Module 4.3 (Urinary Incontinence) Flashcards
Define the following terms:
A) Urinary incontience/enuresis
B) Nocturnal enuresis
C) Urgency
D) Nocturia
E) Increased daytime frequency
F) Retention
A)
- The complaint of any involuntary leakage of urine
B)
- Any involuntary loss of urine during sleep
C)
- The complaint of a sudden, compelling desire to pass urine, which is difficult to defer
- Urgency can be with/without incontinence
D)
- The complaint that the individual has to wake at night one or more times ot void
E)
- The complaint by the patient who considers that he/she voids too often by day
F)
- Inability to urinate
What is meant by continene?
A normal bladder
- empties 4-8 times each day (every 3-4 hours)
- can hold up to 400-600ml of urine (the sensation of needing to empty occurs at 200-300 ml)
- may cause nocturnal awakening once at night to pass urine (twice if over 65 years of age)
- Tells a person when it is full but gives them enough time to find a toilet
- Empties completely each time urine is passed
- Does not leak urine
What does untreated UI heighten the risk of?
- Infection
- Pressure ulcers –> skin infections
- Social isolation and depression
- Loss of sleep
- De-conditioning
- Falls and associated fractures
- Nursing home admission
What is the physiology the bladder?
When want to fill ballder = cholinergic nerves turned off and beta adrenergic system turned on. If beta adrenergic system turned on = sphincter will constrict.
When want to urinate = cholinergic nerves turned on and beta adrenergic system turned off. Cholinergic nerves turned = detrusor contracting and push urine out of the bladder and into the urethra.
What are the basic requirements for continence?
Bladder – relaxed while filling, contracts to empty ◼
Sphincter mechanism – prevents leakage and relaxes to urinate ◼
Pelvic floor – supports the bladder and aids the sphincter ◼
Nervous system – transmits messages to/from brain ◼
Brain – interprets messages and sends commands ◼
Locomotor ability – to get to and use the toilet
What does urine storage require?
Accommodation of increasing volumes of urine at a low intravesical pressure (normal compliance) and with appropriate sensation.
A bladder outlet that is closed at rest and remains so during increases in intra- abdominal pressure.
Absence of involuntary bladder contractions (detrusor overactivity).
Bladder emptying/voiding requires?
A coordinated contraction of the bladder smooth musculature of adequate magnitude and duration.
A concomitant lowering of resistance at the level of the smooth and striated sphincter.
Absence of anatomic (as opposed to functional) obstruction.
What are some risk factors for urinary incontinence?
Women
- Pregnancy
- Child birth
- Menopause
- Pelvic Surgery
Men
- Benign prostatic hyperplasia
- Prostate surgery
Non gender-specific
- Smoking
- Obseity
- Recurrent urinary tract infections
- Reduced mobility
What the medical conditions asscociated with UI?
◼ Stroke ◼ Parkinson’s disease ◼ Dementia◼ Sleep apnoea ◼ Depression ◼ Behavioural disorders ◼ Diabetes (polyuria, polydipsia, neuropathy) ◼ Congestive heart failure
CHF: produce more urine at night time because renal perfusion is better at this time = increased risk of nocturnal enuresis
What are the types of UI?
Stress urinary incontinence
- Involuntary leakage on effort, exertion, sneezing or coughing
Urge urinary incontinence
- Involuntary leakage immediately preceded by urgency
Overflow urinary incontinence
- Also referred to as “chronic retention of urine”
- Emptying failure by outlet obstruction or inability to contract detrusor
Functional incontinence
- Lack of recognition or ability to get to toilet in time - unrelated to bladder and nervous control
Mixed incontinence
- Combinations of the above
General management principles for UI?
- Decrease intake of fluids, caffeine, and carbonated drinks
- Constipation should be managed and avoided
- Lose weight if BMI >25kg/m2
- Urodynamic studies
- UTI investigations
- Bladder diary
> Number of pads needed over 24 hrs and their type
> Activity restriction
> Frequency of accidents
> Record of symptoms – presence, frequency, severity
The most common type of incontinence amongst young and middle-aged women? Caused by?
Stress Incontinence
Caused by:
- Childbirth, pelvic surgery (eg prostatectomy), or an abnormal position of the urethra or uterus
- Lack of oestrogen in postmenopausal women
- Obesity
What medications to cease for stress incontinence?
alpha-adrenergic blockers becuse it relaxes the sphincter
systemic oestrogen
What to use for stress incontinence?
Topical oestrogens = thicken up mucus membranes and strengthen sphincter
Duloxetine (5HT and NA) –> 5HT and NA causes sphincter to constrict
A-adrenergic agonists = not used much
How to manage stress incontinence?
