Urinary & faecal incontinence

Question 1

Define urinary Incontinence

Answer 1

The complaint of involuntary loss of urine after having gained the control on voiding.

Question 2

LUTS: Storage symptoms:

Answer 2

• Frequency, Nocturia, Urgency, Incontinence

Question 3

LUTS: Voiding symptoms:

Answer 3

• Slow stream, splitting/ spraying, intermittency, hesitancy, straining,
terminal dribble

Question 4

LUTS: Post-micturation symptoms:

Answer 4

• Sense of incomplete evacuation,

post-micturation dribble

Question 5

Gender diferences in incontinente

Answer 5

Storage LUTS >Voiding and post-micturation LUTS in both
sexes.

Stress incontinence more common in women Urge incontinence more common in men

Question 6

Normal Micturation stages

Answer 6

• Realize need to void urine
• Plan the act
• Recognize appropriate place • Negotiate environment
• Manage clothing

Question 7

Types of incontinence

Answer 7

• Urge (OAB)
• Stress
• Overflow
• Functional
• Mixed

Question 8

Risk Factors fir incontinance

Answer 8

• Age: SI-peaks in middle age, Urge & mixed UI increase after 50 years in women
• Heredity
• Race: SUI in white women > Hispanic/ black
• Physical activity
• High BMI: Highest quartile of body mass-2-4 times more incidence of UI than lowest
• Diet - High fat, low residue diet, Tea, fizzy drinks, water intake
• Infection (Asymptomatic bacteriuria!!)
• Smoking, cough, Chr. Lung diseases

Disability/disease related (Falls/Leg weakness/postural hypotension, Impaired mobility, visual impairment, Cognitive impairment, DM, constipation

Surgery: Prostatectomy, Hysterectomy • Hormone replacement worsens UI

Question 9

Medications that increase risk of incontinence

Answer 9

• Diuretics
• Sedatives
• Choline esterase inhibitors
• Alpha blockers
• Digoxin, frusemide: anticholinergic effects.
• Antimuscarinics can worsen cognitive function and make incontinence worse.

Question 10

Urge Incontinence mechanism

Answer 10

• Detrusor muscle is overactive
• Contracts unpredictably
• Cytometry shows uninhibited contractions
• Constant fear of not making to toilet in time

Question 11

Definition of stress incontinence

Answer 11

Involuntary leakage of urine on
• effort or
• exertion or
• on coughing or sneezing

Question 12

Mechanism of Urethral closure

Answer 12

• Urethral Smooth muscle
• Striated muscle of urethra
• Mucosa and Connective tissue

Question 13

Continence depends on what three factors:

Answer 13

• Urethral closure pressure
• Abdominal pressure
• Transmission of the pressure

Question 14

Overflow incontinence pathophysiology

Answer 14

• Impaired voiding due to
• Outflow obstruction e.g. BPH
• Lower motor neuron lesion, i.e. neuropathic bladder
• Usually sub acute or chronic, painless retention of urine. • Dribbling, Nocturia

Question 15

Differentiating Urge Vs Stress UI

Answer 15

Urge UI
Sudden severe desire
Need to wake up at night

Stress UI
Making to the toilet
Leaking on physical activity

Question 16

Examination for incontinance

Answer 16

Examination
• Postural drop in BP • Neurological
• Cognition
• P/R and perinium
• Gait

Question 17

Investigations for incontinance

Answer 17

• Urine dip & MSU
• U&Es, Random glucose/ Hba1c
• 3 day bladder diary
• Bladder scan / Flow-meter / Urodynamics • USS KUB, Cystoscopy
• WCC, CRP, Ca++ etc.

Question 18

Urge incontinence Management

Answer 18

• Concept of cure Vs improvement
• What is patient’s expectation?
• Have realistic goals
• Clear communication with carers and training them
• Medicine is not always the answer! (Side effects can be very bothersome!)

Question 19

Potentially treatable problems causing incontinace:

Answer 19

• Acute illness: e.g. delirium, UTI
• Bowel: Constipation
• Cognitive impairment: Dementia and depression
• Drugs: Medication review
• Environmental factors
• Fluids: Inappropriate fluid intake

Question 20

Urge Incontinence management

Answer 20

• Behavioural therapy
• Prompted voiding/Scheduled toileting
• Biofeedback/ ?? Electrical stimulation
• Anticholinergic medication
• Oxybutinin, Tolteradine, Solifenacin, Darifenacin and Fesoterodine
• Adrenoceptor agonists
• Mirabegron
• Intra-vesical botulinum

Question 21

Stress Incontinence

- Conservative Management

Answer 21

• Lifestyle modification
• Weight loss
• Stop smoking
• Fluid management • Timed voiding
• Pelvic floor muscle training, vaginal cones • Pharmacotherapy
• Oestogens
• Alpha agonists

Question 22

Stress Incontinence- Surgical management

Answer 22

Aims at
• Elevate bladder neck
• Support mid-urethra
• Increase urethral resistance

Question 23

Overflow incontinence management:

Answer 23

• Bothersome LUTS, low risk of progression- Alpha blockers

* Bothersome LUTS, high risk of progression- Alpha blockers+5a-RI • LUTS and OAB- Alpha blockers + amtimuscarinic agents