Incontinence

Question 1

Extrinsic causes of Incontinence

Answer 1

Environment, habit, physical fitness

Question 2

Causes intrinsic to urinary system

Answer 2

Bladder or urinary outlet issue

Question 3

Specific Extrinsic factors

Answer 3

Physical state and comorbidities
Reduced mobility
Confusion; delirium or dementia
Drinking too much/at wrong time
Medications - diuretics
Constipation
Home circumstances
Social circumstances

Question 4

Function of bladder

Answer 4

Urine storage and voluntary voiding

Question 5

Detrusor- type of muscle?

Answer 5

Smooth

Question 6

Internal urethral sphincter- type of muscle?

Answer 6

Smooth

Question 7

External urethral sphincter- type of muscle?

Answer 7

Striated

Question 8

Action of detrusor and sphincter on filling

Answer 8

Detrusor relaxes

Sphincter contracts

Question 9

Actions on voluntary voiding

Answer 9

Internal sphincter relaxes involuntarily
External relaxes voluntarily
Bladder contracts

Question 10

Parasympathetic Innervation?

Answer 10

S2-S4

Increases stength and frequency of contractions

Question 11

Sympathetic

Answer 11

T10-L2
Beta adrenoreceptor - detrusor relaxes

T10-S2
Alpha receptor - contraction of neck of bladder and internal sphincter

Question 12

Somatic innervation

Answer 12

S2-S4

Contraction of pelvic floor muscle (urogenital diaphragm|) and external sphincter

Question 13

CNS connections

Answer 13

Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.

Question 14

What mediates sphincter closure?

Answer 14

Reflex increase in alpha adrenergic and somatic activity

Question 15

Which centre exerts the storage through neural connections until switch to voiding?

Answer 15

Pontine micturition centre

Question 16

Which other areas are involved in control of continence?

Answer 16

Frontal cortex

Caudal part of spinal cord

Question 17

Name a specific intrinsic factor of incontinence?

Answer 17

Stress incontinence

Question 18

What causes stress incontinence?

Answer 18

Weakness of bladder outlet

Question 19

Features of stress incontinence

Answer 19

Urine leak on movement, squatting, coughing, laughing
Weak pelvic floor muscles
Common in women with children, after menopause

Question 20

Treatments of Stress incontinence

Answer 20

Physiotherapy
Oestrogen cream
Duloxetine
Surgery - TVT/colposuspension

Question 21

Other treatments

Answer 21

Kegel exercises
Kegel exercisers
Vaginal cones
Biofeedback

Question 22

If bladder outlet ‘too strong’?

Answer 22

Urinary retention with overflow incontinence

Question 23

Features of urinary retention & overflow incontinence

Answer 23

Poor urine flow, double voiding,
hesitancy, post micturition dribbling
Blockage to urethra

Question 24

Overflow incontinence is common in?

Answer 24

Older men with Benign Prostatic Hyperplasia

Question 25

Treatment of urinary retention

Answer 25

Alpha blocker Antiandrogen Surgery - TURP

Question 26

TURP?

Answer 26

Transurethral Resection of the Prostate

Question 27

Purpose of alpha blocker?

Answer 27

Relaxes sphincter

Question 28

Example of alpha blocker

Answer 28

tamsulosin

Question 29

Purpose of antiandrogen?

Answer 29

Shrinks prostate

Question 30

Example of antiandrogen

Answer 30

Finasteride

Question 31

Further procedure that may be needed in urinary retention

Answer 31

Catheterisation - suprapubic

Question 32

Condition when bladder muscle 'too strong'

Answer 32

Urge incontinence

Question 33

Features of urge incontinence

Answer 33

Sudden urge to pass urine immediately

Question 34

What happens the detrusor at low volumes?

Answer 34

Contracts

Question 35

Causes of urge incontinence

Answer 35

Bladder stone or stroke

Question 36

Treatment of urge incontinence

Answer 36

Antimuscarinics

Question 37

Action of antimuscarinics

Answer 37

Relax detrusor

Question 38

Examples of antimuscarinics

Answer 38

Oxybutinin Tolterodine Solifenacin

Question 39

Other management of urge incontinence

Answer 39

Bladder training

Question 40

Underactive bladder known as a

Answer 40

Neuropathic bladder

Question 41

Features of a neuropathic/underactive bladder

Answer 41

No awareness to bladder filling leading to overflow incontinence

Question 42

Type of incontinence experienced with neuropathic bladder

Answer 42

Overflow

Question 43

Neuropathic bladder occurs secondary to

Answer 43

Neurological disease, stroke or multiple sclerosis

Question 44

Treatment

Answer 44

Catheterisation only effective treatment

Question 45

Medical treatment

Answer 45

Parasympathomimetics- not overly effective but may help

Question 46

How to assess incontinence

Answer 46

``` History Examination- general with rectal and vaginal Intake chart and urine output diary Urinalysis, MSSU Bladder scan - residual volume ```

Question 47

How to check residual volume?

Answer 47

Bladder scan

Question 48

Further management

Answer 48

``` Refer to incontinence clinic Consider lifestyle changes Consider drugs and medication review Refer to physio Medical treatment Surgery ```

Question 49

When to refer to specialists

Answer 49

Failure of management - max 3 months pelvic floor exercises

Question 50

Referral at onset

Answer 50

Vesico-vaginal fistula Palpable bladder after micturition or confirmed large residual volume of urine after micturition Disease of the CNS Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele) Severe benign prostatic hypertrophy or prostatic carcinoma Patients who have had previous surgery for continence problems Others in whom a diagnosis has not been made

Question 51

Referral of faecal incontinence

Answer 51

Failure of initial management | Constipation or diarrhoea with normal sphincter

Question 52

Referral for faecal incontinence at onset

Answer 52

Suspected sphincter damage | Neurological disease

Question 53

Options if management fails

Answer 53

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

Question 54

Case 85 y/o lady, taken to bed, incontinent PMHx: OA, CCF, Type II DM, COPD, anxiety DHx: Dihydrocodeine 30mg qds Furosemide 40mg od Combivent nebs qds Ranitidine 150mg bd Prednisolone 10mg od Temazepam 20mg nocte Citalopram 40mg od Metformin 500mg bd

Answer 54

Management ``` Improve pain relief Increase COPD medications Increase diuretics or other CCF medications Stop furosemide Improve diabetic control (up or down) Minimise risk of syncope Use cough suppressant Stop constipating medications Stop anticholinergic and sedative medications Mobility aids Make toilet more accessible e.g. stair-lift, commode Lifestyle changes (e.g. restrict fluid) Bladder exercises Specific treatments (e.g. tolterodine) ```