Urinary Incontinence Flashcards
can incontinence be normal
incontinence is abnormal at any age
how to stop bladder voiding
higher centres (thalamus and cerebral cortex) can inhibit urination unless the bladder volume is very high
on-off switch for voiding
pontine micturition centre (PMC)
bladder emptying occurs when
parasympathetic outflow increases sharply and somatic/sympathetic tone decrease
bladder contracts, sphincters open and the urethra widens
normal amount of voids
5-7 per day (3-4 hourly)
0-2 per night
normal bladder volume
400-600mL
urge to void usually occurs when
bladder volume is 150-300mL
minimum fluid intake should be
> 1500mL/day unless restricted
changes with ageing
- bladder capacity declines
- post-void bladder volume increases
- involuntary bladder contractions increase
- lose the ability to concentrate urine at nigh (ADH secretion decreases) with nocturia 1-2 times per night
- prostate size increases
medical complications of urinary incontinence
UTI and urosepsis, falls, fractures, pressure injuries, skin and perineal rashes (including cellulitis, dermatitis)
psychosocial complications of urinary incontinence
social isolation, stigmatisation, embarrassment, depression, sleed deprivation, sexual dysfunction, caregiver stress, institutionalisation risk
urinary tract infection
infection in any part of he urinary tract (kidney, ureters, bladder, urethra). typically lower tract
stress incontinence
involuntary leakage of urine on stress or exertion. usually die to weakness of the pelvic floor muscle and fascial support, or weakness/damage to the urethral sphincter
urgency
abrupt, strong often overwhelming need to urinate. occurs when the pressure in the bladder increases suddenly, whether or not the bladder is full. can lead to urge incontinence
transient incontinence
typically occurs in association with acute illness
causes of transient incontinence
DIAPPERS:
Delirium
Infection (UTI)
Atrophic vaginitis/urethritis
Pharmaceuticals
Psychological
Excessive urine output
Restricted mobility
Stool impaction
anticholinergics cause
urinary retention
cholinesterase inhibitors cause
incontinence
calcium channel blockers cause
constipation, fluid
ACE-inhibitors cause
cough
Diuretics cause
fluid retention/diuresis
alpha blockers cause
urethral relaxation
beta-agonists cause
retention
narcotics cause
constipation, sedation
sedatives including alcohol cause
reductions in cognition/sedation
pathophysiological causes of incontinence
detrusor overactivity
detrusor underactivity
outlet obstruction
outlet incompetence
detrusor overactivity is caused by
cystitis, cancer, stones, urethral obstruction, MS, stroke, alzeimer’s, Parkinson’s
detrusor under activity is caused by
idiopathic, chronic outlet obstruction, autonomic neuropathy, surgical damage, disc compression, plexopathy
outlet obstruction is caused by
prostate (benign prostatic hypertrophy or cancer), urethhral stricture, spinal cord lesion with detrusor-sphincter dyssynergia
outlet incompetence is caused by
prostate surgery, urethral hyper mobility, sphincter incompetence, radical prostatectomy with nerve damage
types of incontinence
stress, urge, mixed, overflow, functional
stress incontinecen
involuntary leakage of a small volume of urine during periods of raised intra-abdominal pressure such as exertion, sneezing or coughing. most commonly occurs with women, post party or post menopausal
urge incontinence
involuntary loss of urine shortly after the awareness of the need to empty the bladder but before the person can get to the toilet
mixed incontinence
combined stress and urge, the commonest type of incontinence in women aged above 60 years
overflow incontinence
involuntary leakage of small amounts of urine as a result of mechanical forces on an over-distended bladder
functional incontince
physical, cognitive and environmental factors may contribute
factors outside the bladder
causes of stress incontinence
in women, causes include oestrogen deficiency, obesity, previous vaginal deliveries, previous surgery
in men, causes include radiotherapy and prostatectomy
urge incontinence pathophysiology
involuntary loss of urine accompanied by or immediately preceded by urgency.
detrusor has sudden, random contractions.
