Incontinence |X

Question 1

What is the prevalence of urinary incontinence problems among men and women?

Answer 1

Men 5-39%

Women 5-72%

A general rule is that urinary incontinence prevalence in men is less than half that in women

Question 2

How could you approach the question of incontinence with a patient without leading to their embarrassment (2)?

Answer 2

“Do you have any problems with your bladder or bowel?”

“Do you ever pass urine or faeces involuntarily?”

Question 3

Why does incontinence often remain hidden (2)?

Answer 3

1. It is embarrassing

2. People think it is a normal part of ageing

Question 4

What are symptoms of lower urinary tract symptoms (LUTS) i.e. symptoms associated with bladder and urethral problems?

Storage (3)
Voiding (5)

What are 9 symptoms and their meaning?

Answer 4

Storage: Remember by Not fun

1. Frequency
2. Urgency
3. Nocturia

Voiding:

1. Poor stream
2. Intermittent stream
3. Hesitancy
4. Straining to void
5. Terminal dribbling
6. Urgency
   - Sudden, compelling desire to pass urine
7. Nocturia
   - The need to pass urine during the night which awakens one from sleep
8. Nocturnal polyuria
   - Passing >1/3 of your urine volume during the night
9. Hesitancy
   - Involuntary delay or inability in starting the urinary stream
10. Urinary incontinence
    - The involuntary loss of urine
11. Urge incontinence
    - Involuntary leakage or urine accompanied or preceded by urgency
12. Detrusor overactivity
    - The bladder contracts spontaneously during filling as the patient attempts to prevent micturition
13. Stress incontinence
    - Involuntary leakage or urine caused by failure of the bladder outlet to remain closed when intra-abdominal pressure rises
14. Syndrome including urinary urgency +/- urge incontinence

Question 5

What are 6 causes of incontinence?

Answer 5

1. Stress incontinence
   - Weakness of the urinary outlet
2. Urge Incontinence/overactive bladder
   - Failure of the bladder to store urine because of high bladder pressure
3. Mixed incontinence
   - Combo of 1 and 2
4. Bladder outlet obstruction
   - A bladder that is overfull and overflows
5. Fistulae
   - Abnormal communications of the urinary tract
6. Functional
   - Incontinence due to more general impairment
   e. g. cognitive, functional, affective

Question 6

How is continence of the bladder maintained?

Answer 6

Continence is maintained by the co-ordinated interaction of the bladder, urethra, pelvic floor muscles and the nervous system

The bladder is a low pressure – high volume system; the pressure increases slowly as the bladder fills (rate 0.5-5ml /hr)

Continence is maintained so long as the urethral pressure exceeds the bladder pressure

Question 7

What is the capacity of the bladder and at what volume do you feel the desire to void?

Answer 7

Capacity = 600ml

Desire to void = 250ml

Question 8

What is the process of micturition?

Answer 8

The voluntary relaxation of the striated muscle around the urethra; this reduces urethral pressure

This is followed by a corresponding increase in bladder pressure as a consequence of detrusor contraction

Question 9

What are the physiological control mechanisms of micturition?

Answer 9

1. The micturition cycle involves both the somatic (voluntary) and autonomic (sympathetic and parasympathetic) nervous systems
2. The frontal cortex provides voluntary control.
3. The pontine micturition centre (midbrain) co-ordinates detrusor contraction with urethral relaxation.
4. Bladder contraction is mediated by the parasympathetic system.
5. These parasympathetic fibres, along with those responsible for somatic control (pudendal nerve), originate from the sacral plexus (S2 to S4).
6. Excitation of the parasympathetic nerves stimulates the release of acetylcholine, which acts on muscarinic receptors (there are 5 subsets of muscarinic receptors with subset M3 being primarily responsible for bladder contraction) to cause detrusor contraction.

Question 10

What are the physiological control mechanisms of bladder filling?

Answer 10

1. Bladder filling is mediated by the sympathetic system.
2. Sympathetic nerves arise from T11 to L2 and innervate the smooth muscle of the bladder neck and proximal urethra causing contraction, allowing the bladder to fill.
3. Excitation of the pudendal nerve causes contraction of the external urethral sphincter, allowing voluntary control.
4. Voiding therefore depends on parasympathetic activity, with opening of the bladder neck, which is involuntary, followed by voluntary relaxation of the external urethral sphincter.

Question 11

When should you screen an older person for incontinence? How would you screen for it?

