Urinary Incontinence Flashcards
What is the normal fluid intake amount?
Normal fluid intake: 1.5 - 3L (more than this is polydipsia)
What is the normal size of a ‘full’ bladder?
• Normal full bladder: 250ml - 400mL
Therefore go to the toilet 4-8 times a day
What happens to the bladder with age?
• As we get older, our bladder loses capacity to stretch and loses functional reserve
Urinating up to twice a night normal if 65+
What is a normal residual volume post micturition?
After urinating, should have
What are the RF of urinary incontinence?
• Female • Impaired cognition (delirium and dementia) • UTI • Constipation • Impaired mobility • Diabetes • Bladder outflow obstruction • Obesity** major factor in stress incontinence Neurological diseases
What are the DIAPPERS precipitants of incontinence in the frail and disabled elderly?
- Delirium
- Infection
- Atrophic urethritis or vaginitis
- Pharmaceuticals
- Psychological disorders esp depression
- Excessive urine output e.g. HF, hyperglycaemia
- Restricted mobility
- Stool impaction
What is the role of the frontal lobe in urination?
Frontal Lobe: micturition control centre is located in the frontal lobe. It sends inhibitory signals to the detrusor muscle to prevent bladder contraction until it is socially acceptable.
What is the role of the pons in urination?
Pons: pontine micturition centre (PMC) coordinates bladder and sphincter. Promotes voiding.
A full bladder leads to signals from the stretch receptors of the detrusor muscle sent to the pons, which then signals the brain.
The frontal lobe can inhibit this sudden desire until appropriate. The PMC is deactivated, and urinary is delayed.
Children - usually the brain takes over the control of the pons at age 3-4 years, which is why most children undergo toilet training at this age
What is the role of the spinal cord in urination?
• Sacral reflex centre is the primitive voiding centre and is responsible for bladder contractions
Infants: higher centre of voiding has not been developed therefore control of urination is controlled by sacral reflex centre (bladdder fills, excitatory for sacral cord, detrusor muscle contraction)
What happens to the control of urination in a patient with spinal cord injury?
Spinal cord injury - patient will have Sx of urinary f, urgency, urge incontinence but will be unable to empty bladder completely. This is due to the bladder and sphincter are both overactive and leads to detrusor sphincter dyssynergia with detrusor hyperreflexia (DSD-DH) - the pathway from the sacral cord, up the spinal and to the pons is severed therefore pons cannot coordinate sphincter and detrusor
What is the role of peripheral nerves - SNS hypogastric and PNS pelvic nerve in voiding?
SNS via hypogastric nerve (T10-L2): storage. It causes
1. Bladder to increase its capacity without increasing the detrusor resting pressure (accommodation)
2. Stimulates the internal urinary sphincter to remain tightly closed
3. Inhibits PNS stimulation (micturition reflex inhibited)
PNS via pelvic nerve (S2-4): voiding. It causes
1. Stimulate detrusor muscle to contract (Ach)
2. Suppresses SNS influence on internal urethral sphincter, therefore relaxing and opening it
Pudendal nerve is inhibited to cause the external sphincter to open
What is the role of the somatic pudendal nerve in voiding?
Somatic via pudendal nerve (S2-S4)
• Pudendal nerve regulates the voluntary actions of the external urinary sphincter and the pelvic diaphragm. Activation of the pudendal nerve causes contraction of the sphincter and contraction of the pelvic floor muscles
• Neurapraxia of the pudendal nerve during prolonged vaginal delivery can cause stress urinary incontinence
• Suprasacral-infrapontine spinal cord trauma can cause overstimulation of the pudendal nerve resulting in urinary retention
Px findings in urinary incontinence
• Abdominal – masses, percussible bladder
• Pelvic – evaluation of pelvic floor muscles, genital prolapse (cystourethrocele, utero-cervical or vaginal vault prolapse, enterocele or rectocoele), evidence of oestrogen deficiency, sign of stress incontinence, bimanual (presence of tenderness and masses)
• Digital rectal examination of prostate – size and any irregularity
• Neurological – cognitive function, perineal reflexes/sensation, and lower limb reflexes, etc * look especially for MS
• Cardiac, peripheral oedema, orthopaedic, postural blood pressure in elderly
• Valsalva patient- ask patient to sneeze, cough, lift something heavy and look for leakage
If suspecting stress incontinence, make sure it is not overflow incontinence by asking them to valsalva
General Hx Q for all incontinence pts
• DOOFS
• Frequency during day
• Frequency during night
• LUTS esp dysuria
• Haematuria
• Oral intake: water and diuretics - how much fluid are you drinking and what type of fluid ar eyou drinking?
