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Yr4: OPIC > Continence > Flashcards

Continence Flashcards

1
Q

Urinary incontinence is a natural part of ageing process; true or false?

A

FALSE; it is NOT a natural part of ageing process

*Continence is one of major factors leading to falls and people requiring 24hr care

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2
Q

Discuss what questions you should ask in a urinary continence history

A

Presenting complaint

  • Establish type:
    • When it occurs e.g. during coughing, sneezing, exertion
    • Associated urgency
    • Voiding difficulty
    • Constant leakage of urine
  • Frequency of incontinence
  • How much urine
  • Night time symptoms
  • Any other urinary problems (pain, foul smell, haematuria, dribbling etc…)
  • Duration of symptoms
  • Why seek help now
  • Detailed fluid intake
  • Bowel habits
  • Exacerbating & relieving factors (did anything help)
  • Impact on life (may work ICE in here)

PMH, drugs & allergies

  • Specific PMH to enquire about:
    • Pregnancies & vaginal deliveries- any interventions/problems
    • Surgeries
    • Constipation
    • Prostate problems
    • Neurological conditions
    • Dementia
    • Visual problems
    • Mobility problems
  • Current medications (focused on diuretics, antimuscarinics, ACE-inhibitors, antihistamines etc…)
  • Allergies
  • Past surgical history

FH

  • FH of incontinence, prostate issues, neurological issues etc…

Social

  • Where live
  • Who with
  • Toilet facilities
  • Any support
  • ADLs
  • Impact on work
  • Impact on leisure
  • Smoking
  • Alcohol

ICE

  • Ideas
  • Concerns
  • Expectations
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3
Q

What information is collected on a bladder diary?

A
  • Fluid intake
    • When (date & time)
    • What
    • How much
  • Urine output
    • When
    • How much
    • Sometimes they ask about urgency
    • Sometimes they ask about leakage

*Image shows just one example

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4
Q

What information is collected on a stool/bowel movement chart?

A
  • Date
  • Time
  • Type of stool (Bristol stool chart)
  • Amount/quantity
  • Sometimes ask about pain or distress on passing stool
  • Sometimes ask about soiling (staining, loose, solid)
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5
Q

State, and describe the typical presentation, of the 6 types of urinary incontinence

A
  • Stress: involuntary leakage on effort or exertion, sneezing, coughing, laughing etc..
  • Urgency: involuntary leakage accompanied by, or immediately preceded by, sudden compelling desire to urinate which is difficult to defer. UUI is subtype of OAB (OAB is urinary urgency usually associated with frequency & nocturia with or without incontince ‘wet OAB or ’dry OAB’)
  • Mixed: features of both stress & urgency
  • Overflow: involuntary leakage and pt may feel be straining when trying to urinate or feel their bladder is not completely empty
  • Continuous: constant leakage of urine
  • Functional: involuntary leakage because despite being aware of urge to urinate patient is unable to get to bathroom (due to physicla or mental impairment)
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6
Q

Explain the pathophysiology of each of the 5 types of urinary incontinence

A
  • Stress: Intra-abdominal pressure > urethral sphincter pressure. Impaired urethral support most commonly due to weakness of pelvic floor muscles
  • Urgency: detrusor hyperactivity leading to uninhibited bladder contraction, a rise in intravesical pressure, leakage of urine
  • Mixed: mix of both stress & urgency
  • Overflow: chronic retention leads to progressive stretching of bladder wall leads to loss of bladder sensation and damage to efferent fibres of sacral reflex. This results in bladder filling with urine and becoming grossly distended. Intravesical pressure increases and is > urethral sphincter pressure leading to leakage of urine
  • Continuous: anatomical abnormality e.g. ectopic ureter, bladder fistula or due to severe overflow incontinence
  • Functional: as in previous definition, pt unable to get to toilet in time due to physical or mental impairment e.g. impaired mobility, dementia, visual problems
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7
Q

State some risk factors for stress incontinence

A
  • Increasing age
  • Pregnancy & vaginal delivery (weaken muscles & connective tissue)
  • Obesity(pressure on pelvic tissues)
  • Constipation (straining can weaken pelvic floor muscles)
  • Deficiency in supporting tissue which may be caused by:
    • Hysterectomy (damage to pelvic floor muscles)
    • Menopause (lack of oestrogen leads to vaginal atrophy and urethral atrophy)
  • FH
  • Smoking (may be associated with chronic cough)
  • Drugs e.g. ACE-inhibitors (can cause cough)
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8
Q

