Urinary_Incontinence_Flashcards
What is urinary incontinence and how common is it?
Urinary incontinence (UI) is the involuntary leakage of urine, affecting around 4-5% of the population, and is more common in elderly females.
What are the risk factors for urinary incontinence?
Risk factors include advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history.
What are the different types of urinary incontinence?
Types include overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.
What initial investigations are recommended for urinary incontinence?
Initial investigations include bladder diaries, vaginal examination, urine dipstick and culture, and possibly urodynamic studies.
How is urge incontinence managed?
Management includes bladder retraining, antimuscarinic medications like oxybutynin, tolterodine, or darifenacin, and mirabegron for patients concerned about anticholinergic side effects.
How is stress incontinence managed?
Management options include pelvic floor muscle training, surgical procedures like retropubic mid-urethral tape, and medications like duloxetine for those who decline surgery.
A 69-year-old female arrives in your clinic one morning complaining of recent urgency to pass urine and increased frequency, often followed by leakage of urine. A urinary dipstick is negative, a vaginal examination is unremarkable and you do not suspect malignancy. The likely diagnosis is urgency urinary incontinence. With this in mind, what is the best initial option to manage this patient’s condition?
Bladder retraining
Refer to a specialist for botulin injections
Pelvic floor muscle training
Prescribe oxybutynin
Advise her to use absorbent products and toileting aids
Bladder retraining
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Option 1 is correct, bladder retraining is the first conservative approach to managing urge incontinence, not pelvic floor muscle training. Oxybutynin and botulin injections are treatment options used further down the line if required. Advising patient’s to use toileting aids will not resolve their urge incontinence and should not be recommended as the sole treatment.
NICE Clinical Knowledge Summaries - Incontinence
https://cks.nice.org.uk/incontinence-urinary-in-women#!scenariorecommendation:3
‘Candidates were not familiar with indications for different types of HRT, and also found difficulty with management of incontinence, both of which are common issues in womens heath.’
summarise
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
Classification
overactive bladder (OAB)/urge incontinence
due to detrusor overactivity
the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
functional incontinence
comorbid physical conditions impair the patient’s ability to get to a bathroom in time
causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
A 62-year-old female presents as she feels she is becoming incontinent. She describes no dysuria or frequency, but commonly leaks urine when she coughs or laughs. What is the most appropriate initial management?
Bladder retraining
Topical oestrogen cream
Regular toileting
Trial of oxybutynin
Pelvic floor muscle training
Pelvic floor muscle training
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
The correct answer is Pelvic floor muscle training. The patient’s symptoms of leaking urine when she coughs or laughs are indicative of stress urinary incontinence, which is usually caused by weakening of the pelvic floor muscles. Pelvic floor muscle training (PFMT) is recommended as first-line treatment for this condition according to NICE guidelines. This involves exercises to strengthen the muscles that support the bladder and prevent leakage.
Bladder retraining would not be the most appropriate initial management in this case. Bladder retraining can be helpful for patients with urgency or mixed urinary incontinence, where there is a component of overactive bladder syndrome. However, it would not address the underlying issue of weakened pelvic floor muscles in stress urinary incontinence.
Topical oestrogen cream can be used in postmenopausal women if they have symptomatic urogenital atrophy, which can contribute to both urgency and stress urinary incontinence. However, it should not be used as first-line treatment for stress urinary incontinence alone.
Regular toileting, also known as scheduled voiding or timed voiding, may help manage symptoms but it does not treat the underlying cause of stress urinary incontinence. This strategy might be more useful for patients with functional incontinence who have difficulty reaching a toilet due to physical limitations.
A Trial of oxybutynin would not be suitable here either. Oxybutynin is an antimuscarinic medication used primarily to treat overactive bladder syndrome which presents with urgency, frequency and nocturia. It’s less effective for stress urinary incontinence which is due to physical changes such as weakened pelvic floor muscles rather than overactivity of the detrusor muscle.
buzz words
urgency to pass urine and increased frequency, often followed by leakage of urine. - urge incontinence
commonly leaks urine when she coughs or laughs - stress incontinence
An 83-year-old lady attends with a history of falls. She has a past medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease and urge incontinence.
