Incontinence Flashcards
What is urinary incontinence?
Urinary incontinence is the involuntary leakage of urine.
What is functional incontinence?
the patient is unable to reach the toilet in time, for such reasons as poor mobility or unfamiliar surroundings.
What is stress incontinence?
involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.
What is urge incontinence?
involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition. This means a sudden and compelling desire to urinate that cannot be deferred.
In urge incontinence there is detrusor instability or hyperreflexia leading to involuntary detrusor contraction.
This may be idiopathic or secondary to neurological problems such as stroke, Parkinson’s disease, multiple sclerosis, dementia or spinal cord injury.
It can sometimes be caused by local irritation due to infection or bladder stones.
What is mixed incontinence?
involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.
What is overactive bladder syndrome?
urgency that occurs with or without urge incontinence and usually with frequency and nocturia.
It may be called ‘OAB wet’ or ‘OAB dry’, depending on whether or not the urgency is associated with incontinence. The usual cause of this problem is detrusor overactivity.
What is overflow incontinence?
usually due to chronic bladder outflow obstruction. It is often due to prostatic disease in men. It can lead to obstructive nephropathy due to back pressure; therefore, early assessment and intervention are required.
What is true incontinence?
may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine.
Risk factors for urinary incontinence in women?
o Increasing parity (young and middle-aged women)
o Vaginal delivery (become less important with age)
o DM
o Oral oestrogen therapy
o High BMI
o Hysterectomy (related to stress urinary incontinence)
o Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles. A vaginal delivery, forceps use and babies of a heavier birth weight are all risk factors.
Caesarean section does not necessarily confer protection against urinary incontinence but does reduce it.
o Women with recurrent UTIs
What are the risk factors for urinary incontinence in men?
o LUTS o Infections o Functional and cognitive impairment o Neurological disorders o Prostatectomy
What are the risk factors for urinary incontinence in both genders?
o Stroke o Dementia o Parkinson’s disease o Obstruction such as enlarged prostate gland in men and pelvic tumours in women. o Stool impaction in elderly patients
Which questions do you include in the history of incontinence?
o Stress incontinence: leakage of urine on sneezing, coughing, exercise, rising from sitting, or lifting.
o Urge incontinence: urgency and failure to reach a toilet in time.
o Frequency of urine during the day/at night.
o Dribbling of urine after leaving the toilet.
o Loss of bladder control.
o Feeling of incomplete bladder emptying.
o Dysuria: pain or burning sensation on passing urine.
o Bladder spasms.
What should you consider when assessing urinary incontinence in neurological disease?
Consider factors likely to affect management, such as mobility, hand co-ordination, cognitive function, social support and lifestyle.
Assessment of urinary incontinence in women
- A full obstetric history should be taken in women.
- The patient should be asked, during their initial assessment, to complete a bladder chart for a minimum of three days. These should include both working days and days off. Especially for women with urge incontinence and overactive bladder.
- Enquire about sexual dysfunction and quality of life.
- Assess functional status and access to toilet.
- Establish whether any medication contributes to symptoms.
- Enquire about bowel habit.
- Enquire about desire for treatment
Examination for urinary incontinence
o Perform digital assessment of pelvic floor muscle contraction.
o Perform a bimanual/vaginal examination to assess for the presence of prolapse.
o Look for signs of vaginal atrophy.
o Abdominal, pelvic and neurological examination should also be performed
Men:
o Perform digital rectal examination to assess prostate shape, size and consistency and to check for other rectal pathology.
o Digital anal assessment can be used to give an indication of pelvic floor muscle strength in men.
o Abdominal, pelvic and neurological examination should also be performed
Investigations for urinary incontinence
- Urinary dipstick testing
- Assess residual urine
- Cystometry
Why do you do urinary dipstick testing?
o Perform a urinary dipstick test to look for blood, glucose, protein, leukocytes and nitrites.
o If a woman has symptoms of a UTI and dipstick testing shows leukocytes and nitrites, send an MSU for culture and sensitivities. Prescribe antibiotics whilst waiting for results.
o Also send an MSU in other women with symptoms of UTI but negative urine dipstick testing. Consider antibiotics whilst waiting for results.
o If a woman has no symptoms of UTI but positive dipstick testing for leukocytes and nitrites, send an MSU but don’t start antibiotics until results are available.
o If a woman has no symptoms and negative dipstick testing for nitrites and leukocytes, no MSU is needed.
o Renal function tests may be indicated.
Why do you assess residual urine?
o Post-void residual volume should be measured in women who have symptoms suggesting voiding dysfunction or recurrent UTI. This is best performed using a bladder scan. Catheterisation may also be used.
o Post-void residual volume should also be measured in men
When should you refer people to specialist services?
o persisting bladder or urethral pain o palpable bladder on bimanual or abdominal examination after voiding o clinically benign pelvic masses o associated faecal incontinence o suspected neurological disease o symptoms of voiding difficulty o suspected urogenital fistulae o previous continence surgery o previous pelvic cancer surgery o previous pelvic radiation therapy. o Men: Any criteria present that meet the two-week suspected cancer referral.
Tests that shouldn’t be used in urinary incontinence
o Do not use pad tests in the routine assessment of women with UI.
o Do not use the Q-tip, Bonney, Marshall and Fluid-Bridge tests in the assessment of women with UI.
o Do not use cystoscopy in the initial assessment of women with UI alone.
o Do not use imaging (MRI, CT, X-ray) for the routine assessment of women with UI. Do not use ultrasound other than for the assessment of residual urine volume.
Which treatments should not be used in urinary incontinence?
Do not offer absorbent containment products, hand-held urinals or toileting aids to treat UI.
When should you offer absorbent containment products or toileting aids?
o Offer them only:
as a coping strategy pending definitive treatment
as an adjunct to ongoing therapy
for long-term management of UI only after treatment options have been explored.
What is the treatment for stress incontinence?
Pelvic floor muscle exercises
Duloxetine is used as second line treatment
Surgical treatment:
- Open colposuspension
- Autologous rectus fascial sling
- Rectropubic mesh sling
What is involved in pelvic floor muscle exercises?
- A three-month trial of pelvic floor muscle exercises is the first-line treatment (subsequent to digital assessment of pelvic muscle contraction).
- This should include eight contractions, three times a day.
- Continue if successful.
- Consider electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.
- Provide the patient with a patient information leaflet about pelvic floor exercises.
- Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of UI.
What should you counsel patients about duloxetine?
Duloxetine should not be used as first-line treatment. It may be considered as second-line treatment in women who do not want surgery or who are unsuitable for surgery. Counselling about adverse effects is important.
What should be considered when offering retropubic mesh sling as a surgical treatment?
Only offer ‘top-down’ retropubic mid-urethral mesh sling or single-incision sub-urethral short mesh sling insertion as part of a clinical trial.
Women considering a retropubic mesh sling procedure should be advised that it is a permanent implant and complete removal may not be possible.
After mesh surgery, women should be given the name, manufacturer, date of insertion, and the implanting surgeon’s name and contact detail.
Synthetic tapes should be selected which are made from type 1 macroporous polypropylene material and are coloured for high-visibility colour.
What is the treatment for mixed incontinence?
o Pelvic floor exercises and bladder training, as above, are first-line treatment, both in men and in women.
o An antimuscarinic drug can be started if these are not effective. Oxybutynin has traditionally been used as first-line, but all antimuscarinics are equally effective. Oxybutynin should be avoided in the elderly as it may adversely affect cognitive performance.
What are the names of newer antimuscarinic drugs?
Darifenacin
Solifenacin
Tolterodine
Trospium
