Incontinence Flashcards

1
Q

What is incontinence?

A

Lack of voluntary control over urination or defecation

Multifactorial problem:

  • normal anatomy and function
  • neuro integrity
  • physical mobility and dexterity
  • environment
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2
Q

Innervation of the bladder

A
  • sympathetic fibres travel from the spinal cord T11-L2 to the bladder. These maintain relaxation of the bladder for urine storage.
  • parasympathetic nerves from S2-S4 produce bladder contraction and sphincter relaxation to allow voiding
  • internal sphincter plus external sphincter which is under voluntary control
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3
Q

Clinical types of urinary incontinence?

A

Urge incontinence / overactive bladder

Stress incontinence

Mixed incontinence

Overflow incontinence

Functional incontinence

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4
Q

Tell me about stress incontinence?

A
  • Most common type in women under 75yrs
  • Weakening of urethral sphincter and pelvic floor muscles
  • Occurs with increased intraabdominal pressure (cough, sneeze, laugh, lift)
  • May be in relation to prostate surgery or childbirth or hysterectomy
  • May be provoked by alpha-adrenergic blocks (prazosin/doxazosin)
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5
Q

Tell me about urge incontinence?

A
  • aka overactive bladder, detruser instability / hyperactivity
  • leakage accompanied by urgency
  • most common type in institutionalised elderly and over 75yrs
  • associated frequency and nocturne
  • post void residual volume is normal

Caused by:

Decreased inhibition:

  • intracranial (stroke, mass, haemorrhage)
  • demyelinating disease
  • Alzheimers
  • Parkinsons

increased afferent stimulation:

  • lower UTI
  • atrophic urethritis
  • faecal impaction
  • uterine prolapse
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6
Q

Tell me about overflow incontinence?

A

Reduction in force and calibre of urinary stream, incomplete micturition and voiding.

Over-distention of bladder
- obstruction of urinary flow (constipation, BPH, urinary stones, neoplasm)

Non-contractile bladder
- hypoactive detrusor
- atonic bladder
(diabetic / alcoholic neuropathy, sacral spina cord lesions, medications, neuroleptics, narcotics, TCA)

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7
Q

Tell me about functional incontinence?

A
  • does not involve lower urinary tract
  • result of psychological, cognitive, physical impairment and environment
  • patients have lost their cognitive function, or had not developed it in childhood
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8
Q

Red flags in urinary Hx?

A
  • microscopic haematuria in women aged 50 and older
  • visible haematuria
  • recurrent or persisting UTI with haematuria in women over 40
  • Sx associated with pelvic pain and abdo swelling
  • weight loss and night sweats
  • suspected malignant mass arising from the urinary tract
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9
Q

Dx tests for urinary incontinence?

A
  • dipstick and culture (careful in elderly)
  • blood tests
  • U+Es, calcium, glucose, CRP
  • bedside US / bladder scan
    (pre and post void volumes)
  • patient diaries of fluid intake and toileting habits
  • urodynamic studies
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10
Q

Reversible causes of incontinence?

A

DIAPPERS:

  • Delirium
  • Infection
  • Atrophic vaginitis or urethritis
  • Pharmaceuticals
  • Psychological disorders, polydipsia
  • Endocrine disorders
  • Restricted mobility
  • Stool impaction
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11
Q

Drugs that may cause incontinence?

A
  • Diuretics
  • Anticholinergics, antihistamines, antidepressants, antipsychotics
  • Sedatives and muscle relaxants
  • Alcohol
  • Opioid based pain killers
  • alpha-adrenergic antagonists/ agonists
  • CCBs
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12
Q

Management of incontinence?

And for each of the types?

A

Treat reversible causes.

Dementia: regular toileting

Lifestyle: reduce about or timing of fluid intake, avoid bladder stimulants

Medications: use diuretics judiciously and not just before bed

Weight loss if high BMI

Reduce physical barriers to toilet (use bedside commode)

Urge: bladder retraining, anticholinergic/oestrogen cream. Botox injection, nerve therapy.

Stress: pelvic floor exercise, prolapse then a pessary. Invasive options available.

Overflow: BPH (tamsulosin, finasteride, TURP), intermittent self catheterisation

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13
Q

What is faecal incontinence?

A

Faecal incontinence is unintentional loss of solid or liquid stool.

3-10% of over 65s have it.

Common reason for entering long term care.

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14
Q

Physiology of bowel control?

A
  • controlled by anal sphincter pressure, rectal storage capacity and rectal sensation
  • intraabdominal pressure
  • innervation from the pudendal nerve, mixed motor/sensory nerves S2-S4
  • sphincter muscles stretched, weakened, not strong enough
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15
Q

Factors for normal bowel function?

A
  • hydration
  • dietary fibre
  • mobility
    (and not stressed)
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16
Q

Loss of faecal continence causes?

A

Poor anal tone / dysfunction

  • haemorrhoids or skin tags
  • fistulae

Altered bowel physiology

  • IBD
  • infections
  • laxatives
  • faecal impassion
  • radiation enteritis
  • coeliac disease
  • bacterial overgrowth

Altered neurology

  • MS/CVA
  • PD
  • diabetes
  • alcohol

Mechanical disruption

  • damage to sphincters / nerve/ tissue
  • can be iatrogenic, surgical or traumatic
17
Q

What is runniest on the Bristol stool chart?

A

Type 7 running

Type 1 hard

18
Q

Medication that can cause faecal incompetence/ constipation?

A
  • opiates
  • metallic ions (iron, calcium)
  • CCBs
  • antispasmodics
  • anticholinergics
  • dopamine agonist
  • diuretics
19
Q

Ix for faecal incompetence?

A

Hb, ferritin, U+Es, bone profile, TFT
stool sample
AXR and bowel visualisation

20
Q

Management of faecal incompetence?

A

Address underlying cause
Factors, dehydration /in-mobility

Bowel training
Use of laxatives
Skin protection
Carer training

21
Q

What are the types of laxatives and name some from each group?

A
  • Poor data on efficacy
  • bulking agents (psyllium husk)
  • osmotic (lactulose, macrogol, phosphate enema, glycerol enema)
  • stimulant (Senna, bisacodyl)
  • softener (docusate)