Urinary Incontinence

Question 1

What is the things you should assess for if someone is incontinent? How would you assess for them?

Answer 1

DIAPPERS

• Delirium
• Infection (avoid overtreatment of asymptomatic bacteriuria but urinalysis) ○
• Atrophic vaginitis
• Pharmaceuticals
• Psychological (bladder diary)
• Excess urine output
• Reduced mobility
• Stool impaction targeted physical exam (cognition, mobility, DRE, neuro)

DRIP

• delirium
• restricted mobility and retention
• infection
• polyuria

Question 2

What are the different types of Incontinence diagnosis? Whats the pathophysiology?

Answer 2

Filling is sympathetic on parasympathetic off Emptying is parasympathetic on ACH causing detrusor contraction

Urge

• OAB complex (urgency, frequency, nocturia, urge incontinence)
• Inappropriate contraction - neurogenic (PD, MS, stroke, AD)

Neurogenic - Lost nerve supply (overactivity if UMN, weak detrusor reflex in LMN)

Stress incontinence

• damage to pelvic floor and mobile urethra
• constant wetting with activity.

Urinary retention:

1. outflow obstruction (BPH or neurogenic diabetic)
2. acontractile bladder (neurological spinal or prolonged distension)

Functional factors

Question 3

What is the treatment for Stress incontinence?

Answer 3

• Council risk decreasing/behavioral ○ Weight loss ○ Smoking decrease ○ Kegal exercises - Refer if QOL, failure of above: ○ Pelvic floor biofeedback ○ Pessaries (plastic inserts) - Surgery ○ Urethral bulking agents (collagen) - not durable ○ Urethral slings (synthetic mesh underneath)

Question 4

Urge incontinence treatment?

Answer 4

• Behavioural therapy (avoid coffee, voiding schedule, fluid intake reduction, kegals) - Meds (anticholinergics) - not in glaucoma and in elderly (mentation) ○ Oxybutynin ○ Tolterodine ○ Dolferisine - Surgery/Refer

Question 5

What is the treatment for BPH in men?

Answer 5

1. Education:

• Reassurance
• ↓caffiene, alcohol, evening fluids
• Spontaneously resolves in 50%

1. ± need for catheter = suspected retention – may wish to get urology assessment first if stable + no signs of distress/derangement
2. α-blocker = tamsulosin, prazocin (relax muscles around bladder neck)

• Care in elderly
• Start w. ↓dose → titratea ↑ slowly
• May need to ↓antihypertensive
• SE = postural hypotension, acute urinary retention

1. 5α-reductase inhibitor = dutasteride

• Typically Ø given to younger pts
• SE = impotence
• Often takes 6-12mo to see response – should see corresponding ↓PSA (~50%) Duodart - tamsulosin + dutasteride

1. Sx = TURP •

• Indications
  
  • Renal failure (obstructive uropathy)
  • Refractory urinary retention Relative = recurrent UTIs, refractory hematuria, renal insufficiency, bladder stones…

Question 6

what is the pathophysiology of BPH?

Answer 6

• symptoms are:
  
  • hesitancy
  • urgency
  • haematuria
  • dysuria
• Mostly affects transitional zone
• Fixed component = hyperplasia • Dynamic component = smooth muscle contraction

Question 7

What are some symptoms of BPH?

Answer 7

• Obstructive = frequency, hesitancy, weak flow, intermittency, terminal dribbling, incomplete emptying • Irritative = urgency, dysuria Incontinence consider DDx? • Constipation • Anxiety • DM • Recent radiotherapy / sx • Medications

Question 8

A 27 year old woman comes to her GP because she has had urgency of micturition for the past few weeks. Two years ago she had episodes of visual disturbance over a period of a few weeks. These resolved spontaneously.

Answer 8

Multiple Sclerosis (MS)

• Rule this out with a neuro exam, MRI of brain and CSF exam for oligoclonal bands.

Question 9

A way to structure the incontinence history

Answer 9

• LUTS (storage vs voiding)
• HOPC - impact
• degree of bother to patient and carer
• aids and assisstances in managing patient
• layout of house
• mobility/cognition
• bowel habits
• fluid intake
• PMHx (meds, obs/gynae)

Question 10

What investigations would you do to assess incontinence?

Answer 10

1. Basic assessment:

• urine dipstick
• DRE
• post-void residual (overflow) US
• medications review
• UEC, BSL, CMP
• bladder diary (important - determining the aetiology)

1. Formal

• urine flow rates
• urodynamics

Question 11

Management of Incontinence

Answer 11

Order it rather than jump into pharmacotherapy:

• establish goals (amount of bother)
• general measures
  
  • caffiene
  • aids
  • environments
• behavioural and physicals
  
  • pelvic floor exercises
  • bladder retraining
• pharm
  
  • anticholinergics (oxybutynin)
  • antimuscarinics (tolteradine)
  • alpha antagonists (overflow from BPH)
• surgical
  
  • botox injects periurethral (tighten pelvic floor)