Incontinence |X Flashcards
What is the prevalence of urinary incontinence problems among men and women?
Men 5-39%
Women 5-72%
A general rule is that urinary incontinence prevalence in men is less than half that in women
How could you approach the question of incontinence with a patient without leading to their embarrassment (2)?
“Do you have any problems with your bladder or bowel?”
“Do you ever pass urine or faeces involuntarily?”
Why does incontinence often remain hidden (2)?
- It is embarrassing
2. People think it is a normal part of ageing
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?
Storage: Remember by Not fun
- Frequency
- Urgency
- Nocturia
Voiding:
- Poor stream
- Intermittent stream
- Hesitancy
- Straining to void
- Terminal dribbling
- Urgency
- Sudden, compelling desire to pass urine - Nocturia
- The need to pass urine during the night which awakens one from sleep - Nocturnal polyuria
- Passing >1/3 of your urine volume during the night - Hesitancy
- Involuntary delay or inability in starting the urinary stream - Urinary incontinence
- The involuntary loss of urine - Urge incontinence
- Involuntary leakage or urine accompanied or preceded by urgency - Detrusor overactivity
- The bladder contracts spontaneously during filling as the patient attempts to prevent micturition - Stress incontinence
- Involuntary leakage or urine caused by failure of the bladder outlet to remain closed when intra-abdominal pressure rises - Syndrome including urinary urgency +/- urge incontinence
What are 6 causes of incontinence?
- Stress incontinence
- Weakness of the urinary outlet - Urge Incontinence/overactive bladder
- Failure of the bladder to store urine because of high bladder pressure - Mixed incontinence
- Combo of 1 and 2 - Bladder outlet obstruction
- A bladder that is overfull and overflows - Fistulae
- Abnormal communications of the urinary tract - Functional
- Incontinence due to more general impairment
e. g. cognitive, functional, affective
How is continence of the bladder maintained?
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
What is the capacity of the bladder and at what volume do you feel the desire to void?
Capacity = 600ml
Desire to void = 250ml
What is the process of micturition?
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
What are the physiological control mechanisms of micturition?
- The micturition cycle involves both the somatic (voluntary) and autonomic (sympathetic and parasympathetic) nervous systems
- The frontal cortex provides voluntary control.
- The pontine micturition centre (midbrain) co-ordinates detrusor contraction with urethral relaxation.
- Bladder contraction is mediated by the parasympathetic system.
- These parasympathetic fibres, along with those responsible for somatic control (pudendal nerve), originate from the sacral plexus (S2 to S4).
- 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.
What are the physiological control mechanisms of bladder filling?
- Bladder filling is mediated by the sympathetic system.
- 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.
- Excitation of the pudendal nerve causes contraction of the external urethral sphincter, allowing voluntary control.
- Voiding therefore depends on parasympathetic activity, with opening of the bladder neck, which is involuntary, followed by voluntary relaxation of the external urethral sphincter.
When should you screen an older person for incontinence? How would you screen for it?
- At any consultation, include a screening q about continence issues i.e. “do you have any problems with either your bladder or bowels?
- If the answer is positive, a full assessment should be offered.
- Validated screening questionnaires are also available for selected patients, e.g. the Bladder Control Self Assessment Questionaire (B-SAQ)
What is a useful website about incontience that you can point patients to?
Bladder and bowel foundation
What are the 4 elements of an assessment of a patient?
- History
- Examination
- Investigations
- Management
What is the format for a history of incontinence (8)?
- Presenting complaint / History of presenting complaint (PC/HPC)
- hx/volume/when does it occur - Constipation
- Systems review (SR)
- Past medical history (PMH)
- Drug history (DH)
- Obstetric history
- Family history (FH)
- Social history SH
- smoking/alcohol/caffeine intake
What are the 7 components of management?
- Investigations
- Treatment (medical or surgical)
- Procedures
- Multidisciplinary team
- Patient education
- Monitoring
- Specialist opinion
What specific areas do you need to ask about in a history of incontinence (3)?
- LUTS
- Hesitancy
- Urgency
- Urinary incontinence
- Nocturnal polyuria
- Urge incontinence
- Detrusor overactivity
- Nocturia
- Stress incontinence
- Syndrome including urinary urgency +/- urge incontinence - Pain, dysuria. haematuria
- Urinary symptoms during childhood e.g. nocturnal enuresis
What 3 symptoms would indicate an urgent medical review?
Pain, dysuria. haematuria
What are some important systems to enquire about in the systems review for urinary incontinence (2)?
- Bowel function and frequency
2. Symptoms that may be associated with diseases that predispose a patient to urinary incontinence e.g. diabetes
What is important to ask about in PMH, and especially in female patients (3)?
- Associated co-morbidities (CCF, COPD, DM)
- Previous surgical procedures, particularly those in or around the pelvis
- O+G history for females
What specific things do you need to ask about for FH and SH in urinary incontinence?
