Urinary Incontinence

Question 1

What is urinary incontinence a major culprit of in older people?

Answer 1

Falls

Delirium

Question 2

Types of incontinence.

Answer 2

Stress incontinence

Urge incontinence

Overflow incontinence

Function incontinence

Question 3

Explain stress incontinence.

Answer 3

Small volumes of urine leak during any sort of stress exerted on the body, such as coughing or laughing.

This is more common in women.

Question 4

Explain urge incontinence.

Answer 4

Frequent voiding, often cannot hold the urine.

Symptoms such as frequency, urgency and nocturia.

It is commonly seen in detrusor muscle overactivity but can occur in obstruction as well.

Question 5

If urge incontinence is acute in onset, what should be considered?

Answer 5

UTI

Question 6

History of urge incontinence.

Answer 6

Do you ever not make it to the toilet in time?

Able to hold it or do you need to go quickly?

What happens if you do not go to the bathroom?

Do you plan your day around going to the bathroom?

Do you use continence pads?

Question 7

What is urgency and leaking precipitated by?

Answer 7

Arriving home

Cold

The sound of running water

Caffeine

Obesity

Question 8

Causes of urge incontinence.

Answer 8

Detrusor overactivity e.g. from central inhibitory pathway malfunction.

Bladder muscle problem

Parkinson’s

Dementia

UTI

Diabetes

Diuretics

Atrophic vaginitis

Urethritis

Question 9

Causes of stress incontinence.

Answer 9

Pelvic floor weakness/prolapse/pelvic masses.

Look for cough leak on standing and with a full bladder.

Common in pregnancy and following birth.

Post-menopausal women

Uterine prolapse or urethrocele.

Question 10

Explain overflow incontinence.

Answer 10

Due to urinary retention.

Symptoms include difficulty initiating micturition, poor stream and terminal dribbling.

This can also lead to renal failure due to obstructive uropathy.

Question 11

Causes of overflow incontinence.

Answer 11

This can be seen with obstructive symptoms in men with BPH or prostate cancer for example.

Also medication such as anticholinergics can cause this.

Also constipation.

Question 12

Explain functional incontinence.

Answer 12

There is no primary urogenital problem in this, the physiological factors are relatively unimportant.

Instead the patient is caught short and too slow in finding the toilet in time.

This can be due to cognitive impairment, immobility or behavioural problems.

It can also be due to unfamiliar surroundings.

Question 13

Management of functional incontinence.

Answer 13

CGA to address any modfiable components such as pain control to allow improved mobilisation.

Question 14

Continence history.

Answer 14

How people void, frequency, symptoms, oral intake

Types of drinks ocnsumed.

Bowel habit including stool type and frequency.

Full drug history and collateral if need be.

Question 15

Examination of continence.

Answer 15

Review of bladder and bowel diary

Abdominal examination

Urine dip stick and MSU

PR examination including prostate assessment in a male

External genitalia review paricularly looking for atrophic vaginitis in females.

Post-micturition bladder scan

Question 16

Incontinence in men.

Answer 16

Most commonly enlarged prostate leading to overflow incontinence.

Urge incontinence can also happen in enlarged prostate.

TURP and other pelvic surgery may weaken the bladder sphincter and cause incontinence as well.

Question 17

Incontinence in women.

Answer 17

Stress incontinence is a big issue - post-menopausal, prolapse, weak pelvic floor and obesity are factors needed to be considered as well as pregnancy.

Functional incontinence also happens.

Urge incontinence and overactive bladder syndrome can also be seen.

Question 18

Investigation of incontinence.

Answer 18

UTI

DM

Diuretic use

Faecal impaction

Palpable bladder

GFR

Question 19

Drugs and pads are not first line management for urinary incontinence.

What is?

Answer 19

Pelvic floor strengthening

Bladder diary

Review of fluid intake

Weight loss

Optimisation of resp disease

Bladder retraining

Question 20

Pharmacological management of incontinence.

Answer 20

Anticholinergics - you need to be mindful with these drugs in the elderly however due to its side effects and interaction with cognitive impairment.

Oxybutynin can be used in young patients but should not be used in older people.

Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.

Question 21

Management of stress incontinence.

Answer 21

Pelvic floor exercises is first line.

Intravaginal electrical stimulation can also be done but a lot of women do not like it and refuse.

A ring pessary to help uterine prolapse may be tried.

There are surgical options such as;

Stabilising mid-urethra by tension-free vaginal tape.
Urethra bulking.

Medical options such as duloxetine.

Question 22

Management of urge incontinence.

Answer 22

Patient/carer should complete an incontinence chart for 3 days to define the pattern of incontinence.

Examine for spinal cord and CNS signs as well as vaginitis.

Bladder training and weight loss are important. Bladder training involves not going to the bathroom when ever you feel like, but holding in the urine to a certain time and then going and then gradually increasing that time period.

Absorbent pads if this does not help.

In males you can consider a condom catheter.

Question 23

Treatment of urge incontinence due to vaginitis.

Answer 23

Topical oestrogen therapy

Question 24

Pharmacological treatment of the nocturia in urge incontinence.

Answer 24

Antimuscarinics to improve frequency and urgency.

Topical oestrogens for post-menopausal urgency, frequency and nocturia.

B3 agonists if antimuscarinics are CId.

Botox if anything else is ineffective.

Question 25

Non-prostate related urinary incontinence.

Answer 25

Detrustor overactivity

PRimary bladder neck obstruction.

Urethral strictures.