State some risk factors for urgency incontinence

A

Most commonly idiopathic but risk factors include:

  • Systemic neurological conditions e.g. MS, Parkinson’s disease, injury to spine or pelvic nerves
  • Drugs
    • Parasympathomimetic e.g. cholinesterase inhibitors
    • Antidepressants
    • Hormone replacement
    • Diuretics
  • Obesity (increase symptoms)
  • T2DM (increase symptoms)
  • Chronic urinary tract infection (increase symptoms)
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9
Q

State some risk factors for overflow incontinence

A
  • Urethral obstruction
    • Enlarged prostate (BPH, cancer)
    • Constipation
  • Systemic neurological conditions
  • Damage to spine or pelvic nerves
  • Medications that decrease bladder contractility:
    • ACE inhibitors
    • Antidepressants
    • Antimuscarinics
    • Antihistamines
    • CCBs
    • Beta-adrenergic agonists
    • Opioids
    • Sedatives
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10
Q

State some risk factors for functional incontinence

A
  • Dementia
  • Visual problems
  • Mobility problems
    • Arthritis
    • Recent surgery
  • Sedating medication
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11
Q

Most incontinence is multi-factorial; true or false?

A

True

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12
Q

What examinations & investigations might you do for a pt presenting with urinary incontinence and why?

A

Will depend on type of incontinence you suspect and other features of history but examples include:

Examinations

  • Bladder diary: look at drinking & toileting habits
  • Bowel diary: look at bowel habits and type of stool
  • Abdominal examination: check for full bladder, any masses (tumours, constipation)
  • DRE: check for faecal impaction (and prostate in men) which could be causing retention
  • Vaginal examination: checking for weak pelvic muscles or prolapse
  • External genitalia examination in males: particularly if presenting with LUTs looking for phimosis etc…

Investigations

  • Urine dipstick: rule out UTI (caution in elderly- see separate FC) and also check for haematuria which may suggest more serious underlying pathology
  • Urine MSU: dipstick not always reliable (see separate FC and also need to know sensitivities)
  • Post-void bladder scan: assess for retention
  • U&Es: check renal function
  • eGFR: check renal function
  • PSA: dependent on DRE results & after counselling pt
  • Urodynamic assessment (measure intravesicular and intra-abdominal pressure to calculate detrusor pressure. Hyperactivity may suggest urge)
  • Outflow urodynamics (measure detrusor activity against urine flow rate. High intravesical pressure with weak stream suggest overflow)
  • Cystoscopy: most likely if suspect obstruction or something more serous e.g. cancer
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13
Q

Of the investigations listed in previous card, which are considered mandatory for a complete continence examination?

A
  • Bladder diary review
  • Bowel diary review
  • Abdominal examination
  • PR examination (including prostate assessment in males)
  • External genitalia review (looking for atrophic vaginitis in females and any causes of LUTs in males e.g. phimosis)
  • Urine dipstick
  • Urine MSU
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14
Q

What is considered a normal finding on a bladder scan (both pre-void & post-void)?

A
  • Pre-void: hard to find definitive answer, but bladder capacity is around 600-800mL
  • Post-void: 50mL or less left in bladder after voiding is considered adequate emptying in younger pts, this rises to 100mL in elderly pts
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15
Q

What is considered a normal DRE?

What findings suggest constipation/faecal impaction?

A
  • Normal DRE: no faeces in rectum, no enlarged prostate or hard, craggy, nodular prostrate
  • Abnormal DRE: faeces in rectum suggests faecal impaction, enlarged smooth prostate suggests BPH, hard/craggy/nodular prostate suggests prostate cancer
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16
Q

Discuss the management of stress UI

A
  • Lifestyle advice
    • Avoid drinking excessive amounts of fluids
    • Reduce caffeine
    • Weight loss
    • Smoking cessation
  • Refer for at least 3 months of supervised pelvic floor muscle training. Do 3x daily for at least 3 months
  • If above doesn’t work or pt unsuitable, duloxetine (serotonin-noradrenaline reuptake inhibitor) can be trialled- causes stronger urethral contraction. *Consultant said doesn’t work very well
  • If above conservative treatments don’t work surgical options should be explored:
    • Autologous sling (using rectal fascia)
    • Colposuspension (**lifts the neck of the bladder into the correct position and holds it in place with stitches)
    • Intramural bulking agents (50-60% success)
    • Retropubic mid-urethral mesh sling (support the neck of bladder)
  • Duloxetine (SNRI) can be used if pt prefers drug treatment to surgical treatment or is not suitable for surgical treatment

