Incontinence

Question 1

Incontinence

Answer 1

Urge
Stress
Mixed urge/stress - most common
Overflow
Functional - ie in person with dementia/brain injury/reduced mobility
Faecal

Question 2

Incontinence - clinical

Answer 2

Hx - CNS, cognition, mobility
Voiding record/bladder chart
Review all meds
Physical exam - near, faecal impaction, prolapse, vulval oestrogenisation, urethral meatus, sacral root sensation, pelvic floor strength

Question 3

Incontinence - investigations

Answer 3

Post void residual volume estimation (bladder scan preferred to IDC)
MSU to exclude UTI
Causes of osmotic diuresis (DM, Ca, K)
AXR to exclude high faecal loading

Question 4

Incontinence - non-drug treatment

Answer 4

Cognitively intact

• pelvic floor exercises (for genuine stress incontinence- first line)
• bladder retraining
• timing of oral fluids, reduced caffeine, rationalise meds
• treat constipation

Cognitively impaired

• scheduled toileting
• containment (aids)
• full body suits
• treat consipation

Question 5

Incontinence - drug treatment

Answer 5

Urge, cognitively intact
- anti-muscarinic agent (oxybutynin, solifenacin, tolteridone)

Stress, females

• try topical oestrogens
• duloxetne has little evidence

Question 6

Incontinence - surgical treament

Answer 6

Stress
- mid-urethral sling (last line)

May make urge worse, therefore need urodynamics to exclude significant detrusor instability

NEJM: surgery more effective as first line, but given risk in elderly, would always try conservative first