Incontinence

Question 1

Is incontinence a normal part of ageing?

Answer 1

No

Question 2

What proportion of women will become incontinent?

Answer 2

50%

Question 3

Explain an analogy for thinking about incontinence

Answer 3

Think of the bladder as a reservoir and the pelvic floor muscles as a dam that keep the urine in the reservoir

Question 4

What are the types of incontience?

Answer 4

Stress
Urge 
Mixed stress and urge 
Overflow 
Functional

Question 5

What is stress incontinence?

Answer 5

Weakness in the pelvic floor muscles

- the dam is not big or strong enough

Question 6

What is urge incontinence?

Answer 6

Overactive bladder (pelvic floor ok)
- The reservoir contracts suddenly

Question 7

What is overflow incontinence?

Answer 7

Blockage to the passage of urine causes accumulation in the bladder and eventual sudden release of urine

• The reservoir is getting bigger and bigger and then overflows
• The dam/pelvic floor is ok

Question 8

What is functional incontinence and give causes?

Answer 8

something external from the urogenital tract is causing incontinence

• poor mobility and frailty
• arthritis
• cognitive impairment - can’t remember where toilet is

Question 9

What are the causes of stress incontinence?

Answer 9

Obesity

Weak pelvic floor muscles

Question 10

What are the causes of urge incontinence?

Answer 10

Caffeine – diuretic and irritant
Alcohol – diuretic
Drinking too much – overstretches the bladder
Drinking too little – concentrated urine acts as irritant
UTI

Question 11

What is the main cause of overflow incontinence?

Answer 11

Usually in men with prostatic enlargement

Question 12

How does stress incontinence present?

Answer 12

Incontinence when sneezing, coughing, exercise, laughing

Question 13

How does urge incontinence present?

Answer 13

Frequency
Urgency - if you are doing an activity, can you finish it or do you have to drop everything and go?
Nocturia

Question 14

How does overflow incontinence present?

Answer 14

Hesitancy - Difficulties starting to pass urine
Poor stream
Dribbling
Large residual volume – chronic

(think of someone with BPH)

Question 15

What questions might you ask sb in an incontinence history?

Answer 15

Identify what type of incontinence it is
Ask about LUTS and situations where incontinence happens
Severity - do they have to plan where the toilets are when they go out, do they have any accidents, do they wear pads?
Is it new or old (especially in geriatric pts on a ward- don’t assume it is new, check GP record)

Question 16

What investigations would you do for urinary incontinence?

Answer 16

• urine dip for all women presenting with incontinence
• Bloods - which bloods?
• Bladder diary - what they drink and how much and when they are incontinent - alcohol, caffeine, minimum of 3 days, mixture of work and leisure days

Question 17

Is management of incontinence mainly pharmacological or non-pharmacological?

Answer 17

NON-PHARAMCOLOGICAL

Question 18

How would you manage stress incontinence?

Answer 18

STRESS

• step 1 - weight loss if BMI over 30
• step 2 strengthen pelvic floor, need to be supervised by a physio who has had specific training in this
• step 3 - surgery - colposuspension - autologous rectus fascial sling or retropubic mid-urethral mesh sling
• step 4 - bulking agent - injections

Question 19

How would you manage urge incontinence?

Answer 19

URGE

• Step 1 - avoid caffiene
• find the right balance of fluid intake, not too much, not too little
• step 2: bladder training - wait longer before going to the toilet
• step 3: medications , oxybutinin
• step 4: botulinum toxin type A
• step 5: Percutaneous sacral nerve stimulation

Question 20

How would you manage mixed incontinence?

Answer 20

MIXED

• pelvic floor exercises
• bladder retraining

Question 21

How would you manage functional incontinence?

Answer 21

FUNCTIONAL

• MDT assessment
• OT – overnight needs, commode, risk and prevention of falls, home and falls risk

Question 22

How would you manage overflow incontinence?

Answer 22

o Need to see GP or urologist – the only one where pharmacological/ medical management is needed
o Post-void residual US scan – essential
o Tamsulosin – postural hypotension side effect, but relaxes the muscle in the prostate
o Finasteride (5-alpha reductase inhibitor/dihydrotestosterone blocker)– prevents conversion of testosterone to the more potent androgen dihydrotestosterone (DHT), takes 3 months to start working and only for people with a slightly raised PSA – shrinks the prostate
o Surgical – open up the urethra – Transurethral Resection of the Prostate (TURP) for BPH
o Catheters

Question 23

What other problems may result as a result of incontinence?

Answer 23

• depression
• sexual dysfunction
• poor sleep

Question 24

When would catheters be used for incontinence?

Answer 24

in urinary retention, where it is:

• causing symptomatic infections
• renal dysfunction
• incontinence
• cannot otherwise be corrected

Question 25

What are the referral criteria to urology for incontinence?

Answer 25

- persisting bladder or urethral pain - palpable mass after voiding - Pelvic mass - associated faecal incontinence - urogenital fistulae - suspected neurological disease - voiding difficulty - previous pelvic radiation or pelvic cancer - previous continence surgery