause Smoking Increase in intra abdominal pressure Pelvic floor trauma Connective tissue disease Nerve problems Pelvic Surgery Obesity
What are other causes of SUI / Ddx that should be looked for
Anxiety Excess fluid UTI Stone Atrophy
What is important in the Hx
Obstetric
Gynae
Medical
Previous PFMT / surgery