Answer 11

1. At any consultation, include a screening q about continence issues i.e. “do you have any problems with either your bladder or bowels?
2. If the answer is positive, a full assessment should be offered.
3. Validated screening questionnaires are also available for selected patients, e.g. the Bladder Control Self Assessment Questionaire (B-SAQ)

Question 12

What is a useful website about incontience that you can point patients to?

Answer 12

Bladder and bowel foundation

Question 13

What are the 4 elements of an assessment of a patient?

Answer 13

1. History
2. Examination
3. Investigations
4. Management

Question 14

What is the format for a history of incontinence (8)?

Answer 14

1. Presenting complaint / History of presenting complaint (PC/HPC)
   - hx/volume/when does it occur
2. Constipation
3. Systems review (SR)
4. Past medical history (PMH)
5. Drug history (DH)
6. Obstetric history
7. Family history (FH)
8. Social history SH
   - smoking/alcohol/caffeine intake

Question 15

What are the 7 components of management?

Answer 15

1. Investigations
2. Treatment (medical or surgical)
3. Procedures
4. Multidisciplinary team
5. Patient education
6. Monitoring
7. Specialist opinion

Question 16

What specific areas do you need to ask about in a history of incontinence (3)?

Answer 16

1. LUTS
   - Hesitancy
   - Urgency
   - Urinary incontinence
   - Nocturnal polyuria
   - Urge incontinence
   - Detrusor overactivity
   - Nocturia
   - Stress incontinence
   - Syndrome including urinary urgency +/- urge incontinence
2. Pain, dysuria. haematuria
3. Urinary symptoms during childhood e.g. nocturnal enuresis

Question 17

What 3 symptoms would indicate an urgent medical review?

Answer 17

Pain, dysuria. haematuria

Question 18

What are some important systems to enquire about in the systems review for urinary incontinence (2)?

Answer 18

1. Bowel function and frequency

2. Symptoms that may be associated with diseases that predispose a patient to urinary incontinence e.g. diabetes

Question 19

What is important to ask about in PMH, and especially in female patients (3)?

Answer 19

1. Associated co-morbidities (CCF, COPD, DM)
2. Previous surgical procedures, particularly those in or around the pelvis
3. O+G history for females

Question 20

What specific things do you need to ask about for FH and SH in urinary incontinence?

Answer 20

1. Impact on the patient’s quality of life, can use self-assessment questionnaire
2. Alcohol, tobacco, caffeine and fluid intake

Question 21

What are some consequences of incontinence (7)?

Answer 21

1. Pressure ulcers - skin is always wet
2. Skin infections
3. Falls
4. Depression
5. Isolation
6. Impaired quality of life
7. Admission to care homes

Question 22

What are important systems to examine in urinary incontinence (4)?

Answer 22

1. Cognition - abbreviated mental test score if there are concerns
2. Neurological
3. Abdomen
4. Cardiorespiratory - to look for signs of chronic lung disease and congestive cardiac failure

Question 23

What specific things would you look for in the neurological exam (6)?

Answer 23

1. Neurological clues at the bedside
2. Assess the patients gait as they walk into clinic
3. Check dorsiflexion of the toes (S3)
4. Check perineal sensation (L1-L2)
5. Check sensation of the sole (S1)
6. Check posterior aspect of the thigh (S3)

Question 24

What specific things would you look for in the abdominal exam (3)?

Answer 24

1. Palpate for masses or enlarged kidneys.
2. Palpate and percuss for a distended bladder.
3. DRE should be performed in all patients to assess anal tone, presence of constipation or rectal mass and to assess prostate size in males.

Question 25

What specific things would you look for in the pelvic exam (3)?

Answer 25

1. Inspection may reveal vaginal atrophy or prolapse 2. The pelvic floor muscle strength can be assessed during a vaginal examination. 3. Finally ask the patient to cough or strain to enable demonstration of stress incontinence; repeat this with the patient standing if possible

Question 26

What is the Oxford classification grading system of pelvic floor muscle strength?

