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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
Examinations needed for incontinence presentation - males only
Digital rectal exam - check for enlarged prostate
26
Examinations needed for incontinence presentation - females
External genitalia stress test - get pt to cough and see if leakage Vaginal exam
27
Investigations for incontinence presentation
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
Optional investigations for incontinence presentation
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
Invasive urodynamics probes used and what these measure
Probe in bladder - measure intravesicle pressure (bladder pressure) Probe in vagina/rectum - measure abdominal pressure Detrusor pressure = intravesical pressure minus abdominal pressure
30
What is pt asked to do in urodynamic testing?
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
What does the urethra run through and what does this mean?
Through pelvic floor - strengthening this can help incontinence
32
What does weakened pelvic floor result in?
Prolapse - usually supports rectum, bladder and uterus in women
33
Lifestyle conservative management for incontinence
Modify fluid intake Weight loss Stop smoking Decrease caffeine intake Avoid constipation - increases pressure Timed voiding - schedule
34
Interventions for patients which lifestyle changes haven't helped and are unsuitable for surgery in general, broad
Indwelling catheter - urethral or suprapubic Sheath device - similar to condom attached to catheter tubing and bag Incontinence pads
35
Risk with indwelling catheter
Urinary tract infection
36
Specific management for stress incontinence
Pelvic floor muscle training - 8 contractions 3x daily, for 3 months at least Weight loss Duloxetine
37
What does duloxetine do in general?
Noradrenaline and serotonin uptake inhibitor - remains at receptor for longer and has prolonged action
38
What does duloxetine do specifically in bladder?
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
When is duloxetine offered?
Not first or second line routinely but if surgery is not an option/alternative to surgery
40
Surgery for stress urinary incontinence female
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
Why do some surgeries for stress incontinence have temporary intention?
Women may still want to have further pregnancies - no point doing permanent surgery when it could damage it again
42
Surgery for stress incontinence for males
Artificial urinary sphincter Male sling
43
Describe male artificial sphincter
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
Initial management of urgency urinary incontinence
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
Pharmacological management of urgency incontinence
Anticholinergics - act on M1, M2 and M3 eg Oxybutynin, Solifenacin B3 adrenoreceptor agonist eg Mirabegron
46
What do anticholinergics do?
Act on M3 receptor in detrusor muscle Stop Ach causing contraction of detrusor from parasympathetic pathway
47
What does B3 adrenoreceptor agonist do?
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
What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?
Botulism toxin intravesicle injection (into bladder(
49
What can be offered if anticholinergics and B3 agonists dont work for urgency incontinence?
Botulism toxin intravesicle injection (into bladder)
50
Actions of botulism toxin
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
Duration of botulism toxin effects
3-6 months - type A in uk under general anaesthetic or local
52
Problem with using anticholinergics in UUI management
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
Example of anticholinergic
Oxybutynin Solifenacin
54
Surgery for urgency urinary incontinence (if pharmacological doesnt work)
Sacral nerve neuromodulation - alter nerve activity Autoaugmentation - removal of detrusor muscle Augmentation cystoplasty - makes bladder larger Urinary diversion - new route for urine
55
Examples of ADLs
* Getting dressed * Feeding yourself * Washing * Control over bladder/bowels
56
Examples of intermediate ADLs
* Cooking * Shopping * Cleaning house * Finances
57
What are higher ADLs?
Societal role of patient - can they fulfil these eg mother, volunteer at local shop etc
58

Elderly YR3 (14 decks)

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