W12 Urinary incontinence and Urinary retention (GM)

Question 1

Definition of Nocturnal enuresis?

Answer 1

Commonly known as bedwetting, refers to involuntary urination during sleep, especially at night, beyond the age where bladder control is typically established.

Question 2

What are the types of urinary incontinence? (5)

Answer 2

Urgency
Stress
Mixed
Overflow
Continuous

Question 3

What are the risk factors of urinary incontinence?

Answer 3

• Increasing age, pregnancy,
  constipation, obesity, lifestyle
  *

Question 4

What is urinary incontinence?

Answer 4

Involuntary loss or leakage of urine, leading to an inability to control urination.

Question 5

What does urinary retention refer to?

Answer 5

Inability to empty the bladder completely or at all, leading to the accumulation of urine in the bladder.

Question 6

What is stress incontinence?

Answer 6

Incontinence occurring on effort or exertion, such as coughing or sneezing, due to loss of pelvic floor support or damage to the urethral sphincter.

Question 7

What is urgency incontinence?

Answer 7

Involuntary leakage accompanied by a sudden compelling desire to pass urine which is difficult to defer.

Question 8

What is mixed incontinence?

Answer 8

Both stress and urgency incontinence occurring together.

Question 9

What is overflow incontinence?

Answer 9

Constant loss of urine due to severe overflow incontinence or a fistula.

Question 10

What are common risk factors for urinary incontinence?

Answer 10

• 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

Question 11

Questions to ask to determine type of incontinence:

Answer 11

• 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.

Question 12

Questions to ask about severity?

Answer 12

• 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?

Question 13

Clinical Assessment:
What diagnostic procedures can be used for urinary incontinence?

Answer 13

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.

Question 14

Red Flags/ Referral

Answer 14

• 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

Question 15

What lifestyle advice can help manage urinary incontinence? (5)

Answer 15

• Reduce alcohol
• Modify fluid intake to <1.5L/day
• Stop smoking
• Reduce weight
• Stop caffeine

Question 16

What is the first line treatment for stress incontinence?
What is second line?

Answer 16

1. Pelvic floor exercises for at least 3 months.
   -At least 8 contractions TDS
2. Consider surgical intervention, if inappropriate OR or due to patient preference Duloxetine (40mg BD) offered

Question 17

What is the lifestyle advice for urgency incontinence?
What medications are first line for urgency incontinence?

What is 2nd line?

Answer 17

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

Question 18

Who should oxybutynin (IR) not be prescribed to?

Answer 18

Older women who may be at
higher risk of a sudden deterioration in their physical or mental health

Question 19

Urgency Incontinence Treatment pathway:
After trying 2-3 medicines, if treatment has failed?

Answer 19

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.

Question 20

What is the mechanism of action of antimuscarinics?

Answer 20

Inhibit involuntary contractions of detrusor muscle, increase bladder capacity, and constrict internal sphincter.

Question 21

What are the side effects of antimuscarinics?

Answer 21

Tachycardia
Urinary retention
Dry throat/mouth, constipation
Feeling hot, decreased sweating
Blurred vision, dry eyes
Sedation, dizziness, confusion, hallucinations

Question 22

What are the cautions of Antimuscarinics? (for info? assessed in GpHC)

Answer 22

• 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

Question 23

What are the contraindications of Antimuscarinics? (for info? assessed in GpHC)

Answer 23

• 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

Question 24

What is primary nocturnal enuresis?
What is primary with daytime symptoms?

Answer 24

1. Persistent bedwetting since childhood without ever achieving nighttime dryness.
2. Never achieved nighttime dryness and has daytime symptoms e.g. wetting, urgency

Question 25

What is secondary nocturnal enuresis?

Answer 25

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

Question 26

What information gathering is needed for nocturnal enuresis? (3)

Safeguarding- child maltreatment
what to psychologically consider?

Answer 26

• 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

Question 27

Key counselling pounts for nocturnal enuresis:

Answer 27

• 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

Question 28

What is the treatment for nocturnal enuresis in children over below and above 5 years?
Lifestyle?
Drug Treatment?

Answer 28

<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

Question 29

What are the causes of urinary retention?

Answer 29

• 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

Question 30

What are the types of Urinary retention? (2)
Treatment?

Answer 30

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.

Question 31

What is the first line treatment for urinary retention caused by BPH (benign prostatic hyperplasia)?

Answer 31

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

Question 32

Alpha-adrenoceptor blocker e.g. Tamsulosin
Mechanism of action?
Key counselling points?

Answer 32

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

Question 33

Treatment: 5α-reductase inhibitor e.g. finasteride

Answer 33

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

Question 34

What should be monitored when prescribing alpha1-selective adrenoceptor blockers?

Answer 34

Risk of first-dose hypotension and postural hypotension.

Question 35

True or False: Urinary incontinence is always the result of a serious underlying condition.

Answer 35

False

Question 36

Fill in the blank: The first line drug for urgency incontinence is _______.

Answer 36

Antimuscarinics.