Answer 26

``` 0 = no contraction 1 = flicker 2 = weak 3 = moderate 4 = good 5 = strong contraction ```

Question 27

What are 4 simple investigations that can be done for incontinence? i.e. can usually be carried out by junior medical or nursing staff

Answer 27

1. Frequency/volume chart 2. Urinalysis 3. Blood tests 4. Imaging

Question 28

How does a frequency/volume chart work?

Answer 28

Ask the patient to complete a diary over a three day period that records fluid intake, volume of urine passed and episodes of incontinence

Question 29

What would you check for in urinalysis (4)?

Answer 29

1. glucose – suggests diabetes 2. protein – suggests a primary kidney pathology 3. leucocytes and nitrites – may suggest urinary tract infection 4. blood – suggests renal stones or urinary tract malignancy Do urine microscopy, culture and sensitivity

Question 30

What blood tests would you do for incontinence?

Answer 30

1. Full Blood Count – leucocytosis may indicate infection 2. U&Es – to determine renal function and electrolytes 3. Glucose – to rule out diabetes 4. Calcium – useful to rule out hypercalcaemia which can cause constipation and confusion

Question 31

What imaging can you do for incontinence? 1 essential and 4 non-essential

Answer 31

Essential 1st line -Post void bladder scan. Performed to rule out chronic retention of urine Only if there are specific indications: - USS Abdo – requested if renal failure to evaluate kidney size and look for signs of obstructive uropathy. - CT urography – requested if considering renal stones. - CT abdo – to exclude abdominal or pelvic masses if these are suspected. - Intravenous Urogram (IVU) – useful if renal stones are suspected. However this has largely been superceded by CT urography in most centres.

Question 32

What are 5 specialist investigations of urinary incontinence done after simple ones have been done? - in order of least to most complex

Answer 32

1. Uroflowmetry 2. US cystodynamogram 3. Cystometry 4. Videourodynamics 5. Ambulatory urodynamics

Question 33

What urgent investigation is needed if a patient presents with haematuria?

Answer 33

Urgent referral to a urologist for consideration of cystoscopy

Question 34

What do certain trends in the frequency/volume chart indicate (4)?

Answer 34

1. Frequent small volumes of urine - suggests overactive bladder/urge incontinence 2. > 1/3 of the 24 hour urine is produced at night - indicative of nocturnal polyuria 3. >2500 ml urine / day - indicates polyuria 4. Excessive intake of fluid or increased fluid intake in the evening – this could lead to increased frequency

Question 35

What does uroflowmetry measure and diagnose?

Answer 35

Measures urinary flow rate and volume Diagnoses bladder outlet obstruction

Question 36

How does uroflowmetry work?

Answer 36

Urine flow rate and volume is measured using a flowmeter. Patients are left in private to void normally (either sitting or standing) There are different kinds of flowmeter but a common one is the rotating disc – the urine flows onto a rotating disc in the commode and this increases the inertia of the disc which can be measured and translated by the computer software into a flow rate.

Question 37

What are normal results of uroflowmetry? 1. Total voided volume 2. Flow time 3. Qmax (Max flor rate) 4. Parabolic curve

Answer 37

1. Total voided volume > 200ml 2. Flow time 15-20 secs 3. Qmax > 20mls/sec 4. Smooth parabolic curve

Question 38

What are average Qmax readings for: 1. Males 40yrs 2. Females 40yrs 3. Males > 60yrs 4. Females > 60 yrs

Answer 38

Males 40yrs = 22ml/sec Females 40yrs = 25ml/sec Males > 60yrs = 13mls/sec Females >60yrs = 18mls/sec

Question 39

What would the following patterns on the trace in uroflowmetry indicate? 1. Exaggerated flow rate 2. Prolonged flow rate and low Qmax 3. Intermittent flow

Answer 39

1. Stress incontinence or problematic detrusor overactivity 2. Bladder outflow obstruction 3. Straining

Question 40

What techniques does US cystodynamogram use? What do they measure (3)?

Answer 40

Combines the flowmetry with pre and post void bladder scanning Measures functional bladder capacity, flow rate and post void bladder volume (residual)

Question 41

What does cystometry measure (3)?

Answer 41

1. bladder pressure, sensation 2. capacity 3. compliance during filling and voiding i.e. bladder pressure studies.

Question 42

How does cystometry work (3)?

Answer 42

1. The bladder is filled with saline at room temperature via a small bore urethral catheter which is passed along with a pressure transducer. 2. A further pressure transducer is placed in the rectum. 3. Pressure recordings are measured as the bladder is filled

Question 43

What techniques do videourodynamic studies use? What do they measure?

Answer 43

Combination of cystometry and radiographic screening, so that both pressure and visual information is obtained

Question 44

What are the advantages of ambulatory urodynamics over conventional cystometry?

Answer 44

The non-physiological nature of conventional cystometry (i.e. the faster filling of the bladder) means abnormalities may be missed Ambulatory urodynamics may overcome some of these limitations because it measures physiological filling and pressures during a patients usual daily routine

Question 45

How does ambulatory urodynamics work?

Answer 45

It uses the same transducer catheters as conventional urodynamics but connects them to a small “walkman-size” device and also uses electronic continence pads to detect leakage around the catheter

Question 46

What is the mneumonic for diagnosing potentially transient reversible causes of incontinence?

Answer 46

