Sponsors

You're browsing as an anonymous user. Join the community today to view notes at your university, edit pages, and share knowledge!

Incontinence

From Mediwikis

Incontinence is weakness of the sphincter and an inability to perform its role effectively. As sphincters are commonly found in the gastro-intestinal and genito-urinary systems, incontinence can be used to describe an inability to control both micturition and/or defecation.

Incontinence can be physically, as well as socially and emotionally, extremely difficult for a patient to live with.

Urinary Incontinence

Normal Continence

Anatomy of the bladder

Normal continence depends upon urethral pressure being greater than that of the bladder, to impede flow of urine through the urethra. Urethral pressure is affected by urethral muscle tone, pelvic floor muscle pressure, and intra-abdominal pressure. Parasympathetic nerves contract the detrusor muscle, and open the bladder neck.The pons controls this micturation reflex, and it can be modified by the higher cerebral cortex.

History

  • Frequency- number of times per day
  • Dysuria
  • Nocturia
  • Haematuria
  • Urgency or incontinence
    • Provoking factors- laughing, coughing, stress, exercise

Always check for RED FLAGS:

These may indicate cauda equina syndrome:

  • Low back pain
  • Paraethesia/pain in both legs
  • Severe, sudden onset urinary/faecal incontinence
  • Saddle anaesthesia
  • Other progressive neurological deficit in lower limbs

Investigations[1]

Investigations should be guided by the presentation (see below). General ideas include:

  • Digital assessment of pelvic muscle function
  • Urine dipstick
    • Features of UTI should lead you to investigate appropriately- MSU
  • Post-micturation residual bladder volume measurement
  • Bladder diaries to assess fluid intake, output, any triggers.

Stress Incontinence

This is where increases in intra-abdominal pressure are transmitted to the bladder, but not the urethra. Bladder pressure increases above urethral pressure, for instance when coughing (see Triggers below). Risk factors for stress incontinence include increased age, obesity and pelvic floor damage, for example during birth. If the neck of the bladder has prolapsed below the pelvic floor, it cannot be adequately compressed, and urine will leak.

Triggers

Any event that increases the pressure in the abdominal cavity:

  • Coughing
  • Laughing
  • Sneezing
  • Exercising

Investigation

  • Urine dip to exclude UTI
  • Cystometry to rule out Overactive Bladder

Management

After conservative management options (fluid & caffeine restriction, weight loss) have failed, stress incontinence can be managed with PRIDE:

  • Pelvis floor exercises ("kegel exercises")
  • Ring pessaries - preventing the occurrence of prolapse
  • Intra-vaginal electrical stimulation
  • Duloxetine - an SNRI which relieves symptoms. However it should be noted that SNRIs carry significant side effects.
  • Elective surgery - including the sling procedure.(tension-free vaginal tape)[2]

Overactive Bladder

Otherwise known as Urge incontinence or detrusor instability, this involves the urge to empty one's bladder, often followed by uncontrolled emptying. Urodynamic studies may demonstrate detrusor overactivity. Urge incontinence can be caused by involuntary contractions of the detrusor muscle, which may be provoked by increased abdominal pressure (coughing), or features from the environment e.g. a running tap. This in turn can be due to local or higher cortical factors; local inflammation/infection or due to neuropathy, e.g. Multiple Sclerosis or Spinal Cord Injury

Investigation

OAB is diagnosed clinically after ruling out other causes e.g. UTI.

Management[1]

  • Limit fluid and caffeine intake
  • Bladder retraining with incontinence specialists.
  • Weight loss for high-BMI women.
  • Botulinum toxin injections for women with proven detrusor overactivity that has not responded to conservative management.
  • Antimuscarinic drugs e.g. Oxybutynin or tolterodine.
  • Monitor for irritant foods with food diary and limit irritant food intake
  • Electrical Stimulation[3]

Overflow Incontinence

This is associated with constant dribbling, post-voidal dribbling & hesitancy. Overflow incontinence results from a bladder with high residual volume (>300ml). Overflow incontinence can be caused by:

  • urethral stricture - associated with an enlarged prostate/stones
  • Detrusor weakness - associated with MS/diabetes

Rarer Causes

  • Mixed Stress & OAB
  • Painful Bladder Syndrome
  • Fistulae

References

  1. 1.0 1.1 http://www.nice.org.uk/guidance/cg171/chapter/1-Recommendations
  2. http://www.nice.org.uk/guidance/ipg262
  3. Stewart F, Gameiro OLF, El Dib R, Gameiro MO, Kapoor A, Amaro JL. Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD010098. DOI: 10.1002/14651858.CD010098.pub3.<http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010098.pub3/full>