Incontinence Flashcards
How much more common is urinary incontinence in women versus men?
Three times more common
How common is urinary incontinence in residential care?
25%
How common is urinary incontinence in nursing home care?
40%
How common is urinary incontinence in hospital care?
50-70%
Where is there a peak increase in incidence off urinary incontinence?
Between 50-59 years of age although over 80+ have the highest rates of severe and moderate urinary incontinence
Causes of incontinence?
> Extrinsic to the urinary system
- Environment, habit, physical fitness, etc.
> Intrinsic to the urinary system
- Problem with bladder or urinary outlet
> Often a bit of both
Extrinsic causes of incontinence?
> Physical state and co-morbidities > Reduced mobility > Confusion (delirium or dementia) > Drinking too much or at the wrong time > Medications, e.g. diuretics > Constipation > Home circumstances > Social circumstances
Function of the bladder?
Function of bladder:
> Urine storage
> Voluntary voiding
What is the muscle of the bladder?
Detrusor, which is a smooth muscle
Is the internal or external urinary sphincter smooth or striated muscle?
> Internal urethral sphincter is smooth muscle
> External urethral sphincter is striated muscle
How does voluntary voiding occur?
Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder.
How is urine stored and which volume?
Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction.
What is the local innervation of the urinary tract - Parasympathetic?
S2-S4:
- Increases strength and frequency of contractions
What is the local innervation of the urinary tract - Sympathetic?
T10-L2:
- ß - adrenoreceptor : Causes detrusor to relax.
- a - adrenoreceptor : Causes contraction of neck of bladder, and internal urethral sphincter.
What is the local innervation of the urinary tract - Somatic?
S2-S4:
- Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter
Role of the CNS with urinary storage?
1) Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.
2) Sphincter closure is mediated by reflex increase in a-adrenergic (internal) and somatic activity (External).
3) The pontine micturition centre normally exerts a “storage program” of neural connections until a voluntary switch to a voiding program occurs.
Other areas involved include:
- Frontal cortex
- Caudal part of spinal cord
Intrinsic factors of urinary incontinence?
> Bladder
Outlet
Pelvic floor/Sphincters
In stress incontinence what has happened to the bladder outlet?
Bladder outlet too weak
What are the characteristic features of stress incontinence?
> Urine leak on movement, coughing, laughing, squatting, etc.
Weak pelvic floor muscles
Common in women with children, especially after menopause
Treatments include: physiotherapy (Kegel exercises/pelvic floor stimulators), vaginal cones, oestrogen cream and duloxetine
Surgical option – TVT/colposuspension 90% cure at 10 years
With overflow incontinence what has happened to the bladder outlet?
Bladder outlet ‘too strong’ which leads to urinary retention prior to overflow
What are the characteristic features of overflow incontinence?
> Poor urine flow, double voiding,
hesitancy, post micturition dribbling
Blockage to urethra
Older men with BPH
Treat with alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
May need catheterisation, often suprapubic
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
Can be caused by bladder stones or stroke
Treat with anti-muscarinics (relax detrusor)
e.g. oxybutinin, tolterodine, solifenacin
Bladder re-training sometimes helpful
With urge incontinence what has happened to the bladder muscle?
Bladder muscle ‘too strong
Types of incontinence?
1) Overflow:
- Urethral blackage
- Bladder unable to empty properly
2) Stress:
- Relaxed pelvic floor
- Increase abdominal pressure
3) Urge:
- Bladder oversensitivity from infection
- Neurologic disorder
What are the main drugs used in incontinence?
1) Antimuscarinics (relax detrusor)
oxybutinin, tolterodine, solifenacin, trospium
2) Beta-3 adrenoceptor agonists (relax detrusor)
mirabegron
3) Alpha-blockers (relax sphincter, bladder neck)
tamsulosin, terazosin, indoramin
4) Anti-androgen drugs (shrink prostate)
finasteride, dutasteride
What are the main drugs used in incontinence - relax detrusor?
1) Antimuscarinics (relax detrusor): oxybutinin, tolterodine, solifenacin, trospium
2) Beta-3 adrenoceptor agonists (relax detrusor): mirabegron
What are the main drugs used in incontinence - relax sphincter and bladder neck?
Alpha-blockers (relax sphincter, bladder neck): tamsulosin, terazosin, indoramin
What are the main drugs used in incontinence - shrink prostate?
Anti-androgen drugs (shrink prostate): finasteride, dutasteride
What is the role of antimuscarinics in incontinence?
Relax detrusor
What is the role of Beta -3- adrenoceptor agonists in incontinence?
Relax detrusor
What is the role of alpha-blockers in incontinence?
Relax sphincter and bladder neck
What is the role of anti-androgen drugs in incontinence?
Shrink prostate
What is mirabegron?
Beta-3 adrenoceptor agonists (relax detrusor in incontinence)
What is oxybutinin?
Antimuscarinics (relax detrusor in incontinence)
What is tolterodine?
Antimuscarinics (relax detrusor in incontinence)
What is solifenacin?
Antimuscarinics (relax detrusor in incontinence)
What is trospium?
Antimuscarinics (relax detrusor in incontinence)
What is tamsulosin?
Alpha-blockers (relax sphincter, bladder neck in incontinence)
What is terazosin?
Alpha-blockers (relax sphincter, bladder neck in incontinence)
What is indoramin?
Alpha-blockers (relax sphincter, bladder neck in incontinence)
What is finasteride?
Anti-androgen drugs (shrink prostate in incontinence)
What is dutasteride?
Anti-androgen drugs (shrink prostate in incontinence)
What is a neuropathic bladder?
Underactive bladder
Characteristic features of neuropathic bladder (Underactive bladder)?
> “Rare”
Secondary to neurological disease, typically multiple sclerosis or stroke
ALSO 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
Scheme for assessing incontinence?
1) Careful history – may need closed question
2) Good social history to assess impact of incontinence and identify ‘extrinsic’ factors
3) Intake chart and urine output diaries
4) General examination to include rectal and vaginal examination
5) Urinalysis and MSSU
6) Bladder scan for residual volume
7) Consider referral to incontinence clinic for further investigation in difficult cases
8) Suggest lifestyle/behavioural changes and stopping unnecessary drugs
9) Consider physio, medical treatment or surgical options
Indications for referral to specialists for urinary incontinence?
Urinary incontinence:
1) Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
2) Vesico-vaginal fistula
3) Palpable bladder after micturition or confirmed large residual volume of urine after micturition
4) Disease of the CNS
5) Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
6) Severe benign prostatic hypertrophy or prostatic carcinoma
7) Patients who have had previous surgery for continence problems
8) Others in whom a diagnosis has not been made
Indications for referral to specialist in faecal incontinence?
Faecal incontinence
1) Referral after failure of initial management:
- Constipation or diarrhoea with normal sphincter
2) Referral necessary at onset:
- Suspected sphincter damage
- Neurological disease
Options for incontinence if all else fails?
Options include: > Incontinence pads > Urosheaths > Intermittent catheterisation > Long term urinary catheter > Suprapubic catheter
Options for incontinence?
1) Improve pain relief
2) Increase COPD medications
3) Increase diuretics or other CCF medications
4) Stop furosemide
5) Improve diabetic control (up or down)
6) Minimise risk of syncope
7) Use cough suppressant
stop constipating medications
8) Stop anticholinergic and sedative medications
9) Mobility aids or Make toilet more accessible e.g. stair-lift, commode
10) Lifestyle changes (e.g. restrict fluid)
11) Bladder exercises (Kegel)
12) Specific treatments (e.g. tolterodine)
13) Use containment strategies, etc, etc… a lot can normally be done