Pelvic floor exercises ◼ Treat chronic cough ◼ Treat constipation/ faecal impaction ◼ Weight reduction ◼ Surgery ◼ Vaginal pessaries (nonmedicated)
When should pelvic floor muscle training be used (PFMT)
Should be offered to all women with SUI and UUI (urge urinary incontinence) as first-line management
> most effective for stress urinary incontinence
Women treated with PFMT more likely to report improved or cured UI
>Also report fewer incontinence episodes per day and a better quality of life
Must contract correct pelvic muscles to be effective
> may require more than verbal and written isntructions
SNRIs for UI?
Duloxetine may reduce the frequency of episodes of incontinence and improve quality of life scores
Generally not curative
Nausea common, but does not commonly cause discontinuation
What are examples of adrenergic agonists? Are they used?
D-adrenergic agonists - phenylpropanolamine, midodrine
Side effects common
- insomnia, restlessness and vasomotor stimulation
- cardiac arrhythmias and hypertension have been reported but are rare
Almost never used in australia
what is urge continence? what are the causes?
Urine loss, accompanied by or immediately preceded by urgency (sudden compelling desire to pass urine which is difficult to defer)
Commonest in elderly, often in combination
Causes
- Neurological conditions e.g. Parkinson’s, MS, Alzheimer’s, CVA
- Constipation
- Enlarged prostate
- UTIs
What is an overactive bladder? What are the types?
Symptom syndrome suggestive of lower urinary tract dysfunction
- Urgency, with or without urge incontinence
- Usually with frequency and nocturia
- Also called overactive bladder syndrome, urge syndrome, urgency-frequency syndrome (previously detrusor instability)
OAB wet –> urge with loss of urine
OAB dry –> urge without incontinence
How to manage urge incontinence?
Exclude UTI
Treat constipation/ faecal impaction ◼ R
educe caffeine and alcohol intake ◼
Limit fluid intake ◼
Bladder training ◼
Pelvic floor exercises
Medications
- anticholinergic or tricyclic antidepressant ◼
- mirabegron ◼
- Botulinum toxin (BotoxTM) ◼
- E-adrenergic agonists (terbutaline)
What anticholnergics/TCA are used for urge incontinence?
cautious using in elderly, cognitive AE = confused, delirious, forgetful
Imipramine (Tofranil) ◼ and other TCAs ◼ Dicyclomine (Merbentyl) ◼ Propantheline (Pro- Banthine) ◼
Specific for urinary function:
Oxybutynin (Ditropan, Oxytrol) ◼ Darifenacin (Enablex) ◼ Tolterodine (Detrusitol) ◼ Solifenacin (Vesicare)
Discuss anticholinergics in overactive bladder?
Benefit varies between individuals
- on average there is one fewer episode of incontinence per 48 hours compared with placebo
No evidence of superior efficacy with newer agents (eg solifenacin, darifenacin) compared to oxybutynin
- Newer agents potentially better tolerated
Monitor for adverse effects (including changes in cognitive function) and assess for improvement in symptoms
- Stop after 4 weeks if there is no overall benefit
When is botox an option?
Onabotulinumtoxin-A is an option for people who cannot use, or do not adequately respond to, anticholinergics
Injected into the detrusor every few months
Patients must be willing to perform self-catheterisation if necessary
How does mirabegron work?
Beta3-adrenoceptor agonist
- relaxes bladder muscle during the storage phase of micturition, increasing bladder capacity
May increase BP and heart rate; avoid use in severe, uncontrolled hypertension
Sinilar effectiveness to anticholinergics
What is overflow incontinence?
due to urinary retention or underactive bladder
outfow blockage
- enlarged prostate
- constipation
symptoms
- frequency, urgency, nocturia
- incomplete bladder emptying
- frequent UTIs
How to manage overflow incontinence?
Cease anticholinergics
Try
- ◼ D-adrenergic antagonists –> prazoisn, terazosin, tamsulosin (relax sphincter and urethra as much as possible to mininise outflow obstruction)
- 5 alpha reductase inhibitors (shrink prostate)
> finasteride, dutasteride
> saw plametto
- catherisation
- srugery
When to give alpha blockers? How do they help? When not to give?
a-adrenergic antagonists
- Alfuzosin
- Prazosin
- Terazosin
- Tamsulosin
Block receptor in bladder neck and urethra, which may help to reduce outflow obstruction and overflow incontinence in males –> may precipitate or worsen incontinence in women
dont give in stress incontinence = urethra and sphincter need to be closed and may worsen it in women
What is functional incontinence? Treatment?
Loss of urine due to inability/unwillingness to go to a toilet
Associated with
- Immobility (stroke, arthritis)
- Loss of mental function eg AD
Treatment
- Regular toileting assistance
- Try to avoid reliance on garments/pads
Key messages?
Urinary incontinence is common and treatable
Medications can improve or worsen urinary incontinence
> Ensure medications are reviewed when incontinence presents or worsens
> Review effectiveness of medications used for continence
