Incontinence Flashcards
Extrinsic causes of Incontinence
Environment, habit, physical fitness
Causes intrinsic to urinary system
Bladder or urinary outlet issue
Specific Extrinsic factors
Physical state and comorbidities Reduced mobility Confusion; delirium or dementia Drinking too much/at wrong time Medications - diuretics Constipation Home circumstances Social circumstances
Function of bladder
Urine storage and voluntary voiding
Detrusor- type of muscle?
Smooth
Internal urethral sphincter- type of muscle?
Smooth
External urethral sphincter- type of muscle?
Striated
Action of detrusor and sphincter on filling
Detrusor relaxes
Sphincter contracts
Actions on voluntary voiding
Internal sphincter relaxes involuntarily
External relaxes voluntarily
Bladder contracts
Parasympathetic Innervation?
S2-S4
Increases stength and frequency of contractions
Sympathetic
T10-L2
Beta adrenoreceptor - detrusor relaxes
T10-S2
Alpha receptor - contraction of neck of bladder and internal sphincter
Somatic innervation
S2-S4
Contraction of pelvic floor muscle (urogenital diaphragm|) and external sphincter
CNS connections
Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.
What mediates sphincter closure?
Reflex increase in alpha adrenergic and somatic activity
Which centre exerts the storage through neural connections until switch to voiding?
Pontine micturition centre
Which other areas are involved in control of continence?
Frontal cortex
Caudal part of spinal cord
Name a specific intrinsic factor of incontinence?
Stress incontinence
What causes stress incontinence?
Weakness of bladder outlet
Features of stress incontinence
Urine leak on movement, squatting, coughing, laughing
Weak pelvic floor muscles
Common in women with children, after menopause
Treatments of Stress incontinence
Physiotherapy
Oestrogen cream
Duloxetine
Surgery - TVT/colposuspension
Other treatments
Kegel exercises
Kegel exercisers
Vaginal cones
Biofeedback
If bladder outlet ‘too strong’?
Urinary retention with overflow incontinence
Features of urinary retention & overflow incontinence
Poor urine flow, double voiding,
hesitancy, post micturition dribbling
Blockage to urethra
Overflow incontinence is common in?
Older men with Benign Prostatic Hyperplasia
Treatment of urinary retention
Alpha blocker
Antiandrogen
Surgery - TURP
TURP?
Transurethral Resection of the Prostate
Purpose of alpha blocker?
Relaxes sphincter
Example of alpha blocker
tamsulosin
Purpose of antiandrogen?
Shrinks prostate
Example of antiandrogen
Finasteride
Further procedure that may be needed in urinary retention
Catheterisation - suprapubic
Condition when bladder muscle ‘too strong’
Urge incontinence
Features of urge incontinence
Sudden urge to pass urine immediately
What happens the detrusor at low volumes?
Contracts
Causes of urge incontinence
Bladder stone or stroke
Treatment of urge incontinence
Antimuscarinics
Action of antimuscarinics
Relax detrusor
Examples of antimuscarinics
Oxybutinin
Tolterodine
Solifenacin
Other management of urge incontinence
Bladder training
Underactive bladder known as a
Neuropathic bladder
Features of a neuropathic/underactive bladder
No awareness to bladder filling leading to overflow incontinence
Type of incontinence experienced with neuropathic bladder
Overflow
Neuropathic bladder occurs secondary to
Neurological disease, stroke or multiple sclerosis
Treatment
Catheterisation only effective treatment
Medical treatment
Parasympathomimetics- not overly effective but may help
How to assess incontinence
History Examination- general with rectal and vaginal Intake chart and urine output diary Urinalysis, MSSU Bladder scan - residual volume
How to check residual volume?
Bladder scan
Further management
Refer to incontinence clinic Consider lifestyle changes Consider drugs and medication review Refer to physio Medical treatment Surgery
When to refer to specialists
Failure of management - max 3 months pelvic floor exercises
Referral at onset
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
Others in whom a diagnosis has not been made
Referral of faecal incontinence
Failure of initial management
Constipation or diarrhoea with normal sphincter
Referral for faecal incontinence at onset
Suspected sphincter damage
Neurological disease
Options if management fails
Incontinence pads Urosheaths Intermittent catheterisation Long term urinary catheter Surprapubic catheter
Case
85 y/o lady, taken to bed, incontinent
PMHx: OA, CCF, Type II DM, COPD, anxiety
DHx: Dihydrocodeine 30mg qds
Furosemide 40mg od Combivent nebs qds Ranitidine 150mg bd Prednisolone 10mg od Temazepam 20mg nocte Citalopram 40mg od Metformin 500mg bd
Management
Improve pain relief Increase COPD medications Increase diuretics or other CCF medications Stop furosemide Improve diabetic control (up or down) Minimise risk of syncope Use cough suppressant Stop constipating medications Stop anticholinergic and sedative medications Mobility aids Make toilet more accessible e.g. stair-lift, commode Lifestyle changes (e.g. restrict fluid) Bladder exercises Specific treatments (e.g. tolterodine)
