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Elderly YR3 > Incontinence > Flashcards

Incontinence Flashcards

1
Q

Types of urinary incontinence

A

Stress
Urgency
Mixed
Overflow
Functional
Over active bladder (technically not always incontinent)
True - communication of bladder with vagina/rectum from fistula (eg IBD, cancer)

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2
Q

What is stress urinary continence?

A

Involuntary leakage of urine on effort, exertion, sneezing or coughing (increased intrabdominal pressure)

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3
Q

what is urgency urinary incontinence?

A

Involuntary leakage of urine accompanied by or immediately preceded by urgency

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4
Q

What is mixed urinary incontinence?

A

involuntary leakage of urine associated with urgency and with exertion, effort, sneezing or coughing

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5
Q

What is overflow incontinence?

A

Involuntary release of urine when the bladder becomes overly full - weak bladder muscle or blockage (may not be getting signals to brain etc)

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6
Q

What is over active bladder?

A

Frequent and sudden urge to urinate that may be difficult to control - can be wet (incontinent) or dry

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7
Q

What is functional incontinence?

A

Bladder and muscles are fine but cannot make it to toilet in time due to mobility issues. Eg OA, paralysis of legs etc

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8
Q

Which incontinence is most prevalent?

A

Over active bladder - wet and dry most prevalent then:

Stress incontinence
Urgency
Then mixed

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9
Q

Symptoms of overactive bladder

A

Urgency
Increased frequency
Nocturia

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10
Q

How does urinary incontinence prevalence change with age?

A

Increases as you get older
Increase for women of childbearing age due to impacts of pregnancy and childbirth on pelvic floor and bladder

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11
Q

Risk factors for urinary incontinence - obs and gynae

A

Pregnancy and childbirth - foetus pressure and trauma during birth

Pelvic surgery - muscles/nerve injured?

Pelvic prolapse

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12
Q

Risk factors for urinary incontinence -predisposing factors

A

Race
Family predisposition
Anatomical abnormalities
Neurological abnormalities

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13
Q

Risk factors for urinary incontinence - promoting

A

Obesity
Age
Co-morbidities
Increased intra abdo pressure
UTI
Drugs
Menopause
Cognitive impairement

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14
Q

Why does menopause promote urinary incontinence?

A

Loss of oestrogen = atrophy of genitalia and sometimes loss of pelvic floor tone from atrophy

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15
Q

Quality of life with urinary incontinence?

A

MASSIVELY affected - some cannot leave the house worried of embaressment, hygiene worries, cost - pads, change of underwear etc.

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16
Q

What else could result in frequency, urgency and nocturia?

A

UTI

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17
Q

How can we classify lower urinary tract symptoms?

A

By stage of micturition:
Storage
Voiding
Post-micturition

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18
Q

Storage lower urinary tract symptoms

A

Increased frequency
Urgency
Nocturia
Incontinence

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19
Q

Voiding lower urinary tract symptoms

A

Slow stream
Splitting/spraying
Intermittency
Hesitancy
Straining
Terminal dribble

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20
Q

Post micturition lower urinary tract symptoms

A

Post-micturition dribble
Feeling of incomplete emptying

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21
Q

Additional history needed from female presenting with frequency, urgency and nocturia

A

Fluid intake - caffeine/alcohol as diuretic effects
Previous pelvic surgery
Childbirths - large babies?
How long?
Uterovaginal prolapse?
Faecal incontinence too?

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22
Q

What else can cause polyuria?

A

Diabetes - check for this too

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23
Q

Dermatomes to examine when checking neurological cause for incontinecne

A

S2, 3 and 4
- back of thigh, bum cheek)
(keep the wee and poo off the floor)

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24
Q

Examinations needed for incontinence presentation - male and female

A

BMI - obesity?
Abdo exam - palpable bladder suggests retention and problems voiding
Examine S2,3,4 dermatomes - neuro cause?

25
Q

Examinations needed for incontinence presentation - males only

A

Digital rectal exam - check for enlarged prostate

26
Q

Examinations needed for incontinence presentation - females

A

External genitalia stress test - get pt to cough and see if leakage
Vaginal exam

27
Q

Investigations for incontinence presentation

A

MANDATORY - Urine dipstick: rule out UTI, haematuria, proteinuria, glucosuria

Non invasive urodynamics maybe:
Frequency-volume chart
Bladder diary (longer than 3 days)
Post-micturition residual volume - voiding problems? use catheterisation following urination or bladder scan pre and post void

28
Q

Optional investigations for incontinence presentation

A

Invasive urodynamics - pressure and flow studies
Pad tests - wear pad, has dye if urinate and can weigh pad to see liquid amount
Cystoscopy - camera in urethra to bladder

29
Q

Invasive urodynamics probes used and what these measure

A

Probe in bladder - measure intravesicle pressure (bladder pressure)

Probe in vagina/rectum - measure abdominal pressure

Detrusor pressure = intravesical pressure minus abdominal pressure

30
Q

What is pt asked to do in urodynamic testing?

