Incontinence

Question 1

Why is incontinence an important topic?

Answer 1

Common
Stigmatising
Disability
Treatable
Drs bad at treating it
If left untreated can often become permanent

Question 2

In which groups of people is urinary incontinence most common?

Answer 2

3x more common in women

More common in those having hospital care, nursing home residents, those in residential care

Question 3

Is incontinence a symptom or a diagnosis?

Answer 3

Symptom with many causes

Must find and treat the cause

Question 4

What are the two groups of causes of incontinence?

Answer 4

Extrinsic to urinary system (environment, habit, physical fitness etc)

Intrinsic to urinary system (problem with urinary bladder/bladder outlet)

Often bit of both

Question 5

What are the extrinsic factors contributing to urinary incontinence?

Answer 5

Physical state and comorbs 
Reduced mobility
Confusion (delirium, dementia)
Drinking too much or at the wrong time
Diuretics
Constipation
Home or social circumstances

Question 6

Continence depends on the effective function of what three things?

Answer 6

Bladder and urethra
Local innervation
CNS connections

Question 7

What are the functions of the bladder?

Answer 7

Storage of urine

Voiding

Question 8

What muscle is in the bladder wall? What kind of muscle is it?

Answer 8

Detrusor

Smooth

Question 9

What is the internal urethral sphincter made from?

Answer 9

Smooth muscle

Question 10

What is the external urethral sphincter composed of?

Answer 10

Striated muscle

Question 11

What does urine storage involve?

Answer 11

Detrusor relaxation

With filling <10cm pressure to normal volume 400-600ml combined with sphincter contraction

Question 12

What does voluntary voiding involve?

Answer 12

Voluntary relaxation of external urethral sphincter
Involuntary relaxation of internal urethral sphincter
Contraction of bladder

Question 13

What is the parasympathetic supply to the bladder and what does it’s stimulation result in?

Answer 13

S2-4

Increases frequency and strength of contractions of detrusor

Question 14

What is the sympathetic supply to the detrusor and what does it’s stimulation result in?

Answer 14

T10-12
B-adrenoreceptor
Causes detrusor to relax

Question 15

What is the sympathetic supply to the neck of the bladder and what does it’s stimulation cause?

Answer 15

T10-S2
A-adrenoreceptor
Causes contraction of neck of bladder and internal urethral sphincter

Question 16

What is the somatic nervous supply to the bladder?

What does it’s stimulation cause?

Answer 16

S2-4

Contraction of pelvic floor muscles (urogenital diaphragm) and external urethral sphincter

Question 17

How do centres in the CNS contribute to continence?

Answer 17

By inhibiting parasympathetic tone and promoting bladder relaxation leading to storage of urine

Question 18

What is bladder sphincter closure mediated by?

Answer 18

Reflex increase in a-adrengeric and somatic reflexes

Question 19

What is the function of the pontine micturition centre?

Answer 19

Exerts a storage programme of neural connections until a voluntary switch to voiding programme occurs

Question 20

What other parts of the CNS are involved in micturition?

Answer 20

Frontal cortex

Caudal part of spinal cord

Question 21

What are the intrinsic factors for urinary incontinence?

Answer 21

Bladder or outlet is too weak or too strong

Question 22

If the bladder outlet is too weak what kind of incontinence results?

Answer 22

Stress incontinence

Question 23

What are the characteristic features of stress incontinence?

Answer 23

Urine movement on laughing, coughing, squatting, movement etc.
Weak pelvic floor muscles
Common in those who’ve had children, esp after menopause

Question 24

What are the treatment options for stress incontinence?

Answer 24

Physiotherapy
Oestrogen cream
Duloxetine

Question 25

What are the surgical treatment options for stress incontinence?

Answer 25

TVT/colposuspension

Question 26

What may be involved in physiotherapy for stress urinary incontinence?

Answer 26

``` Pelvic floor muscle training Vaginal cones Biofeedback Kegel exercisers Pelvic floor simulation ```

Question 27

What kind of incontinence occurs if the bladder outlet is too strong?

Answer 27

Urinary retention with overflow incontinence

Question 28

What are the characteristic features of urinary retention with overflow incontinence?

Answer 28

Poor urine flow, double voiding, hesitancy, post-micturition dribbling

Question 29

What causes urinary retention with overflow incontinence? In which group is it most common?

Answer 29

Urethral blockage | Older men with BPH

Question 30

How do you treat urinary retention with overflow incontinence?

Answer 30

Alpha blocker (relaxes sphincter, eg tamsulosin) or anti-androgen (shrinks prostate, eg finasteride) or surgery, eg TURP May need catheterisation, often suprapubic

Question 31

What kind of incontinence results from the bladder muscle being too strong?

Answer 31

Urge incontinence

Question 32

What are the characteristic features of urge incontinence?

Answer 32

Detrusor contracts at low volumes Sudden urge to pass urine immediately Patients often know every public toilet

Question 33

What can cause urge incontinence?

Answer 33

Bladder stones | Stroke

Question 34

How do you treat urge incontinence?

Answer 34

Anti-muscarinics (relaxes detrusor), eg oxybutinin, tolterodine, solifenacin Bladder retraining

Question 35

Apart from anti-muscarinics, what other drugs can be used to relax the detrusor?

Answer 35

Beta-3 adrenoreceptor agonists (eg mirabegron)

Question 36

What do alpha blockers do?

Answer 36

Relax bladder neck and sphincter | Egs - tamsulosin, terazosin, indoramin

Question 37

Name two anti-androgen drugs

Answer 37

Finasteride | Dutasteride

Question 38

What is neuropathic bladder?

Answer 38

Underactive bladder Rare Usually secondary to neurological disease, typically MS/stroke Also secondary to prolonged catheterisation No awareness of bladder filling leading to overflow incontinence

Question 39

How to treat neuropathic bladder?

Answer 39

Medical treatments unsatisfactory but parasympathiometics may help Catheterisation is only effective option

Question 40

What should be your scheme for assessing incontinence?

Answer 40

Hx (ensure to rule out extrinsic factors) Intake chart and urine output diaries General Ex and rectal/vaginal Urinalysis and MSSU Bladder scan for residual volume Refer to incontinence clinic for further Ix Suggest behaviour/lifestyle changes and maybe stopping drugs Consider physio, medical or surgical Rx

Question 41

When should you refer urinary incontinence to a specialist?

Answer 41

After failure of initial management (max 3 months of pelvic floor exercise, cone therapy, habit retraining, and/or appropriate medications)

Question 42

When should you refer on a first visit with someone with urinary incontinence?

Answer 42

Vesico-vaginal fistula Palpable bladder after voiding or confirmed large residual urine volume after voiding Disease of CNS Certain gynae conditions, eg fibroids, procedentia, rectocele, cystocele) Severe BPH or prostatic carcinoma Patients who’ve had previous surgery for incontinence Other in whom a diagnosis has not been made

Question 43

When should you refer to a specialist for faecal incontinence?

Answer 43

Failure of initial management Referral at onset if suspected sphincter damage or neurological dx

Question 44

What are last resort treatment options?

Answer 44

``` Incontinence pads Urosheaths CISC Long term urinary catheter Suprapubic catheter ```