W12 Urinary incontinence and Urinary retention (GM) Flashcards
Definition of Nocturnal enuresis?
Commonly known as bedwetting, refers to involuntary urination during sleep, especially at night, beyond the age where bladder control is typically established.
What are the types of urinary incontinence? (5)
Urgency
Stress
Mixed
Overflow
Continuous
What are the risk factors of urinary incontinence?
- Increasing age, pregnancy,
constipation, obesity, lifestyle
*
What is urinary incontinence?
Involuntary loss or leakage of urine, leading to an inability to control urination.
What does urinary retention refer to?
Inability to empty the bladder completely or at all, leading to the accumulation of urine in the bladder.
What is stress incontinence?
Incontinence occurring on effort or exertion, such as coughing or sneezing, due to loss of pelvic floor support or damage to the urethral sphincter.
What is urgency incontinence?
Involuntary leakage accompanied by a sudden compelling desire to pass urine which is difficult to defer.
What is mixed incontinence?
Both stress and urgency incontinence occurring together.
What is overflow incontinence?
Constant loss of urine due to severe overflow incontinence or a fistula.
What are common risk factors for urinary incontinence?
- Coughing
- Sneezing
- Physical activity
- Urgency
- Increasing age, pregnancy, constipation, obesity, lifestyle
- Medicines
-likely to cause coughs e.g. ACEi
-lead to detrusor muscle overactivity e.g. diuretics - Neurological conditions/cognitive impairment e.g. multiple sclerosis, spinal cord injury, PD
- Systemic diseases e.g. HF, DM
- Lower urinary tract conditions e.g. UTI, urinary obstruction, oestrogen deficiency
Questions to ask to determine type of incontinence:
- Occurs when coughing, sneezing, or on effort or exertion? (stress)
- If there is sudden urgency, and if they have frequency and nocturia? (urgency)
- Occurs about equally with physical activity and urgency (mixed)
- Occurs without physical activity or a sense of urgency (urinary retention/overflow)
- If not characterized by stress or urgency incontinence, ask about:
- Voiding difficulty (for example straining to void, sensation of incomplete emptying)
- Constant leakage of urine (may be intermittent if position dependent) — suggestive of a fistula
- Post-void dribbling, pain, urgency, frequency, recurrent urinary tract infection, vaginal discharge, and dyspareunia — consider a urethral diverticulum.
Questions to ask about severity?
- Ask how often the woman is incontinent, at what times, and during which activities.
- Ask about the use of pads (including pad size) or changing of clothing.
- Ask the woman how often she passes urine, including at night.
- Ask the woman to keep a bladder diary for a minimum of 3 days, making sure that variations in her usual activities (for example working and leisure days) are covered.
- The diary should document the amount, type, and timing of fluids she drinks,
voided volume, frequency of micturition, episodes of urgency, episodes of
incontinence, activities causing leakage, and pad and clothing changes.
Questions to ask about severity?
Clinical Assessment:
What diagnostic procedures can be used for urinary incontinence?
Urine dipstick:
Blood, Glucose, Protein, Leukocytes, Nitrites
Pelvic examination:
Ask to cough, pelvic floor grading system, palpate- any mass/atrophy
Bladder diary, clinical assessment, and patient history.
Red Flags/ Referral
- persistent bladder or urethral pain;
- pelvic mass that is clinically benign;
- associated faecal incontinence;
- suspected neurological disease, or urogenital fistulae;
- history of previous incontinence surgery, pelvic cancer surgery or pelvic radiation therapy;
- recurrent or persistant UTI for those aged over 60;
- palpable bladder after voiding, or symptoms of voiding difficulty
URGENT referral for women > 45 years:
- unexplained visible haematuria no UTI
- visible haematuria persisting
- recurring despite successful treatment of UTI.
URGENT referral women > 60 years
-unexplained non-visible haematuria AND either dysuria OR raised white cell count
What lifestyle advice can help manage urinary incontinence? (5)
- Reduce alcohol
- Modify fluid intake to <1.5L/day
- Stop smoking
- Reduce weight
- Stop caffeine
What is the first line treatment for stress incontinence?
What is second line?
- Pelvic floor exercises for at least 3 months.
-At least 8 contractions TDS - Consider surgical intervention, if inappropriate OR or due to patient preference Duloxetine (40mg BD) offered
What is the lifestyle advice for urgency incontinence?
What medications are first line for urgency incontinence?
What is 2nd line?
Bladder training for at least 6 weeks.
1st line: **Antimuscarinics **e.g. IR oxybutynin (5 mg BD/TDS), IR
tolterodine tartate (2 mg BD), darifenacin (7.5 mg OD)
If CI: Mirabegron (50 mg OD)
NB: If oral not tolerated, but effective: Oxybutynin transdermal patches.
2nd line: Alternative antimuscarinic e.g. fesoterodine fumarate,
propiverine hydrochloride, solifenacin succinate, trospium chloride or
MR oxybutynin, tolterodine tartate
Who should oxybutynin (IR) not be prescribed to?
Older women who may be at
higher risk of a sudden deterioration in their physical or mental health
Urgency Incontinence Treatment pathway:
After trying 2-3 medicines, if treatment has failed?
Specialist: botulinum toxin type A or surgical intervention
Troublesome Nocturia: Desmopressin
Post-menopausal and vaginal atrophy:
Intravaginal oetrogen
Medication review:
* Review after 4 weeks, or sooner if required.
* If effective review again at 12 weeks, then annually.
* Or every 6 months if the woman is over 75 years of age.
