OPIC - Continence

Question 1

Types of Urinary Incontinence

Stress
Urge
Overflow
Others

Answer 1

1.) Stress - involuntary leakage of urine due to an incompetent sphincter and ↑intra-abdominal pressure
- e.g. coughing, straining, laughing, or lifting
- often due to weakness of pelvic floor muscles so commonly seen in post-partum and post-menopause

2.) Urge - sudden urge to urinate followed by un-controllable urination, due to an overactive bladder:
- detrusor instability: idiopathic, cystitis, stone, cancer
- hyperreflexia: stroke, MS, SC injury, dementia
- drugs: AChEi e.g. rivastigmine, donepezil

3.) Overflow - bladder becomes overly full w/o any urge to urinate due to blockage or weak bladder muscles
- blockage (often also have voiding sx): prostate hyperplasia, stricture/stone, constipation
- weak bladder: often a complication of chronic urinary retention, can also be due to SC injury, previous bowel surgery, or certain medications

4.) Others
- mixed: combination of stress and urge incontinence
- continuous: constant leakage of urine due to severe overflow incontinence or an anatomical abnormality (e.g. ectopic ureter, vesicovaginal fistulae)
- functional: unable to reach the toilet in time, for such reasons as poor mobility or unfamilar surroundings

Question 2

Assessment of Urinary Incontinence

History
Examinations
Investigations
Others

Answer 2

1.) History
- timing: duration, onset, progression, frequency
- detailed questions to categorise the type
- urological review: storage/voiding sx, infective sx
- PMH: neuro conditions, fistula, prolapses
- surgical history: prostate, pelvic, bowel surgery
- obstetric history in women
- DH: ACEi, diuretics, AChEi, sedatives, HRT

2.) Examinations
- abdominal, pelvic, and neurological examination
- vaginal exam: atrophic vaginitis, weak pelvic musculature, pelvic organ prolapse, pelvic mass
- DRE: prostate hyperplasia, faecal impaction

3.) Investigations
- urine dip: send MSU if the patient has UTI sx or the urine dipstick is positive for leukocytes and nitrites
- post-void bladder scan: for voiding sx or recurrent UTIs, overflow UI: low post-void residual volume
- urodynamic assessment if unclear aetiology: normal function (voiding detrusor pressure rise of < 70 cm + peak flow rate of > 15 ml/s), in overflow UI (↑detrusor pressure and ↓peak flow rate)
- urinary dye studies: vesico-vaginal fistulae
- others: cystoscopy, IV urogram, MRI

4.) Others
- bladder diary: can help assess the underlying cause
- QoL questionnaire can help quantify the severity

Question 3

Management of Urinary Incontinence

Conservative Management
Pharmacological Management
Antimuscarinics
Surgical Management

Answer 3

1.) Conservative Management - first line
- improve oral intake, avoid caffeinated drinks
- regular toileting, good bowel habits
- stress/mixed UI: supervised pelvic floor muscle training for at least 3 months
- urge UI: bladder training for at least 6 weeks
- overflow UI is managed by relieving the obstruction, intermittent self-catheterisation or indwelling catheter

2.) Pharmacological Management
- stress/mixed UI: duloxetine (SNRI) if pelvic floor training fails and patient does not/cannot have surgery
- urge: anti-muscarinic drugs or mirabegron (ß-3 agonist) in elderly

3.) Antimuscarinics - treat overactive bladder (urge UI)
- used if bladder training is ineffective or as an adjunct
- oxybutynin is ‘first-line’ but avoid in elderly, others:
- solifenacin, tolterodine, trospium
- side-effect: constipation, urinary retention, confusion, dry mouth, fatigue, blurred vision, glaucoma

4.) Surgical Management
- stress: tension-free vaginal tape, artificial urinary sphincter, open colposuspension
- urge: botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty

Question 4

Faecal Incontinence

Aetiology
Faecal Impaction
Investigations
Management

Answer 4

1.) Aetiology - ageing causes the rectum to become more vacuous and the anal sphincter to gape
- cannot exert same muscle tension to force out stool
- risk factors inc: ↑age, frailty, cognitive impairment, LD
- chronic constipation, diarrhoea, urinary incontinence
- anal problems: perianal pathology, anal surgery, obstetric injury, prolapses, colonic resection
- neuro deficit causing ↓anal tone and ↓anal sensation: SC injury, stroke, MS, tumour, infection, spina bifida

2.) Faecal Impaction - stool stuck in rectum or colon
- soft stool can also fill the rectum causing impaction
- faecal impaction with overflow diarrhoea is the most common cause of faecal incontinence
- full rectum is often associated with a full bladder

3.) Investigations
- PR: assess rectum, prostate, anal tone and sensation, stool type if in the rectum
- assess for urinary retention as often linked
- abdominal exam, can sometimes palpate faeces

4.) Management
- enemas (+stool softeners if hard stool)
- laxatives esp if taking drugs causing constipation
- manual evacuation in difficult cases when the risk of perforation is outweighed by the positive impact on sx
- exclude complications: stercoral perforation, ischaemic bowel in chronically constipated