Can have voluntary control over stretch reflex mechanism - pontine micturition centre (blocks parasympathetic actions) - frontal cortex exerts overall control - caudal part of spinal cord

Continence Flashcards by Annie Caldwell

What is incontinence linked with?

Functional decline
Nursing home placement
Death
Socially and psychologically challenging

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Definition of incontinence

Unintentional passing of urine

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Types of incontinence

Stress incontinence
Urge incontinence (overactive bladder)
Overflow incontinence

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What is mixed incontinence?

Stress incontinence and urge incontinence

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Bladder control is dependent on….

Functioning bladder
Functioning sphincters
cognition 
mobility 
dexterity

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Bladder changes with age

Vaginal atrophy
Decreased bladder capacity 
Increased residual volume 
Prostate hypertrophy 
Increased urine production at night

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Reversible factors possibly related to incontinence

Polydipsia 
Medications
UTI
Prolapse
Delirium

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Co morbidities associated with incontinence

Decreased mobility
BOO
Constipation 
Stroke
Spinal cord pathology 
Cognitive impairment

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Functions of the bladder

Urine storing
- detrusor muscle relaxation 
- sphincter contraction 
Voluntary voiding
- relaxation of external sphincter 
- involuntary relaxation of internal sphincter
- contraction of bladder

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Involuntary muscles of the bladder

Detrusor (smooth muscle)

Internal urethral sphincter (smooth muscle)

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Voluntary muscles of the bladder

External urethral sphincter (voluntary)

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Innervation of the bladder

parasympathetic
- S2-S4 = detrusor muscle contraction = urine
Sympathetic
- T10-L2 = detrusor muscle relaxation
- T10 - S2 = internal sphincter contraction
Motor/somatic
- S2-4 external sphincter contraction

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Control of urination

Can have voluntary control over stretch reflex mechanism

pontine micturition centre (blocks parasympathetic actions)
frontal cortex exerts overall control
caudal part of spinal cord

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Causes of overflow incontinence

Urethral blockage OR

bladder unable to empty properly

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Pathology of stress incontinence

Relaxed pelvic floor

Increased intraabdominal pressure

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Causes of urge incontinence

Bladder oversensitivity from infection
Neurological disorders e.g. strokes
Bladder stones

Triggers of stress incontinence

Increased intra abdominal pressures

coughing
sneezing
laughing
standing up

Stress incontinence is common in who?

Women

have had children
after menopause

What is urge incontinence?

Incontinence associated with the sudden urge to pass urine (and cannot be delayed)

Symptoms of overflow incontinence

Hesitancy
Reduced stream/poor urine flow
post micturition dribbling
Double voiding

Two types of urinary system disease

Bladder outlet over activity

Bladder outlet under activity

Extrinsic causes of incontinence

Physical state and co morbidities
Decreased mobility 
Confusion (delirium/dementia)
Drinking too much/at wrong time 
Diuretics 
Constipation 
Home / social circumstances

Intrinsic causes of incontinence

Bladder outlet

too weak = stress incontinence
too strong = urinary retention + over flow incontinence

Bladder muscle

too strong = urge incontinence
too weak = neuropathic bladder

Investigations of incontinence

Abdominal exam 
PV
- strength of pelvic floor muscles
- vaginal redness/dryness
- Prolapse 
PR 
- anal one (neuropathic problems)
- constipation 
Urinalysis / MSSU 
Bladder scan (residual volume post void)
Urodynamics 
- cystometry 
- uroflowmetry

Management of incontinence

``` Weight control fluid control reduce bladder irritants Pelvic floor training exercises Bladder retaining Pads/urinals Surgery - colposupension - TVT tape ```

Bladder irritants

Caffeine Fruit juice Alcohol Stop unnecessary drugs

AIDs for pelvic floor muscle exercises

Biofeedback Vaginal cones (adding extra weight) electrical stimulation

Specific treatment for urge incontinence

``` Bladder retaining programme Prompted, regular toileting Anticholinergics Beta-3-adrenoreceptor agonist Botulinium toxin Sacral nerve stimulation ```

Specific treatment for overflow incontinence

Relieve the obstruction - prostatic hypertrophy/tumour - anti-androgen - TURP - Relax sphincter - alpha blocker - bypass obstruction (catheter)

What do antimuscarinics do?

Relax detrusor

What do beta-3-receptor agonists do?

Relax detrusor

What do alpha blockers do?

Relax sphincter, bladder neck

What do anti androgen drugs do?

Shrink the prostate

What is neuropathic bladder secondary to?

Neurological disease e.g. MS or stroke | Prolonged catheterisation

What does a neuropathic bladder result in?

No awareness of bladder filing resulting in overflow incontinence

Only effective treatment for neuropathic bladder

Catheterisation

Criteria for urinary catheters

Symptomatic urinary retention BOO, otherwise unable to clear Undue stress caused by alternative management in elderly/frail/dying

Indications for incontinence referral to specialist

Failure of initial management (max 3 months) Vesico-vaginal fistula Palpable bladder after micturition or confirmed large residual volume Disease of CNS Certain gynae conditions e.g. fibroids, rectocele Severe benign prostatic hypertrophy or prostatic carcinoma Previous surgery for continence problems Diagnosis not been made Faecal incontinence

Measures to promote independence if all else fails

``` Incontinence pads Urosheaths Intermittent catheterisation Long term urinary catheter Suprapubic catheter ```