**Duloxetine mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

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17
Q

Discuss the management of urge UI

A

Conservative

  • Lifestyle advice:
    • Reduce caffeine intake
    • Weight loss
    • Avoid drinking excessive volumes each day
    • Smoking cessation
  • Bladder training for minimum 6 weeks

Pharmacological

  • Antimuscarinic drugs e.g. Oxybutynin, solifenacin, tropsium, tolterodine to inhibit detrusor contraction
  • Mirabegron (beta-3 agonist) used if anticholinergics contraindicated or added as an adjunct. BUT cannot use in uncontrolled hypertension
  • Topical vaginal oestrogen in post-menopausal women

Surgical:

  • Botulinum toxin A injections (paralyses detrusor muscle)
  • Sacral neuromodulation
  • Augmentation cystoplasty (works as it disrupts synchronised waves of detrusor contraction)
  • Urinary diversion via ileal conduit
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18
Q

Discuss the management of mixed overflow incontinence

A

Manage according to most predominant type of incontinence (stress or urgency)

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19
Q

Discuss the management of overflow incontinence

A

Management centred around finding and treating underlying cause to stop/control retention to stop overflow may involve medications for BPH, laxatives, intermittent self-catheterisation etc…(see later flashcards for management of urinary retention)

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20
Q

Discuss the management of functional incontinence

A

Identify causes and treat e.g.:

  • Mobility aids
  • New glasses
  • Commodes
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21
Q

Remind yourself of the neuronal control of micturition (to help you understand why certain drugs work for incontinence)

A
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22
Q

State some ADRs of duloxetine

A
  • Dry mouth
  • GI ADRs: constipation, diarrhoea
  • Nausea
  • Headaches
  • Dizziness
  • Sweating
  • Sexual dysfunction
  • Decreased appetite & weight loss
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23
Q

State some ADRs of antimuscarinics (e.g. oxybutynin, solifenacin, tropsium, tolterodine)

A
  • Dry mouth
  • Dry eyes
  • Constipation
  • Dizziness
  • Urinary problems: pain, not being able to empty bladder
  • Nausea & vomiting
24
Q

State some ADRs of alpha blockers (e.g. Tamsulosin, doxasozin)

A
  • Dizziness
  • Sexual dysfunction
25
Q

State some ADRs of finasteride (5-alpha reductase inhibitor)

A
  • Sexual dysfunction (problems getting an erection, little or no semen)
26
Q

Containment products are NOT first line management for pts with urinary incontinence; when might you offer these?

State some examples

A

Should not be used as ‘treatment’; they should only be used to:

  • Help pt cope with leakage while awaiting assessment & treatment
  • Help pt cope whilst waiting for response to ongoing treatment
  • ONLY to be used as long term management once treatment options have been explored and test; should be regularly reviewed

Examples:

  • Absorbent products e.g. pads & pull-ups
  • Hand-held urinals, sheaths or drainage systems (for males)
  • Washable bed pads
27
Q

State some potential complications of incontinence (think about mental/psychological aswell as physical)

A
  • Skin problems: rashes, sores, infection
  • If overflow due to retention → renal damage, UTIs due to stagnant urine
  • Impaired quality of life (impact on employment, leisure etc…)
  • Psychological problems (embarrassment, loss of self confidence, anxiety, depression)
  • Social isolation
  • Sexual problems (reduced intimacy and impact of this on relationships)
  • Loss of sleep (particularly in OAB)
  • Falls & fractures
28
Q

Which team can you refer pts to if they have incontinence?

A

The Continence team; they will assess, treat and provide individual management advice for:

  • Bladder dysfunction – urinary incontinence, urgency, frequent urinary tract infections, unable to empty bladder effectively etc.
  • Bowel dysfunction – Chronic constipation, faecal incontinence
  • Urinary catheter problems
  • Advice, teaching and, in some cases, provision of aids required to manage bladder/bowel dysfunction
  • Advice for relatives/carers
29
Q

What urine dipstick results suggest UTI?