DIAPPERS ``` D - delirium I - infection A - atrophy (vaginal) P - pharmacological P - psychological E - excess urine output R - restricted mobility S - stool impaction ```

Question 47

How does delirium cause incontinence?

Answer 47

Patient's who have an acute confusional state often develop urinary incontinence, especially if the delirium is caused by a urinary tract infection.

Question 48

How do infections cause incontinence?

Answer 48

UTIs cause irritability of the bladder

Question 49

How can vaginal atrophy be managed?

Answer 49

Topical oestrogens | -prevent recurrent UTIs, and improve urgency and frequency symptoms. They do not improve incontinence per se

Question 50

What are 2 psychological causes of urinary incontinence?

Answer 50

Depression and dementia

Question 51

What could be some causes of excess urine output (2)?

Answer 51

1. Medical condition such as DM | 2. Excess fluid intake

Question 52

How do you identify stool impaction?

Answer 52

DRE

Question 53

What are 9 main risk factors for stress incontinence?

Answer 53

1. Age 2. Female 3. Childbirth 4. Post-menopausal 5. Obesity 6. Surgery (esp post hysterectomy) 7. Neurological disease -Parkinson's/dementia/stroke/MS 8. Urinary infection 9. Bladder outlet obstruction

Question 54

Why are females more likely to develop stress incontinence (3)?

Answer 54

1. The bladder outlet is weaker due to a shorter urethra and lack of prostate 2. Childbirth increases risk esp with: -C section -Vaginal delivery -Forceps delivery (Damage can be a combo of ligament and nerve damage) 3. Obesity - causes increased strain and weakening of the pelvic floor 4. Vaginal atrophy

Question 55

How does surgery (which one in particular) increase the risk of stress incontinence?

Answer 55

The risk of stress incontinence following transurethral resection of the prostate is approx. 1%

Question 56

What are 4 causes of an overactive bladder (urge incontinence)?

Answer 56

1. Idiopathic – most common 2. Neurogenic – associated with neurological conditions e.g. multiple sclerosis, parkinsonism, stroke or spinal cord injury 3. Infective – urinary tract infection 4. Bladder outlet obstruction

Question 57

What is the main cause of overflow incontinence?

Answer 57

Bladder outlet obstruction (BOO) - Outlet obstruction causes a strain on the bladder which over time may lead to residual urine left in the bladder.

Question 58

What are the causes of bladder outlet obstruction (9)?

Answer 58

1. Phimosis 2. Stricture (male preponderance) 3. STDs particularly in women 4. Trauma 5. Blood clot 6. Calculi 7. Benign prostate hypertrophy (BPH) 8. Cancer of prostate or bladder 9. Carcinoma of cervix or colon

Question 59

What medications worsen urinary incontinence (8)?

Answer 59

1. Alpha blocker 2. Alpha agonist 3. ACEI 4. Haloperidol 5. Opioids 6. Hypnotics 7. Cholinesterase inhibitors 8. Ca channel blockers

Question 60

How do alpha blockers cause urinary incontinence?

Answer 60

Relax bladder outlet which may worsen stress urinary incontinence

Question 61

How do alpha agonist cause urinary incontinence?

Answer 61

Urinary retention may lead to overflow

Question 62

How do ACI cause urinary incontinence?

Answer 62

Chronic cough may worsen SUI

Question 63

How does haloperidol cause urinary incontinence?

Answer 63

Anticholinergic may cause retention

Question 64

How do opioids cause urinary incontinence?

Answer 64

Constipation, which can cause overflow incontinence

Question 65

How do hypnotics cause urinary incontinence?

Answer 65

Reduced awareness of need to urinate

Question 66

How do cholinesterase inhibitors cause urinary incontinence?

Answer 66

Increase bladder contraction

Question 67

How do Ca channel blockers cause urinary incontinence?

Answer 67

Decrease smooth muscle contractility

Question 68

What are the 4 broad areas of management of incontinence?

Answer 68

1. Patient Education 2. Multidisciplinary Team and Non-pharmacological 3. Medical Management 4. Surgical Management

Question 69

What are red flag symptoms that prompt urgent referral to urology or urogynaecology (4)?

Answer 69

1. Pain on micturition 2. Haematuria 3. Prolapse beyond the introitus 4. Suspicion of prostate cancer

Question 70

What are 4 things that can be advised in Patient Education , in the management of SUI?

Answer 70

1. Smoking cessation 2. Weight reduction 3. Managing constipation 4. Reducing alcohol and caffeine

Question 71

What is a medical management of SUI?

Answer 71

Duloxetine (SNRI) - limited evidence and no longer recommended by NICE as 1st or 2nd line treatment

Question 72

What is the MDT and non-pharmacological treatment of SUI (4)?

Answer 72

1. Community continence advisor - Continence advisor may assess patients in their own home and give advice and equipment. - Both continence advisors and physiotherapists can offer advice regarding pelvic floor exercises. 2. Pelvic floor exercises - physiotherapist 3. Vaginal cones -Designed to improve awareness of the pelvic musculature. The woman has to contract her pelvic floor muscles in order to keep the vaginal cone in position. -As the muscle strength improves, cones of increasing weight can be used 4. Pudendal nerve stimulation -If a woman’s initial pelvic floor contraction is weak, this device can be used. The strength of stimulation can be altered as the muscle strength improves

Question 73

What are vaginal cones?

Answer 73

Vaginal cones are small weights that can be placed in your vagina to help you train your pelvic floor muscles. Used to treat SUI

Question 74

What are 3 surgical procedures that can be done for SUI?

Answer 74

