Incontinence

Question 1

What major complication of incontinence are we so concerned about in the elderly?

Answer 1

FALLS

patients rushing to reach the toilet on time, and problematic if pt PU before reaching the toilet

Question 2

how does prevalence of incontinence vary between men and women?

Answer 2

prevalence in men usually half that in women

Question 3

examples of LUTS?

Answer 3

frequency
urgency
nocturia-need to pass urine during the night which wakens one from sleep and is an independent RF for falls
incontinence

Question 4

define overactive bladder

Answer 4

syndrome including urinary urgency with or without urge incontinence, which is usually accompanied by frequency (voiding 8 or more times/24hr) and nocturia
can be associated with detrusor overactivity.

Question 5

what is stress incontinence?

Answer 5

involuntary leakage of urine caused by failure for bladder outlet to remain closed during rises in intra-abdominal pressure

Question 6

how is a diagnosis of detrusor overactivity confirmed?

Answer 6

requires urodynamic studies

Question 7

what diagnosis does the following correspond to: spontaneous bladder contraction during filling as pt attempts to prevent micturition?

Answer 7

detrusor overactivity

Question 8

what is nocturnal polyuria?

Answer 8

passing more than 1/3 of your urine volume during the night

can be identified by viewing frequency volume charts

Question 9

types of urinary incontinence?

Answer 9

stress-result of weakness of the urinary outlet so fails to remain closed during rises in intra-abdo pressure e.g. coughing, laughing
urge-high bladder pressure causes bladder to fail in storing urine
overflow-bladder overfull due to bladder outlet obstruction e.g. BPH, so overflows
mixed-combination of stress and urge
functional-incontinence due to more general impairment e.g. cognitive-e.g. pt with dementia who has frontal cortex dysfunction so makes no attempt to move to the toilet before micturition, functional, affective, pt unable to get to the bathroom on time.
fistulae e.g. in crohns

Question 10

what is necessary for the process of micturition?

Answer 10

there must be voluntary relaxation of the striated muscle around the urethra to reduce urethral pressure (pelvic floor muscles already not functioning adequately in stress incontinence) AND
corresponding increase in bladder pressure due to detrusor contraction-M3 muscarinic receptors stimulated by PNS

Question 11

normal bladder capacity, and what volume causes a desire to void?

Answer 11

around 600ml

desire to void usually felt at around 250ml

Question 12

primary muscle for inhibiting the release of urine?

Answer 12

internal urethral sphincter-smooth muscle, continuation of detrusor muscle, under autonomic (involuntary) control

Question 13

how is detrusor contraction coordinated with urethral relaxation to allow micturition to take place?

Answer 13

by the pontine micturition centre in the midbrain

Question 14

overview of how micturition is stimulated following bladder filling?

Answer 14

filling causes detrusor muscle of the bladder to stretch-increased signals sent to the sacral region, which then causes PNS stimulation of the detrusor via the pelvic nerves (S2-S4) to contract. stretching bladder also causes increased signals to be sent up to the brain, where the pontine micturition centre coordinates detrusor contraction with urethral relaxation-brain decreases APs in somatic motor neurones to the external urethral sphincter (pudendal nerve S2-S4).
if voiding not desired, inhibitor signals sent from the brain to the detrusor muscle (hypogastric nerve T10-L2 SNS).

Question 15

most common cause of stress incontinence in men?

Answer 15

prostate damage, usually post-op following prostatectomy

Question 16

structure most important for stopping stress incontinence in women?

Answer 16

peri-urethral striated muscle

Question 17

useful questions for assessing urinary incontinence?

Answer 17

any problems with your bladder or bowels?
do you ever leak urine?
do you find it difficult to hold urine when you feel the urge to go?
do you have a problem with going to the toilet too often to pass urine during the day?
do you have to wake from sleep at night to pass urine?

Question 18

storage symptoms?

Answer 18

frequency of micturition
urgency of micturition
continual urine loss
nocturia
urge incontinence
stress incontinence

Question 19

voiding symptoms?

Answer 19

terminal dribble
hesitancy
intermittent stream
incomplete emptying

Question 20

what should be asked about in the social history which can exacerbate incontinence?

Answer 20

smoking
alcohol
caffeine
fluid intake

Question 21

complications of incontinence for the patient?

Answer 21

social isolation
admission to care home
falls
pressure ulcers
skin infection
impaired QOL
depression

Question 22

what co-morbidities might incontinence be a consequence of?

Answer 22

dementia-frontal lobe dysfunction-pt doesn’t make attempt to go to the toilet before micturition, plus lack of function of the micturition inhibitory centre.
MSK disease-pt unable to mobilise well enough to access the toilet
chronic lung disease
CCF-causes surges in BNP, commonly assoc. with nocturia, plux tx diuretics-exacerbate all types of incontinence, +ACEIs-bradykinin induced cough exacerbates incontinence.
MS
stroke
DM
parkinson’s disease

Question 23

what examination must NOT be missed in assessing pt with urinary incontinence?

Answer 23

DRE:
assess anal tone
constipation, rectal mass
prostate size and consistency

Question 24

simple investigations for the assessment of incontinence?