Discuss who urine dipsticks are reliable in

A

Dipstick suggests UTI if:

  • +ve leucocytes or nitrites and RBCs
  • Leucocytes more sensitive (proportion of cases correctly identifies)
  • Nitrites more specific (proportion of non-cases correctly identifies)
  • NICE “if urine dipstick negative for nitrite and positive for leucocytes, UTI equally likely to other diagnosis”

Dipsticks unreliable to diagnose UTI in:

  • >65yrs (most have asymptomatic bacteriuria)
  • Catheterised pts
30
Q

State some causes of acute urinary retention

A
  • BPH (most common cause in men)
  • Urethral strictures
  • Prostrate cancer
  • UTIs (can cause urethral sphincter to close especially in those with already narrowed outflow tracts)
  • Constipation (can compress urethra)
  • Medications
    • Antimuscurinics
    • Spinal or epidural anaesthesia
  • Neurological causes
    • UMN disease
    • Bladder sphincter dysinergy
31
Q

Describe the typical presentation of acute urinary retention

A
  • Acute onset
  • Suprapubic pain
  • Inability to micturate
  • Other features associated with underlying cause
  • Palpable distended bladder
  • Suprapubic tenderness
32
Q

For acute on chronic urinary retention, discuss:

  • Pathophysiology
  • Presentation
  • Management
A
  • Either acute deterioration in underlying pathology that causes their chronic retention or a new aetiology on background of chronic retention
  • Minimal discomfort despite large residual volumes
  • Manage same as acute retention but may have higher residual volumes so at increased risk of post-obstructive diuresis
33
Q

What investigations should you do if you suspect acute urinary retention?

A
  • Post-void bladder scan
  • Routine bloods (especially FBC, U&Es, CRP)
  • CSU (catheterised specimen of urine) sent for MC&S
  • US of KUB to assess for associated hydronephrosis if high pressure retention
    • NOTE: if hydronephrosis present need repeat imaging in few weeks after treatment to ensure resolution
34
Q

Discuss the management of acute urinary retention

A
  • Immediate urethral catheterisation
    • ***MUST MEASURE VOLUME
  • If pt has large retention volume (>1000mL) must monitor for post-obstructive diuresis. If this occurs will need IV fluids replacing 50% of what they are loosing
  • Treat underlying causes
    • ​May need to keep catheter in until cause is treated
35
Q

State some complications of acute urinary retention

A
  • AKI
  • Multiple episodes may lead to scarring & CKD
  • Increased risk UTIs
  • Increased risk renal tract stones
36
Q

What is post-obstructive diuresis?

Clinical criteria?

Management?

A
  • Kidneys over diurese following resolution of retention via catheterisation (due to loss of medullary concentration gradient so kidneys can’t cocentrate urine)
  • The volume produced is more than 200mL of urine production per hour for 2 consecutive hours or more than 3 L of urine is produced in 24 hours
  • Have 50% of urine output replaced with IV fluids to avoid AKI
37
Q

Some pts with chronic urinary retention may be passing small quantities of urine however still have significant residual volumes. Is this still classes as chronic urinary retention?

A

YES! because have high residual volumes/still retaining chronically

38
Q

State some causes of chronic urinary retention- think about different causes for men & women

A
  • BPH (males)
  • Urethral strictures
  • Prostrate cancer (males)
  • Pelvic prolpase (females)
  • Pelvic masses (females) e.g. large fibroids
  • Neurolgoical causes e.g. UMN (MS, Parkinson’s)
39
Q

Describe the typical presentation of pts with chronic urinary retention

A
  • Painless urinary retention
  • Associated LUTs
  • Overflow incontinence
  • Nocturnal enuresis (worsening of overflow incontinence at night due to reduced sphincter tone)
  • Palpable distended bladder
40
Q

What investigations are required in suspeted chronic uriinary retention?

A
  • Post-void bladder scan
  • Catheter sample for MC&S
  • Routine bloods (FBC, CRP, U&Es)
  • If have high pressure retention, US of urinary tract (assess hydronephrosis)
41
Q

Discuss the management of chronic urinary retention

A
  • Catheterise
  • Monitor for post-obstructive diuresis
  • Definitive management depends on underlying cause. May include some form of long term catheter e.g. ISC or suprapubic
42
Q

State some potential complications of chronic urinary retention

A
  • Increased risk of UTIs
  • Increased risk of bladder calculi
  • Repeated episodes of high pressure retention may lead to CKD
43
Q

Compare high and low pressure urinary retention

A

High pressure

  • High intravesicle pressure
  • High IVP overcomes antireflux mechanism of bladder & ureter
  • Urine bakcs up into upper renal tract
  • Hydroureter & hydronephrosis
  • May have impaired renal function
  • Risk of permanent renal scarring & CKD

