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Integrative Care > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

Is incontinence a natural part of the aging process?

A

No

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2
Q

Is most incontinence multifactorial or single cause?

A

Multifactorial

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3
Q

What are the different types of incontinence?

A 
Stress
Urge 
Overflow 
Mixed
Functional
Abnormal communications of the urinary tract - fistulae
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4
Q

What is stress incontinence?

A

Urine leakage when intra abdominal pressure exceeds urethral pressure.

Due to weakened pelvic floor muscles - not supporting urethra

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5
Q

What can cause the leakage in stress incontinence?

A

Sneezing, coughing, laughing, straining, lifting, exercise

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6
Q

Does stress incontinence usually occur in men or women?

A

Women

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7
Q

What are some risk factors for stress incontinence?

A 
Pregnancy (vaginal delivery) - damage to pelvic floor muscles and weakening of urethral sphincter 
Constipation - recurrent strain 
Obesity 
Pelvic surgery e.g TURP 
Conditions that cause chronic cough

After menopause muscles become weaker

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8
Q

What is urge incontinence?

A

Frequent voiding, often cannot hold urine. Due to overactive bladder as a result of detrusor hyperactivity (can also occur in obstruction).

Nocturnal incontinence is common

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9
Q

What can cause urge incontinence?

A 
Idiopathic 
Infection 
Malignancy 
Neurological - stroke, PD, Alzheimer’s disease, MS, spinal cord injury 
Bladder outlet obstruction 
Diabetes 
Diuretics
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10
Q

What are the symptoms of urge incontinence?

A

Frequent voiding
The urge to empty the bladder is soon followed by uncontrollable emptying
Can be sudden and without warning
Enuresis (bed wetting)

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11
Q

What is overflow incontinence?

A

Involuntary release of urine from an over full bladder. Often due to bladder outlet obstruction. Can also be due to detrusor underactivity.

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12
Q

What can cause overflow incontinence?

A

Prostate enlargement - BPH, malignancy
Kidney and bladder stones
Strictures due to inflammation / infection
Malignancy

Autonomic neuropathy e.g DM, MS
Anticholinergics
Alpha agonists - sphincter contraction
Calcium channel blockers - reduced smooth muscle contraction

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13
Q

What is functional incontinence?

A

Physical (e.g poor mobility), cognitive or behavioural disability that impairs ability to use toilet

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14
Q

In mixed urinary incontinence, which types are often seen together?

A

Stress and urge

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15
Q

When taking a continence history, what should be included?

A

Symptoms - storage, voiding, pain, dysuria, haematuria
Oral intake and types of drinks - caffeine
Bowel habits - type and frequency
PMH - diabetes, neurological conditions
Drug history
Collateral history
Past surgery
Obstetric and gynaecological history in women

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16
Q

What investigations should be done?

A

Review bladder and bowel diary - frequency and volume chart
Urine dipstick and MSU
Post micturition bladder scan
DRE - prostate and stool
Bloods - FBC, PSA, CRP, U&E (kidney damage), LFT, Alkaline phos (malignancy), HbA1c

Urodynamic studies

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17
Q

What physical examinations should be done?

A

Abdominal examination - feel and percuss for palpable bladder, palpate for masses or enlarged kidneys, DRE
External genitalia review - atrophic vaginitis in females
Vaginal examination - prolapse

Neurological examination - assess gait, check dorsiflexion of toes (S3) and perianal sensation (L1-2), sensation of sole (S1)

Cognition - AMT for cognitive decline
CVS

18
Q

In terms of management, what should be addressed first?

A

Lifestyle factors

  • weight loss
  • switch to decaf drinks
  • smoking cessation (nicotine can irritate bladder and coughing can increase pressure)
  • regular toileting
  • good bowel habit
  • improve oral intake
19
Q

How should stress incontinence be managed?

A

Pelvic floor retraining - 8 contractions at least 3 times per day for at least 3 months
Weight loss if appropriate
Duloxetine (urethral contracture) - not likely to be a cure, it can help in making it less of a problem
Surgery - tension free vaginal tape (like a sling to support urethra and bladder neck)

20
Q

What type of muscle is the detrusor muscle?

A

Smooth muscle - fibres running in all different directions

Controlled by the autonomic nervous system

21
Q

Describe the internal urethral sphincter

A

A thickening of the bladder wall, proximal part of the urethra

Primary function in men: prevent retrograde ejaculation of semen

22
Q

Is the IUS well developed in men or women?