1. Mid-urethral sling insertion -(tension free vaginal tape, or TVT) provides support under the urethra. 2. Colposuspension is a much more invasive operation although is useful if a patient has an associated cystocele. 3. Injecting of bulking agents (e.g. silicone) into the urethra can also be performed although the success rates are much lower and therefore normally only an option in women not suitable for TVT or major surgery.

Question 75

What are 5 causes of pelvic floor muscle weakness?

Answer 75

1. Childbirth 2. Obesity 3. Chronic cough 4. Post pelvic surgery 5. Post menopausal

Question 76

What is the patient education management of overactive bladder (OAB) (4)? -can be with or without urgency -primary or -secondary to: bph, neurological e.g. MS and PD

Answer 76

1. Smoking cessation 2. Weight reduction 3. Manage constipation 4. Reduce caffeine and alcohol intake (switch to decaff) 5. Reduce fluid intake, especially in the evening (advise no drinks after 8pm) (urinary freq and nocturia) - bladder only gest half full and sends signal to spinal cord that you need to urinate, so you go more frequently.

Question 77

What is the medical management of overactive bladder (OAB) (4)?

Answer 77

1. Antimuscarinic drugs - mainstay of treatment - They act on the M3 receptors on the detrusor muscle to reduce contraction - oxybutynin - tolterodine 2. Beta-3-adrenoceptor agonists (Mirabegron) - If there are contraindications, intolerable side effects or poor efficacy to antimuscarinics - Beta-3-adrenoceptors cause the bladder to relax, which helps it to fill and also to store urine. 3. Intravaginal Oestrogens - NICE recommend their use for women who have vaginal atrophy and symptoms of overactive bladder 4. Botulinum Toxin - This can be injected into the detrusor muscle via cystoscopy. - It inhibits neurotransmitter release thereby decreasing contractility

Question 78

What is the MDT and non-pharmacological treatment of OAB (3)?

Answer 78

1. Community continence advisor - Can assess patients in their own homes and offer advice and information regarding urinary incontinence 2. Pelvic Floor Exercises 3. Behavioural Therapy - Involves bladder retraining - A patient increases the interval between first desire to void and actual voiding - This should be tried as first line therapy in combination with pelvic floor exercises for a minimum of 6 weeks - Empty bladder in morning, then pee every 2 hours, regardless of how much they want to. Then increase by 15 mins each week, so internal is 3-4 hours. If they need to pee before, do suppression techniques

Question 79

What is the surgical treatment of OAB (2)?

Answer 79

1. Sacral nerve stimulation | 2. Augmentation cystoplasty (rarely used now)

Question 80

What are the 3 first line anti-muscarinic agents recommended for OAB?

Answer 80

1. Oxybutynin (but not to be used in older adults with frailty) 2. Tolteridone 3. Darifenacin

Question 81

What are some side effects of anti-muscarinic agents? 1. Brain (2) 2. Eyes (1) 3. Salivary glands (1) 4. Heart (1) 5. GI tract (2) 6. Urinary system (1)

Answer 81

Brain 1. Cognitive impairment 2. Hallucinations Eyes 1. Blurred vision Salivary glands 1. Dry mouth Heart 1. Tachycardia GI tract 1. Nausea 2. Constipation Urinary system 1. Urinary retention

Question 82

What is the patient education management of bladder outlet obstruction (5)?

Answer 82

1. Smoking cessation 2. Weight reduction 3. Manage constipation 4. Reduce caffeine and alcohol intake 5. Reduce fluid intake, especially in the evening (advise no drinks after 8pm)

Question 83

What is the medical management of bladder outlet obstruction (2)?

Answer 83

1. alpha adrenoceptor antagonists (alpha blockers) e.g. doxazocin - these drugs reduce the smooth muscle tone of the prostate 2. 5 alpha reductase inhibitors e.g. finasteride - these drugs reduce prostate volume by blocking the conversion of testosterone to dihydrotestosterone

Question 84

What is the MDT and non-pharmacological of bladder outlet obstruction (3)?

Answer 84

1. Community continence advisor - Can assess patients in their own homes and offer advice and information regarding urinary incontinence 2. Pelvic Floor Exercises 3. Behavioural Therapy - Involves bladder retraining - A patient increases the interval between first desire to void and actual voiding - This should be tried as first line therapy in combination with pelvic floor exercises for a minimum of 6 weeks

Question 85

What is the surgical management of bladder outlet obstruction (1)?

Answer 85

Depend on the actual cause and will require referral to urology or urogynaecology. 1. A transurethral prostatectomy (TURP) can be considered in cases of Benign Prostatic Hypertrophy.

Question 86

Why do you ask about caffeine?

Answer 86

irritant to bladder

Question 87

Treatment of stress incontinence

Answer 87

1. Pelvic floor exercise - 3 months, 8 contractions 3x a day 2. Duloxetine - 2nd line, does not really work 3. Surgery - TVT/TOT (pulls bladder neck up and forward) - or new: Intra-mural bulking agents to enhance external sphincter 4. Botox injections in bladder wall

Question 88

Associations of OAB (4)?

Answer 88

1. Poor quality of sleep 2. Less work productivity 3. Less sexual satisfaction/more erectile dysfunction 4. Depression

Question 89

RF for OAB (6)?

Answer 89

1. Normal vaginal delivery 2. Forceps delivery 3. High caffeine intake 4. Old age 5. Straining/constipation 6. Obesity

Question 90

Investigations of OAB?

Answer 90

Bladder diary - small amounts at a time but frequent

Question 91

What are anti-muscarinic side effects (6)?

Answer 91

SLUDGE: (stops all these apart from emesis) 1. Salivation 2. Lacrimation 3. Urination 4. Defaction 5. Gastric emptying 6. Causes emesis

Question 92

Associations of bladder outflow obstruction (2)

Answer 92

Erectile and ejaculatory dysfunction

Question 93

Causes of bladder outflow obstruction

Answer 93