Low pressure

  • Low intravesicl pressure
  • Competent uretheral valves or reduced detrusor muscle contractility so pressures stay low
  • No hydorureter or hydronephrosis
  • Renal fucntion fine
44
Q

Discuss what questions you would ask when taking a faecal incontinence history

A

Hx presenting complaint

  • Smearing, loose stool or solid
  • Quantity
  • Frequency
  • Pattern (e.g. after certain foods, after opening bowels)
  • Does person feel sensation that they need to go before leakage? Urgency?
  • Measures taken
  • Bowel habits (frequency, stool type, normal for them, recent changes)
  • Other symptoms: bleeding, mucus, wind, pain on defecation, straining, sensation incomplete emptying, ever have to assist passage of stool with finger
  • Fluid & food intake
  • Urine habits

PMH, drugs, allergies

  • Particularly ask about constipation, parity & any difficulties
  • Current medications
  • Allergies
  • Any surgeries

FH

  • FH of bowel issues

Social

  • Where live
  • Who with
  • Access to toilet
  • Carers
  • Impact on work
  • Impact on leisure
  • Smoking, alcohol

ICE

45
Q

State some examples of drugs that can:

  • Alter sphincter tone
  • Cause loose stools
  • Cause constipation
A

Alter sphincter tone

  • Nitrites
  • CCBs
  • Beta blockers
  • Sildenafil
  • SSRIs

Loose stools

  • Abx
  • Laxatives
  • Metformin
  • SSRIs
  • Orlistat

Constipation

  • Opioids
  • Loperamide
  • Antacids (magnesium & aluminium containing)
  • Loperamide
  • Digoxin
46
Q

Faecal incontinence is always abnormal & almost always curable; true or false?

A

True

47
Q

It is abnormal for there to be faeces in the rectum at any time unless passing stool; true or false?

A

True

*NOTE: if stool is present in rectum MUST assess stool type (both hard or soft stool can be present)

48
Q

Faecal incontinence is a sign or symptom- not a diagnosis. It is often caused by multiple underlying factors. What is the most common cause of faecal incontinence?

State some other causes

A
  • Most common = faecal impaction with overflow diarrhoea (50%)
  • Others (some of them are contributing factors as opposed to causes):
    • Neurogenic dysfunction (2nd most common)
    • Abnormal stool consistency
    • Cognitive or behavioural dysfunction
    • Ageing
49
Q

Why is ageing a potential contributing factor (risk factor) for faecal incontinence?

A
  • As body ages, muscles and ligaments weaken hence rectum becomes more vacuous and anal sphincter can gape
  • Factors such as haemorrhoids, constipation etc… can contribute to the above
  • Older people cannot exert the same of intra-abdominal pressure and muscle tension to force stool out hence increased risk of constipation (which puts them at increased risk of overflow incontinence)
50
Q

What do we mean by faecal impaction?

A

Build up of poo in rectum or lower colon (can be hard or soft but usually hard)

51
Q

If a pt has faecal impaction/a full rectum they most likely have a…..?

A

Full bladder (urinary retention)

52
Q

Describe typical presentation of faecal incontinence due to overflow

A
  • Smearing small amounts of type 1 stool or copious amounts of type 6/7 stool with no sensation of defecation
  • May have hx of constipation BUT they could be impacted but still be opening their bowels
53
Q

Discuss the management of faecal incontinence due to constipation & faecal loading

A
  • Disimpaction regime, options include:
    • Enemas
    • Stool softeners & stimulants
    • Manual evacuation (done in difficult cases and risk of perforation outweighed by positive impact on individual)
  • Ongoing management of constipation/faecal impaction:
    • Lifestyle advice: fluids, high fibre, good toilet habits
    • Medication review: reviewing any drugs that are execrating incontinence
    • Laxatives

*Obviously there are other causes of faecal incontinence and hence would need to investigate and treat those e.g. IBD, coeliac disease, cancer, neurological conditions e.g. MS etc…

54
Q

State some potential complications of faecal impaction (both physical & mental/psychological)

A
  • Skin excoriation & damage
  • Impact on employment & leisure activities
  • Psychological (embarrassment, low self-esteem, anxiety, depression)
  • Social isolation
  • Increased caregiver burden/requirement for nursing home placement
55
Q

State some potential complications of chronic constipation

A
  • Stercoral perforation
  • Ischaemic bowel
  • Haemorrhoids
  • Anal fissures
  • Megacolon
  • Faecal impaction (leading to overflow incontinence)

Yr4: OPIC (11 decks)

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