Answer 24

-frequency-volume charts-ask pt to complete diary over 3 day period that records fluid intake, volume of urine passed and episodes of incontinence
-urinalysis-dipstick-glucose, proteinuria-primary kidney pathology, nitrites+leucocytes-infection, haematuria
plus M, C+S
-bloods-FBC, U+Es, Ca2+-hypercalcaemia can cause constipation and confusion, glucose
-imaging-post void bladder scan-rule out chronic urinary retention
others depending on specific indications:
USS Abdo if CKD-evaluate kidney size and look for signs of obstructive uropathy
CT urography-renal stones
CT abdo
IV urogram

Question 25

what trend from a frequency volume chart is suggestive of an overactive bladder?

Answer 25

frequent small volumes of urine being passed

Question 26

what is uroflowmetry?

Answer 26

an example of a urodynamic study, which measures the urinary flow rate, and is useful for diagnosing bladder outlet obstruction e.g. BPH usually pt left to void in private and the commode has a rotating disc-inertia increased as urine falls onto it, which can be measured by the computer and translated into a flow rate. normal results: total voided volume more than 200ml, flow time 15-20s, Qmax more than 20mls/s, smooth parabolic curve.

Question 27

uroflowmetry trace for a pt with bladder outflow obstruction?

Answer 27

prolonged flow rate with low Qmax

Question 28

most important imaging investigation for urinary incontinence?

Answer 28

post void bladder scan

Question 29

what is cystometry?

Answer 29

bladder pressure studies: bladder filled with saline at room temp via small bore urethral catheter passed along with a pressure transducer, and further pressure transducer placed in rectum. pressure recordings measured as bladder filled. combined with radiographic imaging=videourodynamics

Question 30

how is true intravesical pressure measured with pressure urodynamics?

Answer 30

intravesical pressure minus intra abdominal pressure/rectal pressure (measured via rectal transducer)

Question 31

uroflowmetry features of an overactive bladder?

Answer 31

decreased time to maximum flow, increased max flow rate and decreased max flow

Question 32

define polyuria

Answer 32

more than 2.5L urine passed/24hrs

Question 33

what might cause stress incontinence in men?

Answer 33

prostatectomy | prostate essential to bladder outlet integrity in men

Question 34

transient reversible causes of urinary incontinence?

Answer 34

``` DIAPPERS: delirium infection atrophy-vaginal-trial topical oestrogens pharmacological psychological-dementia, delirium excess urine-DM, DI, psychogenic polydipsia reduced mobility stool impaction (constipation)-do DRE! ```

Question 35

RFs for stress incontinence?

Answer 35

females: outlet already weaker due to shorter urethra and absence of prostate, childbirth-nerve and ligament damage, obesity-increased strain and weakening of pelvic floor surgery: hysterectomy, TURP increasing age neurological disease urinary infection post menopausal-oestrogen loss bladder outlet obstruction

Question 36

causes of overactive bladder (urge incontinence)?

Answer 36

idiopathic neurogenic-MS, stroke or SC injury, parkinsonism infective-UTI bladder outlet obstruction

Question 37

causes of bladder outlet obstruction?

Answer 37

``` BPH malignancy-prostate or bladder, or carcinoma of the cervix or colon calculi blood clot trauma STDs, part. in women phimosis stricture (male preponderance) ```

Question 38

why might BPH be a contributer to urge incontinence?

Answer 38

BPH causes bladder outlet obstruction and can cause overflow incontinence, but over time, there is a strain on the bladder which causes residual urine to be left which irritates the bladder and can cause detrusor overactivity.

Question 39

drugs which may cause/worsen urinary incontinence?

Answer 39

anticholinergics-cause urinary retention opioids-cause urinary retention by causing constipation cholinesterase inhibitors-increase bladder contraction-increased ACh acting on M3 ACEI-bradykinin induced cough alpha blockers-relax bladder outlet alpha agonists-urinary retention hypnotics-reduced awareness of need to urinate haloperidol-anticholinergic, may cause retention Ca2+ channel blockers-decrease smooth muscle contractility

Question 40

pt education to manage stress incontinence?

Answer 40

smoking cessation reduce alcohol and caffeine lose weight manage constipation-increase fibre in diet

Question 41

non-pharmacological management of stress incontinence?

Answer 41

pelvic floor exercises-advice can be given by physiotherapists and continence advisors pudendal nerve stimulation if initial pelvic floor muscle contraction weak vaginal cones-must contract pelvic floor muscles to keep cone in place

Question 42

medical and surgical management of stress incontinence?

Answer 42

duloxetine-SNRI, thought to increase urethral sphincter tone during bladder filling surgical: mid-urethral sling insertion (tension free vaginal tape) provides support under urethra colposuspension-much more invasive injection of bulking agents into the urethra e.g. silicone

Question 43

pt education to manage an overactive bladder (urge incontinence)?

Answer 43

reduce fluid intake, especially in the evening reduce alcohol and caffeine lose weight manage constipation

Question 44

non-pharmacological management of an overactive bladder?

Answer 44

pt education e.g. reduce fluid intake community continence advisor-can assess pt in own home and give advice behavioural therapy-bladder retraining-this should be 1st line for at least 6 wks alongside pelvic floor muscle exercises. bladder retraining involves increasing the time between 1st desire to void and voiding. complementary therapy

Question 45

medical and surgical management of overactive bladder?

Answer 45

antimuscarinics e.g. oxybutynin vaginal oestrogens for those with vaginal atrophy botulinum toxin injected via cystoscopy to inhibit NT release hence decrease contractility surgical: sacral nerve stimulation

Question 46

urinary catheter least associated with infection?

Answer 46

low friction intermittent catheter

Question 47

what 2 diagnoses is the failure to produce urine indicative of?

Answer 47

acute urinary retention or AKI | need catheter insertion