Is incontinence a normal part of ageing?
No
What proportion of women will become incontinent?
50%
Explain an analogy for thinking about incontinence
Think of the bladder as a reservoir and the pelvic floor muscles as a dam that keep the urine in the reservoir
What are the types of incontience?
Stress Urge Mixed stress and urge Overflow Functional
What is stress incontinence?
Weakness in the pelvic floor muscles
- the dam is not big or strong enough
What is urge incontinence?
Overactive bladder (pelvic floor ok) - The reservoir contracts suddenly
What is overflow incontinence?
Blockage to the passage of urine causes accumulation in the bladder and eventual sudden release of urine
- The reservoir is getting bigger and bigger and then overflows
- The dam/pelvic floor is ok
What is functional incontinence and give causes?
something external from the urogenital tract is causing incontinence
- poor mobility and frailty
- arthritis
- cognitive impairment - can’t remember where toilet is
What are the causes of stress incontinence?
Obesity
Weak pelvic floor muscles
What are the causes of urge incontinence?
Caffeine – diuretic and irritant
Alcohol – diuretic
Drinking too much – overstretches the bladder
Drinking too little – concentrated urine acts as irritant
UTI
What is the main cause of overflow incontinence?
Usually in men with prostatic enlargement
How does stress incontinence present?
Incontinence when sneezing, coughing, exercise, laughing
How does urge incontinence present?
Frequency
Urgency - if you are doing an activity, can you finish it or do you have to drop everything and go?
Nocturia
How does overflow incontinence present?
Hesitancy - Difficulties starting to pass urine
Poor stream
Dribbling
Large residual volume – chronic
(think of someone with BPH)
What questions might you ask sb in an incontinence history?
Identify what type of incontinence it is
Ask about LUTS and situations where incontinence happens
Severity - do they have to plan where the toilets are when they go out, do they have any accidents, do they wear pads?
Is it new or old (especially in geriatric pts on a ward- don’t assume it is new, check GP record)
What investigations would you do for urinary incontinence?
- urine dip for all women presenting with incontinence
- Bloods - which bloods?
- Bladder diary - what they drink and how much and when they are incontinent - alcohol, caffeine, minimum of 3 days, mixture of work and leisure days
Is management of incontinence mainly pharmacological or non-pharmacological?
NON-PHARAMCOLOGICAL
How would you manage stress incontinence?
STRESS
- step 1 - weight loss if BMI over 30
- step 2 strengthen pelvic floor, need to be supervised by a physio who has had specific training in this
- step 3 - surgery - colposuspension - autologous rectus fascial sling or retropubic mid-urethral mesh sling
- step 4 - bulking agent - injections
How would you manage urge incontinence?
URGE
- Step 1 - avoid caffiene
- find the right balance of fluid intake, not too much, not too little
- step 2: bladder training - wait longer before going to the toilet
- step 3: medications , oxybutinin
- step 4: botulinum toxin type A
- step 5: Percutaneous sacral nerve stimulation
How would you manage mixed incontinence?
MIXED
- pelvic floor exercises
- bladder retraining
How would you manage functional incontinence?
FUNCTIONAL
- MDT assessment
- OT – overnight needs, commode, risk and prevention of falls, home and falls risk
How would you manage overflow incontinence?
o Need to see GP or urologist – the only one where pharmacological/ medical management is needed
o Post-void residual US scan – essential
o Tamsulosin – postural hypotension side effect, but relaxes the muscle in the prostate
o Finasteride (5-alpha reductase inhibitor/dihydrotestosterone blocker)– prevents conversion of testosterone to the more potent androgen dihydrotestosterone (DHT), takes 3 months to start working and only for people with a slightly raised PSA – shrinks the prostate
o Surgical – open up the urethra – Transurethral Resection of the Prostate (TURP) for BPH
o Catheters
What other problems may result as a result of incontinence?
- depression
- sexual dysfunction
- poor sleep
When would catheters be used for incontinence?
in urinary retention, where it is:
- causing symptomatic infections
- renal dysfunction
- incontinence
- cannot otherwise be corrected