A

Empty bladder - urinate
Bladder is then filled with set amount of saline
Measurements are taken when pt coughs to see if bladder/detrusor pressure rises etc

31
Q

What does the urethra run through and what does this mean?

A

Through pelvic floor - strengthening this can help incontinence

32
Q

What does weakened pelvic floor result in?

A

Prolapse - usually supports rectum, bladder and uterus in women

33
Q

Lifestyle conservative management for incontinence

A

Modify fluid intake
Weight loss
Stop smoking
Decrease caffeine intake
Avoid constipation - increases pressure
Timed voiding - schedule

34
Q

Interventions for patients which lifestyle changes haven’t helped and are unsuitable for surgery in general, broad

A

Indwelling catheter - urethral or suprapubic

Sheath device - similar to condom attached to catheter tubing and bag

Incontinence pads

35
Q

Risk with indwelling catheter

A

Urinary tract infection

36
Q

Specific management for stress incontinence

A

Pelvic floor muscle training - 8 contractions 3x daily, for 3 months at least
Weight loss
Duloxetine

37
Q

What does duloxetine do in general?

A

Noradrenaline and serotonin uptake inhibitor - remains at receptor for longer and has prolonged action

38
Q

What does duloxetine do specifically in bladder?

A

Increases inhibitory effect of noradrenaline on B3 receptor at detrusor muscle - continued relaxation during storage phase, preventing increases in pressure

Increase stimulaotry effect of NA at alpha 1 receptor causing contraction and closure of internal urethral sphincter

39
Q

When is duloxetine offered?

A

Not first or second line routinely but if surgery is not an option/alternative to surgery

40
Q

Surgery for stress urinary incontinence female

A

Permanent intention:
- open retropubic suspension procedures (colposuspension) (bladder, urethra and vagina sutured to pelvic bones/ligaments, lifts them which helps them close easier)
- autologous sling procedure (sling under urethra using own tissue)
- low tension vaginal tapes (less popular now, sling under urethra using mesh)

Temporary:
Intramural bulking agents (into neck of bladder)

41
Q

Why do some surgeries for stress incontinence have temporary intention?

A

Women may still want to have further pregnancies - no point doing permanent surgery when it could damage it again

42
Q

Surgery for stress incontinence for males

A

Artificial urinary sphincter
Male sling

43
Q

Describe male artificial sphincter

A

GOLD STANDARD for urethral sphincter deficiency - neurological or post dxt (radiotherapy) or surgery

Cuff lies around circumference of urethra- stimulates action of normal sphincter to close urethra. Males can switch on and off by switch in scrotum

44
Q

Initial management of urgency urinary incontinence

A

Bladder training - schedule voiding eg every hour of the day. MUST NOT void in between - wait or leak
Intervals are then increased by 15-30 mins until interval of every 2-3 hrs is reached

6 weeks long

45
Q

Pharmacological management of urgency incontinence

A

Anticholinergics - act on M1, M2 and M3 eg Oxybutynin, Solifenacin

B3 adrenoreceptor agonist eg Mirabegron

46
Q

What do anticholinergics do?

A

Act on M3 receptor in detrusor muscle
Stop Ach causing contraction of detrusor from parasympathetic pathway

47
Q

What does B3 adrenoreceptor agonist do?

A

Bind to B3 adrenoreceptor
Replicate NA’s normal effect here - relaxation of detrusor muscle despite increased stretch
Therefore increase bladder capacity to store urine

48
Q

What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?

A

Botulism toxin intravesicle injection (into bladder(

49
Q

What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?

A

Botulism toxin intravesicle injection (into bladder)

50
Q

Actions of botulism toxin

A

Biological neurotoxin
Inhibits release of Acetylcholine at presynaptic neuromusclar junction
Causes flaccid paralysis - detrusor doesn’t contract

(eg in bladder M3 contraction of detrusor muscle is inhibited)

51
Q

Duration of botulism toxin effects

A

3-6 months - type A in uk under general anaesthetic or local

52
Q

Problem with using anticholinergics in UUI management

A

NON SELECTIVE - act on all M1, 2, 3 4 and 5 receptors
Eg these are present in smooth muscle in heart ocular and intestinal, salivary glands, CNS, eyes

53
Q

Example of anticholinergic

A

Oxybutynin
Solifenacin

54
Q

Surgery for urgency urinary incontinence (if pharmacological doesnt work)

A

Sacral nerve neuromodulation - alter nerve activity
Autoaugmentation - removal of detrusor muscle
Augmentation cystoplasty - makes bladder larger
Urinary diversion - new route for urine

55
Q

Examples of ADLs

A
  • Getting dressed
  • Feeding yourself
  • Washing
  • Control over bladder/bowels
56
Q

Examples of intermediate ADLs

A
  • Cooking
  • Shopping
  • Cleaning house
  • Finances
57
Q

What are higher ADLs?

A

Societal role of patient - can they fulfil these eg mother, volunteer at local shop etc

58
Q
A

Elderly YR3 (14 decks)

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