- Impact on the patient’s quality of life, can use self-assessment questionnaire
- Alcohol, tobacco, caffeine and fluid intake
What are some consequences of incontinence (7)?
- Pressure ulcers - skin is always wet
- Skin infections
- Falls
- Depression
- Isolation
- Impaired quality of life
- Admission to care homes
What are important systems to examine in urinary incontinence (4)?
- Cognition - abbreviated mental test score if there are concerns
- Neurological
- Abdomen
- Cardiorespiratory - to look for signs of chronic lung disease and congestive cardiac failure
What specific things would you look for in the neurological exam (6)?
- Neurological clues at the bedside
- Assess the patients gait as they walk into clinic
- Check dorsiflexion of the toes (S3)
- Check perineal sensation (L1-L2)
- Check sensation of the sole (S1)
- Check posterior aspect of the thigh (S3)
What specific things would you look for in the abdominal exam (3)?
- Palpate for masses or enlarged kidneys.
- Palpate and percuss for a distended bladder.
- DRE should be performed in all patients to assess anal tone, presence of constipation or rectal mass and to assess prostate size in males.
What specific things would you look for in the pelvic exam (3)?
- Inspection may reveal vaginal atrophy or prolapse
- The pelvic floor muscle strength can be assessed during a vaginal examination.
- Finally ask the patient to cough or strain to enable demonstration of stress incontinence; repeat this with the patient standing if possible
What is the Oxford classification grading system of pelvic floor muscle strength?
0 = no contraction 1 = flicker 2 = weak 3 = moderate 4 = good 5 = strong contraction
What are 4 simple investigations that can be done for incontinence?
i.e. can usually be carried out by junior medical or nursing staff
- Frequency/volume chart
- Urinalysis
- Blood tests
- Imaging
How does a frequency/volume chart work?
Ask the patient to complete a diary over a three day period that records fluid intake, volume of urine passed and episodes of incontinence
What would you check for in urinalysis (4)?
- glucose – suggests diabetes
- protein – suggests a primary kidney pathology
- leucocytes and nitrites – may suggest urinary tract infection
- blood – suggests renal stones or urinary tract malignancy
Do urine microscopy, culture and sensitivity
What blood tests would you do for incontinence?
- Full Blood Count – leucocytosis may indicate infection
- U&Es – to determine renal function and electrolytes
- Glucose – to rule out diabetes
- Calcium – useful to rule out hypercalcaemia which can cause constipation and confusion
What imaging can you do for incontinence?
1 essential
and 4 non-essential
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.
What are 5 specialist investigations of urinary incontinence done after simple ones have been done? - in order of least to most complex
- Uroflowmetry
- US cystodynamogram
- Cystometry
- Videourodynamics
- Ambulatory urodynamics
What urgent investigation is needed if a patient presents with haematuria?
Urgent referral to a urologist for consideration of cystoscopy
What do certain trends in the frequency/volume chart indicate (4)?
- Frequent small volumes of urine - suggests overactive bladder/urge incontinence
- > 1/3 of the 24 hour urine is produced at night - indicative of nocturnal polyuria
- > 2500 ml urine / day - indicates polyuria
- Excessive intake of fluid or increased fluid intake in the evening – this could lead to increased frequency
What does uroflowmetry measure and diagnose?
Measures urinary flow rate and volume
Diagnoses bladder outlet obstruction
How does uroflowmetry work?
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.
What are normal results of uroflowmetry?
- Total voided volume
- Flow time
- Qmax (Max flor rate)
- Parabolic curve
- Total voided volume > 200ml
- Flow time 15-20 secs
- Qmax > 20mls/sec
- Smooth parabolic curve
What are average Qmax readings for:
- Males 40yrs
- Females 40yrs
- Males > 60yrs
- Females > 60 yrs
Males 40yrs = 22ml/sec
Females 40yrs = 25ml/sec
Males > 60yrs = 13mls/sec
Females >60yrs = 18mls/sec
What would the following patterns on the trace in uroflowmetry indicate?
- Exaggerated flow rate
- Prolonged flow rate and low Qmax
- Intermittent flow
- Stress incontinence or problematic detrusor overactivity
- Bladder outflow obstruction
- Straining
What techniques does US cystodynamogram use?
What do they measure (3)?
Combines the flowmetry with pre and post void bladder scanning
Measures functional bladder capacity, flow rate and post void bladder volume (residual)
What does cystometry measure (3)?
- bladder pressure, sensation
- capacity
- compliance during filling and voiding i.e. bladder pressure studies.
How does cystometry work (3)?
- The bladder is filled with saline at room temperature via a small bore urethral catheter which is passed along with a pressure transducer.
- A further pressure transducer is placed in the rectum.
