Urinary Incontinence Flashcards
What are some consequences of urinary incontinence?
- Falls (& subsequent #)
- Skin irritation
- Pressure ulcers
- Social implications
- Psychological
What is important to remember in regards to urinary incontinence in the elderly?
It is abnormal
What is the normal bladder physiology?
- Hollow bag of smooth (detrusor) muscle
- In a complex network of muscle fibres and connective tissue
- Used to store urine
- Expands without pressure rising during filling
- Capacity ̴ 500 mls (usually void at ̴ 250 mls)
- Excretes urine via urethra
- Supported and maintained in the correct position by the pelvic floor muscles
Outline the anatomy of the urethra and sphincters
- Urethra exits bladder at the trigone
- Supporting structures important to maintain continence
- Forms a fibromuscular tube
- Lined by mucosa
- With submucosal vessels & connective tissue
- Urethral lumen surrounded by several muscle layers
- Outer striated sphincter (rhabdosphincter)
- Middle circular smooth muscle (thin layer)
- Inner longitudinal smooth muscle
- Smooth sphincter – Bladder neck & proximal urethra – involuntary control
- Maintained closed during storage phase
- Extends almost the length of urethra
- Striated sphincter – Intra & Extra mural components – voluntary control
- Extramural is part of pelvic floor musculature
What is the peripheral innervation of the LUT?
1. Sympathetic:
• T10–L2 (hypogastric nerve)
- Smooth muscle contraction
- Urethra and bladder base
- α receptors dominant
- *• Detrusor muscle relaxation**
- Bladder body
- β3 receptors in detrusor
- *• Inhibition of detrusor contraction**
- Action on parasympathetic ganglia
-
Parasympathetic:
• S2–S4 (“Spinal micturition centre”)
• Fibres travel in pelvic nerves
• Detrusor muscle contraction
• M3 muscarinic receptors
3. Somatic:
• Sensory
- Stretch, pain & temperature
- From bladder to spinal cord
• Motor
- Pudendal nerve
- Innervation of levator ani
- Contraction of external urethral sphincter
- Nicotinic receptors
What is the central innervation of the LUT?
• Pontine Micturition Centre:
- Brainstem
- Under control of the brain centres
- Switches between storage and micturition
modes
• Brain Centres
- Conscious & unconscious control of PMC
- Inhibitory influences from prefrontal cortex &
hypothalamus
- Critical in delaying voiding
Outline the filling/storage phase of micturition
• Primarily passive
- Requires inhibition of parasympathetic excitatory input
- Dependant on elastic and viscoelastic properties
- Needs suitable outlet resistance
- Needs low bladder muscle tension
• Increased sensory signals to cerebral cortex
• Inhibitory signals from higher centres prevent premature emptying
Outline the voiding stage of micturition
- Voluntary or involuntary
- Higher centres send ‘activating message’ downward
• INHIBITION:
- Somatic & Sympathetic reflexes
- Outlet relaxes
• ACTIVATION:
- Parasympathetic pathways
- Detrusor contracts
*Inhibition and activation must be coordinated
- Pressure rises & urine is expelled
Outline the ageing LUT bladder
- Reduced capacity
- Reduced contractility
- Increased post void volume (> 100 ml – no consensus)
- Increased uninhibited bladder contractions
- Increased incidence of bacteriuria
- Increased volume excreted later in day/night
Outline the ageing LUT urethra and pelvic floor
1. Pelvic floor muscles:
- Muscle atrophy & thinning (reduced sphincter strength/reduced ability to delay void)
- Pelvic floor organ prolapse more likely
- 2. Urethra/Vagina/Prostate:
• Reduced urethral maximal closure pressure
• Reduced vascularity, moisture & collagen
• Reduced oestrogen-collagen effect &
sclerotic change (atrophic vaginitis, storage symptoms &
incontinence)
• Increased prostate mass (overflow)
How is urinary incontinence classified?
- Stress incontinence
- Urge incontinence (over active bladder syndrome)
- Reflex incontinence
- Overflow incontinence
- Functional incontinence
- Mixed incontinence
- Transient or established
Outline the causes of transient urinary incontinence (DIAPPERS mnemonic)
- Delirium
- Infection
- Atrophic urethritis/vaginitis
- Pharmaceutical
- Psychological
- Excessive urinary output
- Reduced mobility
- Stool impaction
Outline urge incontinence/OAB syndrome
- Most common cause of incontinence in older people
- Urgency that occurs with or without incontinence
- Impaired inhibition of bladder contraction
- Bladder contracts precipitantly (urinary leakage)
- Neurological lesion: Detrusor hyper-reflexia
- No neuro lesion: Detrusor instability
What symptoms are seen in urge incontinence?