After a thorough history and examination, you decide that these are likely multifactorial related to a combination of physical frailty, poor balance and medication burden. Which one of the following medications should you stop in the first instance?
Lactulose
Aspirin
Oxybutynin
Trimethoprim
Alendronic acid
Oxybutynin
Oxybutynin should not be used in the frail elderly population due to increased risk of falls. Safer alternatives include solifenacin and tolterodine. Mirabegron, a newer drug on the market, may also be useful as it thought to have less anti-cholinergic side effects.
You are unlikely to help this woman by stopping her laxatives if she has ongoing constipation. The alendronic acid and aspirin are appropriate given her osteoporosis (and falls risk) and ischaemic heart disease respectively.
The use of long term trimethoprim as prophylaxis for urinary tract infections is somewhat controversial but would certainly not be the first thing that should be stopped.
A 60-year-old woman presents to your GP clinic with increased urinary frequency. She says she finds it disruptive to her work in the office as she constantly has to get up to go to the toilet. The patient has also experienced some leakage, which has been very embarrassing. She denies any association of the leakage with coughing or laughing.
The patient has a BMI of 32kg/m². A vaginal examination excludes pelvic organ prolapse and demonstrates an ability to initiate voluntary contraction of the pelvic floor muscles.
Which of the following would form part of your initial investigations for this patient?
A single day bladder diary
CT kidneys, ureter and bladder
CT urogram
Cystoscopy
Urine dipstick and culture
Urine dipstick and culture
In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus
It is important to rule out a UTI and diabetes mellitus as causes of this patient’s urinary incontinence. Of the initial investigations for urinary incontinence, urine dipstick and culture would be the first as this test can easily be performed within the GP surgery. The other initial investigations include a bladder diary for a minimum of 3 days and urodynamic studies. It should also be noted that the NICE guidelines state that a urine dip is unreliable in women aged older than 65 years, and those who are catheterised.
A bladder diary for a minimum of 3 days would form part of your initial investigation, hence a single-day diary would be inappropriate.
CT scans are generally not used for urinary incontinence but are used in the investigation of renal pathology including ureteric calculi.
Cystoscopy would be inappropriate for this patient. This investigation is usually done when bladder cancer is suspected.
A 62-year-old woman presents to her GP with several months of gradually worsening urinary incontinence. Previously she has been too embarrassed to seek help, but it is now preventing her from leaving home. She describes a sudden, strong need to urinate and often does not make it to the toilet in time. This occurs during both the day and night. There is no incontinence with coughing or sneezing, no faecal incontinence, and no systemic symptoms. She is otherwise healthy and takes no regular medication.
Observations, a physical examination, urinalysis and routine blood tests are normal.
What is the next step?
Advise restricting dietary fluids
Prescribe extended-release oxybutynin
Prescribe solifenacin
Refer for bladder retraining
Refer for pelvic floor muscle training
Refer for bladder retraining
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
The correct answer is refer for bladder retraining. This patient has urge incontinence, which is a common and underdiagnosed problem in older women. It is due to overactivity of the detrusor muscle, causing uninhibited and inappropriate contractions of the bladder. Treatment of urge incontinence involves the modification of contributing lifestyle and medical factors and a referral for bladder retraining. Lifestyle factors that can be modified to improve symptoms include weight loss, dietary changes, reducing constipation and smoking cessation. Medical comorbidities should also be optimised where possible. Bladder retraining can take up to 6 weeks to work so patients should be reassured and encouraged to continue during this time.
Advise restricting dietary fluids is incorrect because this strategy is useful only if combined with bladder retraining. Reducing the amount of fluids consumed is important, particularly caffeinated, carbonated or alcoholic drinks because these can worsen the problem. However, bladder retraining is considered first-line treatment in primary care for urge incontinence, which involves keeping a voiding diary and using other strategies to achieve timed bladder voiding. Tracking how much fluid is consumed is part of this.