- Pressure recordings are measured as the bladder is filled
What techniques do videourodynamic studies use?
What do they measure?
Combination of cystometry and radiographic screening, so that both pressure and visual information is obtained
What are the advantages of ambulatory urodynamics over conventional cystometry?
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
How does ambulatory urodynamics work?
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
What is the mneumonic for diagnosing potentially transient reversible causes of incontinence?
DIAPPERS
D - delirium I - infection A - atrophy (vaginal) P - pharmacological P - psychological E - excess urine output R - restricted mobility S - stool impaction
How does delirium cause incontinence?
Patient’s who have an acute confusional state often develop urinary incontinence, especially if the delirium is caused by a urinary tract infection.
How do infections cause incontinence?
UTIs cause irritability of the bladder
How can vaginal atrophy be managed?
Topical oestrogens
-prevent recurrent UTIs, and improve urgency and frequency symptoms. They do not improve incontinence per se
What are 2 psychological causes of urinary incontinence?
Depression and dementia
What could be some causes of excess urine output (2)?
- Medical condition such as DM
2. Excess fluid intake
How do you identify stool impaction?
DRE
What are 9 main risk factors for stress incontinence?
- Age
- Female
- Childbirth
- Post-menopausal
- Obesity
- Surgery
(esp post hysterectomy) - Neurological disease
-Parkinson’s/dementia/stroke/MS - Urinary infection
- Bladder outlet obstruction
Why are females more likely to develop stress incontinence (3)?
- The bladder outlet is weaker due to a shorter urethra and lack of prostate
- Childbirth increases risk esp with:
-C section
-Vaginal delivery
-Forceps delivery
(Damage can be a combo of ligament and nerve damage) - Obesity - causes increased strain and weakening of the pelvic floor
- Vaginal atrophy
How does surgery (which one in particular) increase the risk of stress incontinence?
The risk of stress incontinence following transurethral resection of the prostate is approx. 1%
What are 4 causes of an overactive bladder (urge incontinence)?
- Idiopathic – most common
- Neurogenic – associated with neurological conditions e.g. multiple sclerosis, parkinsonism, stroke or spinal cord injury
- Infective – urinary tract infection
- Bladder outlet obstruction
What is the main cause of overflow incontinence?
Bladder outlet obstruction (BOO) - Outlet obstruction causes a strain on the bladder which over time may lead to residual urine left in the bladder.
What are the causes of bladder outlet obstruction (9)?
- Phimosis
- Stricture (male preponderance)
- STDs particularly in women
- Trauma
- Blood clot
- Calculi
- Benign prostate hypertrophy (BPH)
- Cancer of prostate or bladder
- Carcinoma of cervix or colon
What medications worsen urinary incontinence (8)?
- Alpha blocker
- Alpha agonist
- ACEI
- Haloperidol
- Opioids
- Hypnotics
- Cholinesterase inhibitors
- Ca channel blockers
How do alpha blockers cause urinary incontinence?
Relax bladder outlet which may worsen stress urinary incontinence
How do alpha agonist cause urinary incontinence?
Urinary retention may lead to overflow
How do ACI cause urinary incontinence?
Chronic cough may worsen SUI
How does haloperidol cause urinary incontinence?
Anticholinergic may cause retention
How do opioids cause urinary incontinence?
Constipation, which can cause overflow incontinence
How do hypnotics cause urinary incontinence?
Reduced awareness of need to urinate
How do cholinesterase inhibitors cause urinary incontinence?
Increase bladder contraction
How do Ca channel blockers cause urinary incontinence?
Decrease smooth muscle contractility
What are the 4 broad areas of management of incontinence?
- Patient Education
- Multidisciplinary Team and Non-pharmacological
- Medical Management
- Surgical Management
What are red flag symptoms that prompt urgent referral to urology or urogynaecology (4)?
- Pain on micturition
- Haematuria
- Prolapse beyond the introitus
- Suspicion of prostate cancer
What are 4 things that can be advised in Patient Education , in the management of SUI?
- Smoking cessation
- Weight reduction
- Managing constipation
- Reducing alcohol and caffeine
What is a medical management of SUI?
Duloxetine (SNRI) - limited evidence and no longer recommended by NICE as 1st or 2nd line treatment
What is the MDT and non-pharmacological treatment of SUI (4)?
- 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. - Pelvic floor exercises - physiotherapist
- 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 - 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
What are vaginal cones?
Vaginal cones are small weights that can be placed in your vagina to help you train your pelvic floor muscles. Used to treat SUI
What are 3 surgical procedures that can be done for SUI?
- Mid-urethral sling insertion -(tension free vaginal tape, or TVT) provides support under the urethra.
- Colposuspension is a much more invasive operation although is useful if a patient has an associated cystocele.
- 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.
What are 5 causes of pelvic floor muscle weakness?