• Medications: Li (effect on collecting duct), diuretics
• Habits: counter bladder training “just in case pee”
• What are your triggers for urination?
• Nocturia: what time do you go to bed? What time do you get up?
Must assess impact on life: sleeping during day (if nocturia), waking up partner
Hx Q for urge incontinence
• Urge: Can you defer? • Do you experience constipation? • Have you had Sx of obstruction before? • Bladder Ca: haematuria, constitutional Sx Irritative symptoms or hx of UTI
Hx Q for stress incontinence
Stress:
• Do you leak with sneezing, coughing or lifting
• If female: after childbirth? Type of delivery? How many children? How big were the babies? Were there any complications? Did you do pelvic floor exercise after? Have you had gyne surgery? Have you had a prolapse - when you cough or sneeze do you see anything coming out of vagina, or do you feel like you are sitting on an egg?
If male: have you had prostate surgery
Hx Q for overflow incontinence
Overflow • Obstructive LUTS - Ca prostate Hx? - Hx of diabetes (ANS failure) - LMN disease?
Hx Q for functional incontience
• Are you able to mobilise and reach the toilet?
• How far are you from the toilet?
• What is lighting like?
• Is the toilet clearly marked so they can find it in residential facility
Is it an unobstructed way to get to toilet?
What are the key Ix for urinary incontinence?
• Bloods: rule out biochemical abnormality - high glucose, high Ca
• Ix medication: Li, diuretics
• MSU to rule out UTI, blood, proteinuria
• Bladder diary: 2 day frequency-volume chart
• Urge incontinence will be high F and low volume urine
Post-void residual volume – needs to be repeated if abnormal (want it to be less than 50mL for normal)
What is urodynamics testing?
» Urodynamics (the measure of P within bladder and sphincter) and flow rate study: can measure P intra abdo and P intracycle. Video urodynamics possible to view bladder (if urge: then may see bladder contractions at small volume) therefore can diagnose detrusor overactivity. Can see urinary stress incontinence when they sneeze, cough. Can tell you if obstruction or atony if difficulty emptying bladder. Good for all types of assessements of incontinence. Everyone must have urodynamics before surgery.
• Catheter inserted in backside or bladder. Then can fill up with water (simulate Urine) and watch bladder P monitor. Then can assess contraction, leakage. Not often done on old people.
Main indication for urodynamics is surgery assessment or diagnostic dilemma that wants to be solved by patient and doctor
Three most important investigations (according to geri)
Three most important
- MSU rule out UTI
- Ix: rule out biochem abnormality or drug cause
- Make sure not in urinary retention with bladder US
How do we prevent urinary incontinence?
• Appropriate postures for urination and defaecation
• Avoidance of constipation, straining at stool
• Good general fitness and avoidance of obesity
• Avoid smoking; treat chronic cough
• Good bladder habits (eg avoid frequent “just in case” voiding and over-distension)
Optimal obstetric management
What are the non - drug management options?
- Instruction re appropriate toileting posture
- Appropriate modification of existing medications
- Treat other contributing factors: faecal impaction, urinary tract infection, constipation, acute pain, diabetes, obesity (lose weight!)
- Optimise toilet access
- Appropriate fluids and diet
- Minimise active risk factors
- Continence products-consider referral to continence nurse advisor
- Consider pharmacological causes (see table below)
- Use bladder diary for at least 3 days, recording number of incontnent episodes, amount of loss and the circumstances
What are the complications of urinary incontinence?
• Fear of odour, actual leakage, avoidance of activities, loss of confidence, depression • Carer burden • Skin infection and breakdown • Urinary infection Falls
