Incontinence

Question 1

Aetiology

Answer 1

Extrinsic to urinary system: environment, habit, physical fitness

• PHYSICAL STATE + CO-MORBIDITIES
• REDUCED MOBILITY
• CONFUSION - DELIRIUM/DEMENTIA
• DRINKING TOO MUCH/at WRONG TIME
• MEDICATIONS e.g. diuretics
• CONSTIPATION
• HOME CIRCUMSTANCES
• SOCIAL CIRCUMSTANCES

Intrinsic to urinary system: problem w/ bladder or urinary tract outlet

Question 2

Stress incontinence

Answer 2

PATHOPHYSIOLOGY = BLADDER OUTLET TOO WEAK due to WEAK PELVIC FLOOR MUSCLES

• COMMON in WOMEN W/ CHILDREN esp. AFTER MENOPAUSE

PRESENTATION:

• URINE LEAK on MOVEMENT, COUGHING, LAUGHING, SQUATTING (anything that increased intra-abdominal pressure)

MANAGEMENT:

* PHYSIOTHERAPY (PELVIC FLOOR EXERCISES), PESSARIES, VAGINAL CONES, OESTROGEN CREAM, DULOXETINE
* TVT/COLPOSUSPENSION

Question 3

Urinary retention w/ overflow incontinence

Answer 3

PATHOPHYSIOLOGY = BLADDER OUTLET TOO STRONG

• BLOCKAGE to URETHRA, OLDER MEN w/ BPH

PRESENTATION:

* POOR URINE FLOW
* DOUBLE VOIDING
* HESISTANCY
* POST-MICTURITION DRIBBLING

MANAGEMENT:

• ALPHA-BLOCKER (relaxes sphincter - TAMSULOSIN) Or
• ANTI-ANDROGEN (shrinks prostate - FINASTERIDE) Or
• SURGERY (TURP)

May need CATHETERISATION - often SUPRAPUBIC

Question 4

Urge incontinence

Answer 4

PATHOPHYSIOLOGY = DETRUSOR OVERACTIVE (too strong)

• Can be caused by BLADDER STONES/STROKE

PRESENTATION:

* DETRUSOR CONTRACTS at LOW VOLUMES
* SUDDEN URGE to pass urine immediately

• PT. OFTEN KNOW EVERY PUBLIC TOILET

MANAGEMENT:

* ANTI-MUSCARINICS (relax detrusor - OXYBUTININ, TOLTERODINE, SOLIFENACIN)
* BLADDER RE-TRAINING sometimes helpful

Question 5

Neuropathic bladder

Answer 5

PATHOPHYSIOLOGY = UNDERACTIVE BLADDER

* RARE
* SECONDARY to NEUROLOGICAL DISEASE (typically MS/stroke)
* SECONDARY to PROLONGED CATHETERISATION

PRESENTATION:

• NO AWARENESS of BLADDER FILLING - resulting in OVERFLOW INCONTINENCE

MANAGEMENT:

* MEDICAL Rx UNSATISFACTORY, PARASYMPATHOMIMETICS MIGHT HELP
* CATHETERISATION ONLY EFFECTIVE Rx

Question 6

Anatomy + physiology: bladder + urethra

Answer 6

• BLADDER FUNCTION - URINE STORAGE + VOLUNTARY VOIDING

• DETRUSOR = SM
• INTERNAL URETHRAL SPHINCTER = SM
• EXTERNAL URETHRAL SPHINCTER = STRIATED MUSCLE
• URINE STORAGE = involves detrusor muscle relaxation w/ filling pressure (< 10 cm pressure) to normal volume 400 - 600 mL combined w/ sphincter contraction
• VOLUNTARY VOIDING = involves voluntary relaxation of external sphincter + involuntary relaxation of internal sphincter + bladder contraction

Question 7

Anatomy + physiology: local innervations

Answer 7

• S2 - S4 = PARASYMP. = INCREASED STRENGTH + FREQ. of CONTRACTIONS
• T10 - L2 = SYMP. BETA ADRENORECEPTOR = DETRUSOR RELAXATION
• T10 - S2 = SYMP. ALPHA ADRENORECEPTOR = CONTRACTION of BLADDER NECK + INTERNAL URETHRAL SPHINCTER
• S2 - S4 = SOMATIC = CONTRACTION of PELVIC FLOOR MUSCLES (UROGENITAL DIAPHRAGM/perineal membrane) + EXTERNAL URETHRAL SPHINCTER

Question 8

Anatomy + physiology: CNS connections

Answer 8

• CENTRES W/I CNS INHIBIT PARASYMP. TONE - PROMOTES BLADDER RELAXATION + URINE STORAGE
• SPHINCTER CLOSURE mediated by RELFEX INCREASE in ALPHA-ADRENERGIC + SOMATIC ACTIVITY
• PONTINE MICTURITION CENTRE = normally exerts “storage program” of neural connections until voluntary switch to voiding program occurs
• Other areas involved: FRONTAL CORTEX, CAUDAL SPINAL CORD

Question 9

Assessing incontinence

Answer 9

• CAREFUL Hx - may need closed questions
  
  • GOOD SOCIAL Hx to assess impact of incontinence + identify extrinsic factors
  • INTAKE CHART + URINE OUTPUT DIARIES
  • GENERAL EXAMINATION to incl. RECTAL + VAGINAL EXAM
  • URINALYSIS + MSSU
  • BLADDER SCAN for residual vol.
  • CONSIDER REFERRAL to INCONTINENCE CLINIC for FURTHER INVESTIGATION in DIFFICULT CASES
  • SUGGEST LIFESTYLE/BEHAVIOURAL CHANGES + STOPPING UNNECCESSARY DRUGS
  • CONSIDER PHYSIO, MEDICAL Rx, SURGICAL OPTIONS

Question 10

Urinary incontinence: indications for referral to specialists

Answer 10

• Referral AFTER FAILURE of INITIAL MANAGEMENT - max. 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
• Referral NECESSARY AT ONSET:• Vesico-vaginal fistula
  • Palpable bladder after micturition/confirmed large residual urine vol. after micturition
  • CNS disease
  • Certain gynaecological conditions e.g. fibroids, prosidentia, rectocele, cystocele
  • Severe BPH/prostatic carcinoma
  • Pt. who have had previous surgery for continence problems
  Others in whom diagnosis has not been made

Question 11

Faecal incontinence: indications for referral to specialists

Answer 11

• Referral AFTER of INITIAL MANAGEMENT - constipation/diarrhoea w/ normal sphincter
• Referral NECESSARY AT ONSET:
  • Suspected sphincter damage
  • Neurological disease

Question 12

Management - when all else fails

Answer 12

• INCONTINENCE PADS
  
  • UROSHEATHS
  • INTERMITTENT CATHETERISATION
  • LONG TERM URINARY CATHETER
  • SUPRAPUBIC CATHETER