Incontinence, constipation, urinary retention Flashcards
RF for urinary incontinence?
- advancing age
- high BMI
- female
- FHx
- hysterectomy
List classifications of urinary incontinence
- Stress incontinence
- Urge incontinence/OAB
- Mixed incontinence
- Overflow incontinence
- Functional incontinence
What should you ask in Hx of pt presenting with urinary incontinence?
- Frequency of complaint
- Volume passed
- Degree of incapacity
- Does it occur when coughing/sneezing/standing?
- Urgency? Dysuria? Frequency of micturition?
- Past obsetric and medical Hx
- DH - medications and think about how they may affect incontinence
- Mobilty
- Accessibility of toilets
What should you do o/e for pt presenting w/ urinary incontinence?
- Review bladder and bowel diary
- Abdo exam
- Urine dip and MSU
- PR exam including prostate assessement in a male
- External genitalia review - esp looking for atrophic vaginitis in females
- A post-micturition bladder scan
Presentation of stress incontinence?
- Leakage of urine when there is increase in intra-abdo pressure - coughing, sneezing, laughing, exercise.
- “small amounts of urine” in stem of qu.
- occur throughout the day
Investigations for stress incontinence?
- Bladder diary
- Frequency volume chart
- Urine dipstick - check for UTI
- Urodynamic studies
Why may elderly woman have stress incontinence?
Pelvic floor weakness e.g. with uterine prolapse or urethrocele
Management of stress incontinence:
* Conservative?
* Pharmacological?
Conservative:
* Pelvic floor exercises (8 contractions 3x/day for 3 months)
* weight loss (if high BMI mentioned in stem)
* ring pessary if have uterine prolapse
Pharmacological:
* Duloxetine hydrochloride (40mg bd)
Also - surgical = colposuspension, rectus fascial sling, retropubic mid-urethral mesh sling
Presentation of urge incontinence?
the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
Investigations for urge incontinence?
- Urine dipstick
- frequency volume chart
- urodynamic studies - measure pressure in the bladder
- Bladder scan (post void)
Management for urge incontinence:
* Conservative?
* Pharmacological?
Conservative:
* Alter fluid intake
* reduce caffeine intake
* weight loss (if BMI obese)
* bladder re-training (courses are 6wks, help increase intervals between voiding)
Pharmacological:
* antimuscarinic bladder stabalising drugs:
- oxybutynin (immediate release),
- tolterodine (immediate release) or
- darifenacin (once daily preparation)
- mirabegron
Other: botox injection into detrusor muscle
Presentation of overflow incontinence?
- Small dribble of urine, very often
- also feel as though your bladder is never fully empty
- cannot empty it even when you try
- Pt usually has enlarged prostate
Investigations for overflow incontinence?
- Urine dip - look for UTI, haematuria etc
- Abdo USS - look at bladder, kidneys
- Cytoscopy - see inside urinary tract
- Voiding cystogram
- Post voiding scan
Management of overflow incontinence:
* conservative?
* pharmacological?
Conservative:
* bladder training or timed voiding
* double voiding
* pelvic floor exercises to help support bladder
* use absorbant pads/mesh sling for any dribble or leaks
Pharmacological:
* alpha blockers to relax prostate so make urinating easier - tamsulosin, doxazosin etc
* 5-alpha reductase inhibitors to shrink size of prostate - finasteride, dutasteride
* diuretics
* desmopressin
Other:
* self catheterisation
* suprapubic catheter
* indwelling catheter
Presentation of functional incontinence?
Causes of this?
- comorbid physical conditions impair the patient’s ability to get to a bathroom in time
Causes include:
* dementia
* sedating medication
* injury/illness resulting in decreased ambulation - arthritis
* cognitive impairment
Investigations for functional incontinence?
Do baseline urinary inv:
* urine dipstick
* bladder diary/frequency volume chart
* bladder scan
Investigations for underlying cause - e.g. if arthritic, do bloods for RF, ANA, XR/MRI joint
OT to look at living conditions - is this affecting function
Medication review - any sedating meds that could be stopped using STOPP tool .
Management of functional incontinence?
Depends on what is preventing them achieving continence as well as their individual needs.
- If there are physical barriers, toileting aids, easily removed clothing and wiping aids can help. Removing clutter, ensuring good lighting and mobility aids can also assist.
- If there are cognitive barriers (e.g. dementia) ensure the toilet is visible using signs, pictures, and good lighting.
- Also take notice of any cues the person may give when they want to use the toilet (e.g. pulling at clothing, restlessness, etc.).
Why is fecal incontinence common in elderly pts?
- Rectum becomes more vacous
- Pts have chronic constipation and haemorrhoids - so anal sphincter can gape
- Older pts can’t exert same amount of intra-abdo pressure and muscle tension to force out constipated stool
Most common cause of faecal incontinence in elderly?
Most common: Faecal impaction with overflow diarrhoea
Second most common: neurogenic dysfunction
What is necessary to do when pt presents with faecal incontinence?
A PR EXAM!!!!
Assess:
* rectum - if stool present, assess stool type
* prostate
* anal tone
* sensation
* visual inspection around anus
What kind of stool causes faecal impaction?
Can be hard stools OR soft stools!
- soft stools can fill the rectum too.
If a pt is found to have urinary retention, what must you do as part of your examination?
A PR EXAM!
* if a pt has urinary retention, they must have a PR to assess for an impacted rectum and/or large prostate
Risks associated to faecal impaction and constipation?
- stercoral perforation
- ischaemic bowel (in chronic constipation)
Management of faecal impaction?
- Enemas for rectal loading
- Stool softeners
- Stimulants
- difficult cases = manual evacuation