- Sudden strong desire to void
- Urgency/precipitancy (sudden, compelling, difficult-to-defer desire to pass urine)
- Generally unable to overcome
- Often have nocturia
- May have frequent, periodic incontinent episodes (OAB ‘wet’)
- May not be incontinent (OAB ‘dry’)
*New OAB symptoms require investigation
What may urge incontinence be co-morbid with?
- UTI
- Stones
- Malignancy
- Outflow obstruction (50–75% of enlarged prostates - symptoms resolve in 2/3 after obstruction relieved)
Outline ‘destrusor overactivity’
Demonstrated urodynamically
• Two subtypes:
1. Normal contractility
• Bladder empties most of its contents
2. Impaired contractility (DHIC)
• Bladder unable to empty
• Residual > 100mls after involuntary contraction
• Association with degenerative neurological conditions
• Parkinson’s disease, Parkinson’s+ syndromes…
Outline reflex urinary incontinence
• A sudden loss of control of the bladder, at which
point any urine within the bladder is expelled
• Neurological problem
e.g stroke, MS, Parkinson’s, brain tumors, spinal cord
injuries
• Patients have no awareness of the need to
micturate
Outline stress incontinence (outlet incompetence)
- Symptoms of stress incontinence:
• Standing
• Physical activity
• Coughing
• Unusual in supine position - Volume of leakage can be small or large
- More common in women
- Usually due to weakening of supporting
structures of pelvic floor
• May be due to sphincter damage
• Prior surgery
Outline urethral obstruction
**1. Common cause of incontinence in elderly men
- Urinary retention with overflow incontinence:**
- Post-void dribbling
- May have coexistent detrusor instability
3. Neurological:
• Spinal cord lesions
4. Non-neurological:
• Prostate enlargement
• Urethral stricture
• Medications (adrenergic agonists)
• Tumours
Outline functonal incontinence
1. Intact lower urinary tract
2. Incontinence related to outside influences:
• Poor mobility
• Poor dexterity
• Poor cognition – dementia
3. Lower urinary tract rarely totally normal:
• Functional impairment may just overwhelm the individual’s
ability to compensate
How is urinary incontinence clinically assessed?
**1. Diagnose & treat reversible causes
- Detection of any serious underlying condition
- Determination of any lower urinary tract cause
- Improve quality of life
- Look for causes of increased urine production:**
- Drugs
- DM
- Hypercalcaemia
- CCF
- Peripheral venous insufficiency
What questions should be asked in the history?
- Onset
- Precipitating factors
- Frequency
- Volume
- Dysuria
- Straining
- Feeling of incomplete emptying
- Daily pattern of voiding
- Medications
- Surgery
- Previous attempts to treat the incontinence
What drugs may be the culprit?
1. Diuretics:
• Especially loop diuretics
2. Anticholinergics:
• Especially centrally acting
3. Opiates
4. Alcohol + Caffeine:
- Diuresis & bladder irritation +/− neuropathy (alcohol)
5. NSAIDs
6. Calcium antagonists
What are some neurological and metabolic conditions you should assess for?
- Neurological: stroke, IPD
- Metabolic = diabetes mellitus
Outline your clinical examination in urinary incontinence
**1. Cognitive status
- Functional status (OT/physio assessment)
- Evidence of CCF**
4. Neurological exam:
• Include assessment of sacral nerve segments
5. Rectal exam
• Prostate size & faecal impaction
6. Pelvic exam
• Cystocele, rectocele, atrophic vaginitis
What investigations must be performed?
1. MSSU:
• Cells in absence of sepsis warrants further Ix
2. Post void residual volume:
• If high, hydronephrosis needs excluded
3. Vaginal cytology
4. U&E
5. Serum glucose & Ca2+
How is OAB managed?
- Bladder training & prompted voiding
- Anti-muscarinics
- Mirabegron – β3 agonist
- ? Desmopressin
- ? Surgery or Botulinum Toxin
How is stress incontinence managed?
- Weight loss
- Treat any cough
- Adjust fluid excretion & voiding intervals
- Pelvic floor muscle exercises
- Duloxetine + oestrogen
- Surgery
How is urinary obstructon managed?
- Prompted voiding, bladder retraining (if large PVR & hydronephrosis excluded)
- Alpha antagonists
- Anti-androgens
- Surgery
What investigation is required in mixed incontinence?
Urodynamics to delineate the predominant cause
What are the indications for long term catheter?
**1. Refractory bladder outlet obstruction
- Neurogenic bladder with urinary retention
- Complications of Incontinence:**
- Refractory skin breakdown
- Palliative care for terminally ill
- Patient preference
What are the complications associated with long-term catheters?
- UTI
- Urosepsis
- Bacteriuria
- Chronic renal inflammation
- Pyelonephritis
- Nephrolithiasis
- Cystolithiasis
- Pressure/tension damage
*Catheters are foreign bodies
What are the indications for a short-term catheter?
- Urologic or pelvic surgery
- Acute urinary retention (TOV at 14 days)
- Urinary output monitoring in critically ill