What is the mechanism of action of antimuscarinics?
Inhibit involuntary contractions of detrusor muscle, increase bladder capacity, and constrict internal sphincter.
What are the side effects of antimuscarinics?
Tachycardia
Urinary retention
Dry throat/mouth, constipation
Feeling hot, decreased sweating
Blurred vision, dry eyes
Sedation, dizziness, confusion, hallucinations
What are the cautions of Antimuscarinics? (for info? assessed in GpHC)
- Acute myocardial infarction, arrythmias (may worsen), cardiac insufficiency, cardiac surgery, congestive heart failure, coronary artery disease, conditions characterised by tachycardia.
- Autonomic neuropathy.
- Diarrhoea, gastro-oesophageal reflux
disease or hiatus hernia with reflux
oesophagitis. - Hypertension
- Hyperthyroidism.
- Susceptibility to angle-closure glaucoma.
- Pyrexia.
- Ulcerative colitis
What are the contraindications of Antimuscarinics? (for info? assessed in GpHC)
- Angle-closure glaucoma
- gastro-intestinal obstruction
- intestinal atony
- myasthenia gravis (but some antimuscarinics may be used to decrease muscarinic side-effects of anticholinesterases)
- paralytic ileus
- pyloric stenosis
- severe ulcerative colitis
- significant bladder outflow obstruction
- toxic megacolon
- urinary retention
What is primary nocturnal enuresis?
What is primary with daytime symptoms?
- Persistent bedwetting since childhood without ever achieving nighttime dryness.
- Never achieved nighttime dryness and has daytime symptoms e.g. wetting, urgency
What is secondary nocturnal enuresis?
Developing after a period of dryness for more than 6 months.
Can result from factors like delayed maturation of the bladder control mechanism, psychological factors, or underlying medical conditions
What information gathering is needed for nocturnal enuresis? (3)
Safeguarding- child maltreatment
what to psychologically consider?
- Bedwetting diary
- Daytime symptoms e.g. urgency, frequency
- Previously dry period
If:
* Child deliberately bedwetting, and/or
* Caregiver seen or reported to punish the child for bedwetting, despite counselling on involuntary nature and/or
* 2 daytime/bed wetting persists despite adequate assessment and management, unless medical explanation or a clearly identified stressful situation e.g. divorce/ bereavement
Key counselling pounts for nocturnal enuresis:
- Common in <5s, will decrease with age, but some children have it to 10.
- More common in boys.
- Not the child’s fault – involuntary
- The child should not be punished for bedwetting as this has the potential to humiliate the child and reduce their self esteem
What is the treatment for nocturnal enuresis in children over below and above 5 years?
Lifestyle?
Drug Treatment?
<5 years: Treatment not recommended, reassure families.
> 5 years
Lifestyle: Toileting behaviour/ rewards
* Fluid intake
Non-Drug treatment:
* Enuresis alarm
* Review after 4 weeks, continue until 2
weeks dry.
Drug treatment:
* Desmopressin (200-400mcg ON)
* If alarm is unsuccessful/inappropriate or for short-term
Desmopressin, with caution regarding risk of hyponatraemic convulsions, stop taking during vomiting/diarrhoea, avoid NSAIDs
What are the causes of urinary retention?
- Urethral blockage (e.g., BPH)
- Drug treatment (antimuscarinics, sympathomimetics)
- Neurogenic causes
- Postpartum complications
- Postop
- Conditions that reduce detrusor contractions or interfere with relaxation of the urethra
What are the types of Urinary retention? (2)
Treatment?
Acute- medical emergency, sudden (<few hours) inability to pass urine.
Treatment: Immediate catheterisation + alpha-adrenoreceptor blocker. 2 days drug treatment before catheter removal.
Chronic- gradual (over months) development of inability to empty bladder (residual >1 L)
Treatment: Attempt lifestyle changes, before drug treatment with alpha -
adrenoceptor blocker. Intermittent bladder catheterisation should be offered before indwelling catheter.
What is the first line treatment for urinary retention caused by BPH (benign prostatic hyperplasia)?
Alpha1-selective adrenoceptor blockers.
e.g. tamsulosin
Patients with enlarged prostate, raised PSA and high progression risk: 5α-reductase inhibitor e.g. finasteride or dutasteride
Severe: surgical intervention
Alpha-adrenoceptor blocker e.g. Tamsulosin
Mechanism of action?
Key counselling points?
Mechanism of action:
* Relaxation of smooth muscle in bladder neck and prostate
* Increase urine flow
Key Counselling Points:
* Risk of first-dose hypotension and postural hypotension, particularly in elderly men.
CI: history of postural hypotension, history of micturition syncope, severe hepatic impairment.
RECAP: See Pharmacology lecture
Treatment: 5α-reductase inhibitor e.g. finasteride
Mechanism of action
* Inhibits the production of
dihydrotestosterone (DHT) locally
within the prostate gland
* Reduces prostate volume
* Improves lower urinary tract
symptoms
* Increases peak urinary flow,
Key Counselling Points
* Report any changes to breast tissue
e.g. lumps/ pain – male breast cancer
* Use a condom, if partner likely to
become pregnant
* Finasteride – MHRA warning:
depression and suicidal thoughts
What should be monitored when prescribing alpha1-selective adrenoceptor blockers?
Risk of first-dose hypotension and postural hypotension.
True or False: Urinary incontinence is always the result of a serious underlying condition.
False
Fill in the blank: The first line drug for urgency incontinence is _______.
Antimuscarinics.