unable to delay voiding after sensation go bladder fullness felt.
more common with ageing
DHIC - detrusor hyperreflexia with impaired contractility
a subset of patients with detrusor over activity.
emptying less than 1/3 of bladder volume, predisposed to urinary retention.
urinary retention may be caused by either
outflow obstruction
or
non-contractile detrusor
does a normal sized prostate on rectal exam and normal PVR (post residual void scan) exclude obstruction?
negatory
what can confirm/exclude obstruction
urodynamic studies
crucial points on history
effect on QOL
need for assistance
use of acids
previous UTIs
surgical and obstetric history
bowel and fluid intake
mobility
alcohol, caffeine and smoking
crucial points on examnation
urine stained or malodorous clothing
mobility
cognition
abdo exam - palpable bladder
neuro exam - LL neurological signs
cardiovascular exam - fluid status
PR - anal tone, constipation (faeces), prostate (size, nodules)
urinary stress test
cough and observe for urine leakage
urodynamic studies are used when
used for complex patients not responding to treatment
or patients with previous pelvic surgery or radiation
used for younger patients if diagnosis is uncertain
or used when surgery s being considered
contained incontinence
uses pads or appliances
may be the best goal for some patients
treatment considerations
patient commitment to therapy
tolerance and risk of adverse effects
financial considerations
general management measures
avoid constipation
avoid dehydration
avoid excessive coffee
avoid alcohol
stop smoking
use continence aids such as pads or bed protection
use toileting regimes (timed toileting intervals usually 2-3 hourly)
consider environmental factors (urinary bottle, toilet rials and aids, call bell)
weight loss in overweight or obese women reduces episodes
behavioural/physcial interventions
bladder training, pelvic floor muscle exercises
bladder training
deferred voiding = delayed voiding for progressively longer periods of time so as to train the bladder to hold increasingly larger volumes of urine. recommended for symptomatic overactive bladder
pelvic floor muscle exercises
recommended for men and women with symptoms of overactive bladder, and for stress and mixed incontinence in women.
can assess muscle contraction with ultrasound, or supplement with electrical stimulation.
fluid management
frequent intake of small amounts of fluid (120-150mL per hour) up to 2L per day
avoid large episodic fluid boluses
consider comorbidities eg. heart failure
how do anticholinergics help
significant adverse effects
oxybutinin tablets and patches
acts via mascurinic receptors - antispasmodic effects on bladder
how do beta-3 agonists help
mirabegron (betmega). non PBS
stimulation of the beta-3 pathway promotes smooth muscle relaxation of the bladder to increase urine storage
efficacy similar to anticholinergics
causes HTN as adverse effect
oestrogens
low dose vaginal oestrogens (creams, tablets or rings) are approved for the treatment of vaginal atrophy.
modest improvement in urinary incontinence in post-menopausal women compared to placebo
anticholinergic side effects
dry mouth, blurred vision, urinary retention, constipation, confusion (esp. in older patients) warn patients/carers
surgical management of stress incontinence
highly effective
mid urethral sling is the most commonly performed surgery
also retro pubic Burch colposuspension
surgical management of urge incontinence
prostate surgery (if this is the cause of the urge incontinence)
percutaneous tibial nerve stimulation (acupuncture needle) - messages to sacral plexus
botox A into the bladder
sacral neuromodulation
overflow incontinence may be caused by
- anatomical obstruction: prostate, stricture, cystocoele)
- acontractile bladder: associated with diabetes or spinal cord injury (functional obstruction)
- medication related
overflow incontinence is
leakage of small amounts of urine due to mechanical forces on an over distended bladder
management of overflow incontinence
catheter if significant infection then refer to urology.
can try ‘double voiding’ if no catheter
prostate enlargement due to BPH can be treated with drugs
prostate enlargement due to BPH can be treated with
prazosin, tamsulosin, duodart
or surgery
duodarrt
combination of 5-alpha reductase inhibitor (dutasteride) plus alpha-blocker (tamsulosin)