``` obstruciton outside urethra -bph, ca ostate -tight himosis -chronic constipation ``` within urethral

Question 94

Investigation of bladder outflow obstruction?

Answer 94

Post-void bladder scan | urodynamic assessment - differentiates types of incontinence

Question 95

urodynamic assessment

Answer 95

Flow time vs flow rate catheter goes in with pressure meter. fills bladder and measures the pressure in bladder. pressure meterin rectum to check intra-abdo pressure too. meausre: flow pattern, voided olume , xyz

Question 96

MEdicaloptions for treatning BPH

Answer 96

1. alpha blockers - relax smooth muscle at bladder neck and within prostate - Takes few weeks to work 2. 5 a-reductase inhibitors - inhibit converstion of testosterone to dihydrotestosterone in prostate - takes 6 months to work (can combine the 2)

Question 97

Reasons to be constipated (9)? -may be incontience, or physically cant get to toilet quick enough

Answer 97

1. Dehydration 2. Anti-muscarinics/opiatse 3. Lack of fibre 4. Immobile 5. Mental health - Depression/anxiety 6. Neurological conditions - PD/MS 7. Obstruction - rectal prolapse etc 8. IBS 9. Endocrine - hypothyrodisim - diabetes

Question 98

What are medical treatment options for constipation (3)?

Answer 98

1. Bulking agents 2. Osmotic agents 3. Stimulants