Incontinence

Question 1

Stress Incontinence

Characteristic features:

Treatments:

Answer 1

Bladder outlet too weak – Weak pelvic floor muscles

Urine leak on movement, coughing, laughing, squatting
- Common in women with children (esp. after menopause)

Physiotherapy, oestrogen cream and duloxetine (antidepressant)
Surgical option – TVT/colposuspension

Question 2

Urinary retention with overflow incontinence

Characteristic features:

Treatments:

Answer 2

Bladder outlet ‘too strong’ – Blockage to urethra

Poor urine flow, double voiding, hesitancy,
post micturition dribbling
- Older men with BPH

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

Question 3

Urge Incontinence

Characteristic features:

Treatments:

Answer 3

Bladder muscle ‘too strong

Detrusor contracts at low volumes
Sudden urge to pass urine immediately

Can be caused by bladder stones or stroke

anti-muscarinics (relax detrusor)
e.g. oxybutinin, tolterodine, solifenacin
Bladder re-training sometimes helpful

Question 4

Antimuscarinics

Answer 4

(relax detrusor)

oxybutinin, tolterodine

Question 5

Beta-3 adrenoceptor agonists

Answer 5

(relax detrusor)

mirabegron

Question 6

Anti-androgen drugs

Answer 6

(shrink prostate)

finasteride, dutasteride

Question 7

Alpha-blockers

Answer 7

(relax sphincter, bladder neck)

tamsulosin, terazosin, indoramin

Question 8

Neuropathic Bladder – Underactive bladder

Characteristic features:

Treatments

Answer 8

Secondary to neurological disease, MS or stroke
SECONDARY TO PROLONGED CATHETARISATION

No awareness of bladder filling resulting in overflow incontinence

Medical treatments unsatisfactory but parasympathomimetics might help
Catheterisation is only effective treatment

Question 9

Assessing Incontenence

Answer 9

Impact of incontinence and identify ‘extrinsic’ factors
Intake chart and urine output diaries
General examination to include rectal and vaginal examination
Urinalysis and MSSU
Bladder scan for residual volume
Suggest lifestyle/behavioural changes and stopping unnecessary drugs

Question 10

Consider referral to incontinence clinic for further investigation in difficult cases

Answer 10

after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)

Question 11

Specialist Referral

Answer 11

Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume of urine after micturition
Disease of the CNS
Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
Severe benign prostatic hypertrophy or prostatic carcinoma
Patients who have had previous surgery for continence problems