- Childbirth
- Obesity
- Chronic cough
- Post pelvic surgery
- Post menopausal
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
- Smoking cessation
- Weight reduction
- Manage constipation
- Reduce caffeine and alcohol intake (switch to decaff)
- 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.
What is the medical management of overactive bladder (OAB) (4)?
- Antimuscarinic drugs - mainstay of treatment
- They act on the M3 receptors on the detrusor muscle to reduce contraction
- oxybutynin
- tolterodine - 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. - Intravaginal Oestrogens
- NICE recommend their use for women who have vaginal atrophy and symptoms of overactive bladder - Botulinum Toxin
- This can be injected into the detrusor muscle via cystoscopy.
- It inhibits neurotransmitter release thereby decreasing contractility
What is the MDT and non-pharmacological treatment of OAB (3)?
- Community continence advisor
- Can assess patients in their own homes and offer advice and information regarding urinary incontinence - Pelvic Floor Exercises
- 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
What is the surgical treatment of OAB (2)?
- Sacral nerve stimulation
2. Augmentation cystoplasty (rarely used now)
What are the 3 first line anti-muscarinic agents recommended for OAB?
- Oxybutynin (but not to be used in older adults with frailty)
- Tolteridone
- Darifenacin
What are some side effects of anti-muscarinic agents?
- Brain (2)
- Eyes (1)
- Salivary glands (1)
- Heart (1)
- GI tract (2)
- Urinary system (1)
Brain
- Cognitive impairment
- Hallucinations
Eyes
1. Blurred vision
Salivary glands
1. Dry mouth
Heart
1. Tachycardia
GI tract
- Nausea
- Constipation
Urinary system
1. Urinary retention
What is the patient education management of bladder outlet obstruction (5)?
- Smoking cessation
- Weight reduction
- Manage constipation
- Reduce caffeine and alcohol intake
- Reduce fluid intake, especially in the evening
(advise no drinks after 8pm)
What is the medical management of bladder outlet obstruction (2)?
- alpha adrenoceptor antagonists (alpha blockers) e.g. doxazocin - these drugs reduce the smooth muscle tone of the prostate
- 5 alpha reductase inhibitors e.g. finasteride - these drugs reduce prostate volume by blocking the conversion of testosterone to dihydrotestosterone
What is the MDT and non-pharmacological of bladder outlet obstruction (3)?
- Community continence advisor
- Can assess patients in their own homes and offer advice and information regarding urinary incontinence - Pelvic Floor Exercises
- 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
What is the surgical management of bladder outlet obstruction (1)?
Depend on the actual cause and will require referral to urology or urogynaecology.
- A transurethral prostatectomy (TURP) can be considered in cases of Benign Prostatic Hypertrophy.
Why do you ask about caffeine?
irritant to bladder
Treatment of stress incontinence
- Pelvic floor exercise
- 3 months, 8 contractions 3x a day - Duloxetine
- 2nd line, does not really work - Surgery
- TVT/TOT (pulls bladder neck up and forward)
- or new: Intra-mural bulking agents to enhance external sphincter - Botox injections in bladder wall
Associations of OAB (4)?
- Poor quality of sleep
- Less work productivity
- Less sexual satisfaction/more erectile dysfunction
- Depression
RF for OAB (6)?
- Normal vaginal delivery
- Forceps delivery
- High caffeine intake
- Old age
- Straining/constipation
- Obesity
Investigations of OAB?
Bladder diary - small amounts at a time but frequent
What are anti-muscarinic side effects (6)?
SLUDGE: (stops all these apart from emesis)
- Salivation
- Lacrimation
- Urination
- Defaction
- Gastric emptying
- Causes emesis
Associations of bladder outflow obstruction (2)
Erectile and ejaculatory dysfunction
Causes of bladder outflow obstruction
obstruciton outside urethra -bph, ca ostate -tight himosis -chronic constipation
within urethral
Investigation of bladder outflow obstruction?
Post-void bladder scan
urodynamic assessment - differentiates types of incontinence
urodynamic assessment
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
MEdicaloptions for treatning BPH
- alpha blockers
- relax smooth muscle at bladder neck and within prostate
- Takes few weeks to work - 5 a-reductase inhibitors
- inhibit converstion of testosterone to dihydrotestosterone in prostate
- takes 6 months to work
(can combine the 2)
Reasons to be constipated (9)?
-may be incontience, or physically cant get to toilet quick enough
- Dehydration
- Anti-muscarinics/opiatse
- Lack of fibre
- Immobile
- Mental health
- Depression/anxiety - Neurological conditions
- PD/MS - Obstruction
- rectal prolapse etc - IBS
- Endocrine
- hypothyrodisim
- diabetes
What are medical treatment options for constipation (3)?
- Bulking agents
- Osmotic agents
- Stimulants