A

Men

23
Q

Describe the external urethral sphincter

A

It is part of the pelvic floor

Skeletal muscle - under voluntary control, so when you decide to urinate, the EUS actively relaxes

24
Q

The stretch receptors in the bladder wall are innervated by a sensory neurone that projects into which part of the spinal cord?

A

S2,3,4 keeps the piss and shit off the floor

Area of micturition and defication

25
Q

Describe the storage reflex arc

A

The sensory neurones attached to stretch receptors in the bladder wall ascend up to T10- L2 segment (known to contain sympathetic neurones) synapses with sympathetic preganglionic neurones, which project onto post-ganglionics. These post ganglionics project onto 2 sites - detrusor itself and IUS.

Sympathetics inhibit contraction of detrusor (beta 3 receptor) and stimulate internal sphincter (alpha 1 receptor)

= STORAGE

As volume increasing, pressure not spiking (as muscle stretching)

26
Q

What supplies the EUS?

A

Somatic motor fibres that run along the pudendal nerve.

These fibres at S2,3,4 excite skeletal muscle at EUS, causing it to contract (nAChr receptor)

27
Q

What is the name of the centre within the pons that controls the somatic fibres that close the EUS?

A

L centre

28
Q

Is the voiding reflex primarily mediated by the sympathetic or parasympathetic system?

A

Parasympathetic

29
Q

Describe the voiding reflex arc

A

The sensory neuron attached to stretch receptors enters into the spinal chord at S2,3,4 where it synapses with parasympathetic neurones.

The parasympathetic neurones project to the bladder and synapse in the bladder wall with a short post- ganglionic neuron. The effect = excitation of detrusor.

Receptor = M3

30
Q

Under high levels of bladder stretch, a sensory neuron activates which area in the pons?

A

M centre - projects down onto parasympathetics to EXCITE them = a positive feedback loop

31
Q

When the M centre is activated what is inhibited?

A

The L centre and sympathetics

32
Q

How should urge incontinence be managed?

A

Lifestyle factors
Bladder retraining - minimum 6 weeks
Bladder stabilising drugs:
- antimuscarinics first line e.g oxybutynin or tolterodine
- beta 3 agonist e.g mirabegron (may be useful if concerns about anticholinergic side effects in elderly)

Botox of the bladder neck

33
Q

What drug could be taken to prevent nocturia?

A

Loop diuretics mid afternoon

34
Q

How do antimuscarinic drugs work on the bladder?

A

Prevent contraction

35
Q

What are some antimuscarinic side effects?

A 
Blind as a bad 
Dry as a bone - dry mucous membranes 
Red as a beet - vasodilation 
Mad as a hatter - delirium, confusion
Full as a flask - retention and constipation 
Hot as a hare - lack of sweating

Also dizziness

FALLS risk in elderly

36
Q

What medication is used to treat BPH?

A

Alpha blockers - relax prostatic smooth muscle e.g Tamsulosin, doxazocin

5 alpha reductase inhibitors - stops conversion of testosterone to more potent form (to promote cell division) e.g Finesteride (can take 6 months for symptom benefit)

37
Q

What is an important side effect of alpha blockers in the elderly?

A

Postural hypotension

38
Q

What is the most common cause of urinary incontinence in the elderly?

A

Infection

39
Q

What are some storage symptoms?

A

Frequency
Urgency
Nocturia

40
Q

What are some voiding symptoms?

A 
Post micturition dribble 
Hesitancy 
Intermittent stream 
Terminal dribble 
Feeling of incomplete emptying

(Bladder outlet obstruction usually)

41
Q

Is duloxetine recommended for stress incontinence as first or second line management?

A

No

Could be as alternative to surgery but inform about side effects

42
Q

How is urge incontinence managed?

A

Lifestyle - reduce fluid intake especially in evening, reduce caffeine and alcohol, weight reduction, manage constipation

Medical - antimuscarinics that act on M3 receptor (use with caution in elderly) e.g oxybutynin, tolteridone, darifenacin, trospium, solifenacin, propiverine. The first 3 are NICE recommended first line agents

Oxybutynin not in older adults with frailty or PD

If contraindicated or intolerable side effects: beta 3 adrenoreceptor agonists (mirabegron)

Intravaginal oestrogens - NICE recommends their use for women who have vaginal atrophy and symptoms of overactive bladder

Integrative Care (11 decks)

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