Incontinence Flashcards
Why is incontinence an important topic?
Common Stigmatising Disability Treatable Drs bad at treating it If left untreated can often become permanent
In which groups of people is urinary incontinence most common?
3x more common in women
More common in those having hospital care, nursing home residents, those in residential care
Is incontinence a symptom or a diagnosis?
Symptom with many causes
Must find and treat the cause
What are the two groups of causes of incontinence?
Extrinsic to urinary system (environment, habit, physical fitness etc)
Intrinsic to urinary system (problem with urinary bladder/bladder outlet)
Often bit of both
What are the extrinsic factors contributing to urinary incontinence?
Physical state and comorbs Reduced mobility Confusion (delirium, dementia) Drinking too much or at the wrong time Diuretics Constipation Home or social circumstances
Continence depends on the effective function of what three things?
Bladder and urethra
Local innervation
CNS connections
What are the functions of the bladder?
Storage of urine
Voiding
What muscle is in the bladder wall? What kind of muscle is it?
Detrusor
Smooth
What is the internal urethral sphincter made from?
Smooth muscle
What is the external urethral sphincter composed of?
Striated muscle
What does urine storage involve?
Detrusor relaxation
With filling <10cm pressure to normal volume 400-600ml combined with sphincter contraction
What does voluntary voiding involve?
Voluntary relaxation of external urethral sphincter
Involuntary relaxation of internal urethral sphincter
Contraction of bladder
What is the parasympathetic supply to the bladder and what does it’s stimulation result in?
S2-4
Increases frequency and strength of contractions of detrusor
What is the sympathetic supply to the detrusor and what does it’s stimulation result in?
T10-12
B-adrenoreceptor
Causes detrusor to relax
What is the sympathetic supply to the neck of the bladder and what does it’s stimulation cause?
T10-S2
A-adrenoreceptor
Causes contraction of neck of bladder and internal urethral sphincter
What is the somatic nervous supply to the bladder?
What does it’s stimulation cause?
S2-4
Contraction of pelvic floor muscles (urogenital diaphragm) and external urethral sphincter
How do centres in the CNS contribute to continence?
By inhibiting parasympathetic tone and promoting bladder relaxation leading to storage of urine
What is bladder sphincter closure mediated by?
Reflex increase in a-adrengeric and somatic reflexes
What is the function of the pontine micturition centre?
Exerts a storage programme of neural connections until a voluntary switch to voiding programme occurs
What other parts of the CNS are involved in micturition?
Frontal cortex
Caudal part of spinal cord
What are the intrinsic factors for urinary incontinence?
Bladder or outlet is too weak or too strong
If the bladder outlet is too weak what kind of incontinence results?
Stress incontinence
What are the characteristic features of stress incontinence?
Urine movement on laughing, coughing, squatting, movement etc.
Weak pelvic floor muscles
Common in those who’ve had children, esp after menopause
What are the treatment options for stress incontinence?
Physiotherapy
Oestrogen cream
Duloxetine
What are the surgical treatment options for stress incontinence?
TVT/colposuspension
What may be involved in physiotherapy for stress urinary incontinence?
Pelvic floor muscle training Vaginal cones Biofeedback Kegel exercisers Pelvic floor simulation
What kind of incontinence occurs if the bladder outlet is too strong?
Urinary retention with overflow incontinence
What are the characteristic features of urinary retention with overflow incontinence?
Poor urine flow, double voiding, hesitancy, post-micturition dribbling
What causes urinary retention with overflow incontinence? In which group is it most common?
Urethral blockage
Older men with BPH
How do you treat urinary retention with overflow incontinence?
Alpha blocker (relaxes sphincter, eg tamsulosin) or anti-androgen (shrinks prostate, eg finasteride) or surgery, eg TURP
May need catheterisation, often suprapubic
What kind of incontinence results from the bladder muscle being too strong?
Urge incontinence
What are the characteristic features of urge incontinence?
Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Patients often know every public toilet
What can cause urge incontinence?
Bladder stones
Stroke
How do you treat urge incontinence?
Anti-muscarinics (relaxes detrusor), eg oxybutinin, tolterodine, solifenacin
Bladder retraining
Apart from anti-muscarinics, what other drugs can be used to relax the detrusor?
Beta-3 adrenoreceptor agonists (eg mirabegron)
What do alpha blockers do?
Relax bladder neck and sphincter
Egs - tamsulosin, terazosin, indoramin
Name two anti-androgen drugs
Finasteride
Dutasteride
What is neuropathic bladder?
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
How to treat neuropathic bladder?
Medical treatments unsatisfactory but parasympathiometics may help
Catheterisation is only effective option
What should be your scheme for assessing incontinence?
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
When should you refer urinary incontinence to a specialist?
After failure of initial management (max 3 months of pelvic floor exercise, cone therapy, habit retraining, and/or appropriate medications)
When should you refer on a first visit with someone with urinary incontinence?
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
When should you refer to a specialist for faecal incontinence?
Failure of initial management
Referral at onset if suspected sphincter damage or neurological dx
What are last resort treatment options?
Incontinence pads Urosheaths CISC Long term urinary catheter Suprapubic catheter
