Incontinence

Question 1

Types of incontinence

Answer 1

Stress  
Overflow
Urge 
Mixed
Functional 
Faecal
Reflex

Question 2

What is Stress incontinence

Answer 2

Damage to the nerves or muscles of the pelvic floor causes inability to retain urine under an increase in IAP (e.g. coughing).

Question 3

What may cause Stress incontinence

Answer 3

Vaginal birth 
F>M (Short urethra, no Prostate) 
Obesity 
TURP
Bladder outlet obstruction

Question 4

What are some symptoms of incontinence

Answer 4

Nocturia
Hesitancy
Frequency
Urgency

Question 5

What’s needed for continence to be maintained

Answer 5

Urethral Pressure > Bladder Pressure (co-ordinated by the bladder, urethra. pelvic floor muscles and the nervous system)

Question 6

What nerve controls bladder contraction + urethral relaxation

Answer 6

Pudendal nn + parasympathetic fibres via pontine micturtion center (S2-S4)

Question 7

What controls Bladder filling + urethral contraction

Answer 7

Sympathetic fibres (T11-L3)

Question 8

What is Urge Incontinence + what are some common symptoms

Answer 8

Failure to store urine due to a chronic increase in bladder pressure, usually urgency +/- incontinence w/ frequency and nocturia

Question 9

What may cause Urge incontinence

Answer 9

Overactive Bladder
Patchy Innervation
Decreased Capacity
Detrusor Muscle Overactivity

Question 10

What is overflow incontinence + what are some common symptoms

Answer 10

Overflow due to chronic urine retention, Small urinary volume, nocturia, nocturia enuresis, hesitancy, poor flow, straining, terminal dribbling

Question 11

What causes chronic retention

Answer 11

Detrusor failure (may be neurological, medication, diabetes, spinal surgery)

Obstruction (may be from BPH, stones, stricture, tumour)

Question 12

What is functional incontinence

Answer 12

Incontinence due to external factors 
Usually: 
1. Decreased Communication
2. Cognitive impairment 
3. Unfamiliar Surroundings
4. Sedation
5. Immobility
6. Clothing

Question 13

Why is incontinence more common in old age

Answer 13

Decreased: 
Bladder Capacity
Blood flow
Nerve Conduction speed 
Collagen
Urethral Health

Question 14

Aetiology of Functional incontinence

Answer 14

DIAPPERS

Delirium
Infection
Atrophy (vaginal)
Pharmacology
Psychological
Excess Urine
Restricted Mobility
Stool Impaction

Question 15

Risk Factors for incontinence

Answer 15

Female
Surgery
Age
Post Menopause
Post Hysterectomy
UTI

Question 16

Common Bladder Outlet obstruction causes

Answer 16

Phimosis
Stricture
STD
Trauma
Calculi
BPH
Cancer (prostate/bladder/cervix/colon) 
Blood Clot

Question 17

What medications commonly cause incontinence + why

Answer 17

Cholinesterase inhibitors (more bladder contraction)
ACE-is (cough, stress incontinence)
Opioids (constipation –> overflow)
Alpha-Blockers (Bladder relaxation)
Anti-Psychotics (anticholinergic effects)
CCB (decreased contractility –> retention)
Diuretics
Alpha Agonist (retention)
Hypnotics (decreased awareness)

Question 18

Urinary Symptom Red Flags

Answer 18

Pain on Micturation
Haematuria
Prolapse
Suspicion of Prostate Cancer

Question 19

How do you assess incontinence + rationalise each investigation

Answer 19

History + Exam
AMT
Full PNS + sensation T11-S4 (L1-L2 = Perineal)
Abdominal exam (masses/distention)
DRE (Constipation? Prostate?)
Pelvic inspection (F, atrophy/prolapse + pelvic floor muscles)
Cardiorespiratory (Lung disease/CCF)
Post Void Bladder Scan (retention)
Frequency/Volume Charts
Urinalysis (UTI?)
Bloods (FBC (infection), U+E (Renal Function), Glucose (Diabetes), Calcium (confusion + constipation)
Imaging (USS Abdo, CTKUB, CT Abdo (if USS abnormal))

Question 20

What are some specialist investigations for incontinence

Answer 20

Uroflowmetry
USS Cystodynamogram (Pre + Post bladder voiding scan)
Cystometry (bladder pressure sensation, capacity + compliance)
Videourodynamics (cystoscopy)
Ambulatory Urodynamics

Question 21

How do you manage stress incontinence

Answer 21

1. Pelvic Floor Exercise
2. Patient Education (WL, Smoking cessation, 3.Constipation, alcohol/caffeine)
3. Duloxetine (SNRI, used off-license for incontinence)
4. Surgical (mid-urethral sling, Colposuspencion, injecting silicone into the urethra)
5. MDT (community continence advisor, pudendal nerve stimulation, Vaginal cone (increases awareness of pelvic muscle contraction)

Question 22

How do you manage overactive bladder

Answer 22

1. Patient Directed (bladder training, prompted voiding, timed voiding)
2. Education (decreased fluid, caffeine, weight, manage constipation)
3. Medical
   anti-muscarinic 1st line
   B3-agonist (mirabegron, alternative to antimuscarinics)
   Intravaginal Oestrogen (decreased atrophy)
4. Surgical (sacral nn stimulation)
   Botox (decreased neurological activity)
5. MDT
   Continence advisor
   Behavioural Therapist (bladder therapist, pelvic floor exercise)

Question 23

How do you manage bladder outlet obstruction

Answer 23

1. Education (decreased fluid, caffeine, weight, manage constipation)
2. Surgical (remove obstruction, e.g. BPH –> TURP)
3. Medical (BPH)
   Alpha Agonist (Doxazocin)
   5-alpha-reductase antagonists (finasteride, decreased testosterone = decreased prostate)
4. MDT
   Continence advisor
   Behavioural Therapist (bladder therapist, pelvic floor exercise)