Urinary Incontinence Flashcards by Sarah Moore

Define urinary incontinence

Involuntary loss of urine

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What demographic is most likely to experience incontinence?

Affects females 2:1 over males
Most common among elderly
30% elderly women
15% elderly men

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What is the average volume of urine a bladder can hold?

350- 550 ml

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At what volume does the urge to urinate begin at?

200 ml

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What are the types of urinary incontinence?

Urge 
Stress
Mixed 
Overflow
Neurogenic

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define urge incontinence

Uncontrolled urine leakage occurs immediately after an urgent, irrepressible need to void

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Pathophys of urge incontinence

Detruser muscle overactivity (OAB)
Atrophic urethritis
Idiopathic

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What demographic group is urge incontinence most prevalent in?

Most common type in elderly
Increases w/ aging
Childhood enuresis

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Define stress incontinence

Leakage due to abrupt increases in intra-abdominal pressure:
cough, sneeze, laugh, bend, lift

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What demogrpahic is stress incontinence most prevalent in?

Most common in young to middle aged females

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Stress incontinence pathophys

Urethral sphincter incompetence due to

Childbirth, atrophic urethritis, spinal injury, prostate procedure, obesity

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Define overflow incontinence

Continuous leakage or dribbling

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What is the least common form of incontinence?

Overflow incontinence

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What demographic is overflow incontinence most prevalent in?

Rare in women

2. Seen in men with BPH, stricture, or prostate cancer

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Pathophys of overflow incontinence

incomplete bladder emptying
Impaired detrusor muscle contractility (underactive)
Urinary retention leads to bladder distention & overflow of urine

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Define functional incontinence

Urine loss due to cognitive or physical impairments

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What are risk factors for functional incontinence?

Stroke
Dementia
PD
MS
Spinal injury

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What is the most common type of mixed incontinence?

Urge and stress

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What demographic is mixed incontinence most prevalent in?

Most common in 65+ females

Pathophys of incontinence

Caused by persistent problem affecting nerves or muscles
A. Bladder outlet incompetence or obstruction
B. Detrusor over/under activity

What causes outlet incompetence in women?

1. Usually result of weakened pelvic floor muscles 
A. Multiple vaginal deliveries
B. Pelvic surgery
-Hysterectomy 
C. Age related changes 
-Decreased estrogen causes: 
Atrophic vaginitis
Urethritis
Decreased urethral resistance

What causes outlet incompetence in men?

Damage after radical prostatectomy
A. Sphincter deficiency
B. Bladder neck
C. Posterior urethra

What causes outlet obstruction?

Urethral stricture
Large bladder diverticula (rare)
Bladder calculi
Cystocele: seen in women, a weakness in the muscle between the bladder and the anterior wall of the vagina
BPH
Prostate cancer

What are neurologic causes of detruser overactivity?

Alzheimer disease
Spinal cord injury/dysfunction
Multiple sclerosis
Stroke

What are non- neurologic causes of detruser overactivity?

1. Bladder carcinoma 2. Cystitis 3. Idiopathic 4. Outlet obstruction or incompetence

What are neurologic causes of detruser underactivity?

1. Autonomic neuropathy - Diabetes - Alcoholism - Vitamin B12 deficiency 2. Disk compression 3. Spine surgery 4. Tumor

What are non-neurologic causes of detruser underactivity?

1. Chronic bladder outlet obstruction | 2. Idiopathic (women)

What are common Hx symptoms for incontinence?

1. Meds: anticholinergics, decongestants, antihistamines 2. Drug/ETOH use 3. Obstetric Hx 4. Surgical Hx (spine, pelvis) 5. Voiding diary 48-72hr - Record volume, time of void - Incontinence in relation to associated activities - Eating, drinking, drug use, sleep - Amount of leakage

What are the relevant systems to examine for incontinence?

1. Cardiac exam 2. Abdominal exam 3. Pelvic exam (cystocele, prolapse) 4. Rectal exam (prostate) 5. Neurologic - Gait, mental status, LE function, reflexes, check for peripheral or autonomic neuropathy (orthostatic hypotension, sphincter tone)

What DS tests are indicated in incontinence?

1. UA, urine C&S 2. As indicated A. Glucose if polyuria B. Electrolytes if patient confused C. BUN/Cr D. B12 level if indicated 3. Possible urodynamics by specialist 4. Post void residual (< <50 cc normal, 100cc in elderly)

What is the tx for incontinence?

1. Treat specific causes 2, Treat skin to prevent breakdown 3. Discontinue drugs causing symptoms: CCB, morphine, pseudoephedrine, diphenhydramine, haloperidol, risperidone

What medications are used for incontinence?

1. (Anticholinergics) A. Relax detrusor muscle in OAB 2. Antimuscarinic agents 3. Tricyclic Antidepressants

What are the contraindications for anticholinergics?

Narrow angle glaucoma

What are the SE for antimuscarinic meds?

S/E dry mouth, delirium, constipation

What are the SE for tricyclic antidepressants?

Blurred vision, dizziness, dry mouth, fatigue, insomnia, nausea

What are some examples of antimuscarinic drugs used for incontinence?

``` Oxybutynin (Ditropan, Ditropan XL,Oxytrol-OTC) Darifenacin (Enablex) Fesoterodine (Toviaz) Mirabegron (Myrbetriq) Solifenacin (Vesicare) Tolterodine (Detrol, Detrol LA) Trospium (Sanctura) ```

What are some examples of TCAs used for incontinence?

Imipramine (Tofranil)

What specific incontinence types are TCAs used for?

Nocturia Nocturnal enuresis in children *Alternative-desmopressin (DDAVP) > 6yr

What is the treatment of outlet obstruction in men with urge/overflow incontinence?

``` 1. Alpha antagonists tamsulosin (Flomax) terazosin (Hytrin) doxazosin (Cardura) alfzosin (Uroxatral) 2. 5a-reductase inhibitors finasteride (Proscar) dutasteride (Avodart) 3. Jalyn (dutasteride/tamsulosin) ```

What alternative (off label) treatments can be used for incontinence?

1. Pseudoephedrine A. Alpha agonist effect-urine retention 2. Duloxetine (Cymbalta) A. SNRI-urine retention

What are the contraindications for Pseudoephedrine?

Avoid if HTN, CAD, narrow-angle glaucoma, thyroid Dz

What are the contraindications for Duloxetine (Cymbalta)

Caution with glaucoma, renal isufficiency, elderly

When is surgery used for incontinence?

1. Last resort 2. Cystocele repair, bladder suspension, TURP 3. 96% effective in stress incontinence

What devices can be used in incontinence treatment?

1. Self catheterization 2. Temporary indwelling catheter 3. Pessary

What other tx can be used for incontinence?

1. Suprapubic pressure 2. Double voiding 3. Valsalva maneuver for detrusor underactivity

What education needs to be given for ppl with incontinence?

1. Bladder training A. Void frequently 2. Limit fluid before going out or 3-4hr before hs 3. Avoid bladder irritants A. Caffeine, carbonation B. Drink 48-64oz fluid qd, concentrated urine irritates bladder 4. Pelvic muscle exercises (Kegel) A. Especially effective for stress incontinence B. Contract pelvic muscles x 10 sec, relax x 10 sec 5. Portable commode 6. Specialized pads/undergarments