Prescribe extended-release oxybutynin is incorrect because the first-line treatment of urge incontinence is bladder retraining, not pharmacological management. Bladder retraining should be tried for 6 weeks before considering other therapy options. Pharmacologic treatment of detrusor muscle overactivity with antimuscarinic medications like oxybutynin often comes with unpleasant anticholinergic side effects such as dry mouth, constipation, dizziness and somnolence; these are often not tolerated by many patients. Sometimes these medications can be used for specific events when continence is particularly important, but this patient should be referred for bladder retraining before considering medication like extended-release oxybutynin.
Prescribe solifenacin is incorrect because the first-line treatment of urge incontinence is bladder retraining, not pharmacological management. Bladder retraining should be tried for 6 weeks before considering other therapy options. Solifenacin is an antimuscarinic medication used for bladder overactivity and can have unpleasant anticholinergic side effects which may not be tolerable for the patient. First-line therapy for urge incontinence for this woman would be a referral for bladder retraining, before considering pharmacological therapy like solifenacin.
Refer for pelvic floor muscle training is incorrect because this would be a treatment for stress urinary incontinence, rather than urge incontinence. While incontinence can be a mixture of both urge and stress, this patient does not describe any leakage with things that increase intra-abdominal pressure such as coughing or sneezing. All women should be encouraged where possible to exercise their pelvic floor individually to improve their own muscle strength and prevent incontinence, however, this patient does not require a referral for professional pelvic floor muscle training. Instead, her urge incontinence is an indication for referral for bladder retraining.
Tabitha is a 78-year-old woman who presents with urinary incontinence. Her incontinence has been ongoing for the past 2 years with no relief. Her symptoms usually occur on laughing and coughing. She has not experienced any episodes of nocturia. She also has not experienced a strong need to pass urine prior to her incontinence.
She has tried pelvic floor exercises and reducing caffeine intake but these failed to improve her symptoms.
Her urinalysis today shows no leukocytes or nitrites. A pelvic examination does not show any evidence of uterine prolapse. On consultation, she declines any surgical intervention.
What is the next most appropriate intervention for her incontinence?
Duloxetine
Mirabegron
Oxybutynin
Solifenacin
Tolterodine
Duloxetine
Duloxetine may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention
Her symptoms suggests her incontinence is likely due to stress incontinence. It is important to rule out other causes such as infection as the underlying cause for urinary incontinence prior to embarking on further treatment.
Medical management should be trialled when non-pharmacological management fails. This normally involves pelvic floor exercises and reduction in dietary caffeine.
Medical management of stress incontinence is duloxetine. This acts as a serotonin/norepinephrine reuptake inhibitor and its common side effects include nausea, dizziness and insomnia.
Oxybutynin, tolterodine, and solifenacin are often used as 1st-line treatment for urge incontinence and are all antimuscarinic agents. Should these therapies fail, mirabegron, an β3 agonist, can be used as a 2nd-line therapy.
A 65-year-old woman presents to the GP with urinary incontinence. Her symptoms occur all day, and she has also noticed that when she does manage to go voluntarily her flow of urine is very poor. On examination, the GP can feel a distended bladder even though the patient has just urinated while waiting for the appointment.
Given this woman’s presentation, what is the most likely diagnosis?
Urge incontinence
Overactive bladder syndrome
Stress incontinence
Mixed incontinence
Urinary overflow incontinence
Urinary overflow incontinence
Bladder still palpable after urination, think retention with urinary overflow
This elderly woman is presenting with symptoms of urinary incontinence. This is confirmed by the palpable bladder after urination. The most common causes of urinary overflow incontinence are prostate problems, however, in this case as she is a woman this is not possible. Other causes can include nerve damage causing a neurogenic bladder such as complication of diabetics, chronic alcoholics or surgery to the pelvic area.
Urge incontinence would be preceded by a sudden need to urinate. This is not noted as the patient has a constant incontinence.
An overactive bladder syndrome is a form of urge incontinence caused by an overactive bladder, it too would be associated with incontinence, polyuria and nocturia.
Stress incontinence would be likely associated with raised intraabdominal pressure, such as a sneeze or a cough. This is not noted in this case.
As no symptoms of urge incontinence or stress incontinence were present, a diagnosis of mixed incontinence is not suggested.
