Continence Flashcards
(22 cards)
What are some causes of incontinence?
Extrinsic to urinary system;
- environment
- habit
- physical fitness etc
Intrinsic to urinary system;
- problem with bladder or urinary outlet
Often a bit of both
What are some extrinsic factors involved in incontinence?
Physical state and co-morbidities
Reduced mobility
Confusion
Drinking too much at wrong time
Medications i.e. diuretics
Constipation
Home/social circumstances
What type of muscle is detrusor muscle?
Smooth muscle
What type of muscle is internal urethral sphincter?
Smooth muscle
What type of muscle is external urethral sphincter?
Striated muscle
Describe urinary storage in the bladder
Involves detrusor relaxation with filling (<10cm pressure)
Normal volume 400-600ml
Combined with sphincter contraction to keep fluid inside
Describe voluntary voiding
Voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter
Also contraction of bladder
What is the parasympathetic innervation involved in for continence?
S2-S4
Increases strength and frequency of contractions
What is the sympathetic innervation involved in for continence?
T10-L2
B-adrenoreceptor;
- causes detrusor to relax
a-adrenoreceptor;
- causes contraction of neck of bladder and internal urethral sphincter
What is somatic innervation involved in for continence?
S2-S4
Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter
What ares of the CNS are involved in continence?
Centres within CNS inhibit parasympathetic tone
Sphincter closure mediated by reflex increase in a-adrenergic and somatic activity
Pontine micturation centre exerts “storage program” until voluntary switch to voiding occurs
Other areas include
- frontal cortex
- caudal part of spinal cord
Describe stress incontinence
Bladder outlet too weak
Characteristic features
- urine leak on movement, coughing, laughing etc.
- weak pelvic floor muscles
- common in women with children, especially after menopause
What are treatments for stress incontinence?
Physiotherapy, oestrogen cream, duloxetine
Surgical;
- TVT, colposuspension 90% cure at 10 years
Describe urinary retention with overflow incontinence
Bladder outlet ‘too strong”
Characteristic features
- poor urine flow, double voiding, hesitancy, post micturation dribbling
- urethral blockage
- older men with BPH
Describe treatment for urinary retention with overflow incontinence
Alpha blocker (relaxes sphincter e.g. tamsulosin)
Anti-androgen (shrinks prostate e.g. finasteride)
Surgery - TURP
May need catheterisation (often suprapubic)
Describe urge incontinence
Bladder muscle ‘too strong’
Characteristic features
- detrusor contract at low volumes
- sudden urge to pass urine immediately
- patients often know every public toilet
- can be caused by bladder stones or stroke
Describe treatment for urge incontinence
Anti-muscarinics (relax detrusor e.g. oxybutinin)
Bladder re-training sometimes helpful
Describe the neuropathic bladder
Underactive bladder
Characteristic features
- rare
- secondary to neurological disease; typically MS or stroke
- no awareness of bladder filling; overflow incontinence
Describe treatment of the neuropathic bladder
Medical treatments unsatisfactory but parasympathomimetics might help
Catheterisation only effective treatment
How to assess incontinence
Careful history with good social history
Intake and output charts
General examination incl. rectal and vaginal
urinalysis and MSSU
bladder scan for residual volume
consider referral to incontinence clinic
Suggest lifestyle/behavioural changes and stop unnecessary drugs
Indications for referral to specialists for incontinence
Referral after failure of initial management
Max 3 months pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
When would referral for incontinence be necessary at onset?
- vesico-vaginal fistula
- palpable bladder afetr micturation
- disease of CNS
- certain gynaecological conditions i.e. fibroids, rectocoele, cystocoele
- severe BPH or prostatic carcinoma
- patients who have had previous continence surgery
- others in whom a diagnosis has not been made
