What is incontinence?
Lack of voluntary control over urination or defecation
Multifactorial problem:
- normal anatomy and function
- neuro integrity
- physical mobility and dexterity
- environment
Innervation of the bladder
- sympathetic fibres travel from the spinal cord T11-L2 to the bladder. These maintain relaxation of the bladder for urine storage.
- parasympathetic nerves from S2-S4 produce bladder contraction and sphincter relaxation to allow voiding
- internal sphincter plus external sphincter which is under voluntary control
Clinical types of urinary incontinence?
Urge incontinence / overactive bladder
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence
Tell me about stress incontinence?
- Most common type in women under 75yrs
- Weakening of urethral sphincter and pelvic floor muscles
- Occurs with increased intraabdominal pressure (cough, sneeze, laugh, lift)
- May be in relation to prostate surgery or childbirth or hysterectomy
- May be provoked by alpha-adrenergic blocks (prazosin/doxazosin)
Tell me about urge incontinence?
- aka overactive bladder, detruser instability / hyperactivity
- leakage accompanied by urgency
- most common type in institutionalised elderly and over 75yrs
- associated frequency and nocturne
- post void residual volume is normal
Caused by:
Decreased inhibition:
- intracranial (stroke, mass, haemorrhage)
- demyelinating disease
- Alzheimers
- Parkinsons
increased afferent stimulation:
- lower UTI
- atrophic urethritis
- faecal impaction
- uterine prolapse
Tell me about overflow incontinence?
Reduction in force and calibre of urinary stream, incomplete micturition and voiding.
Over-distention of bladder
- obstruction of urinary flow (constipation, BPH, urinary stones, neoplasm)
Non-contractile bladder
- hypoactive detrusor
- atonic bladder
(diabetic / alcoholic neuropathy, sacral spina cord lesions, medications, neuroleptics, narcotics, TCA)
Tell me about functional incontinence?
- does not involve lower urinary tract
- result of psychological, cognitive, physical impairment and environment
- patients have lost their cognitive function, or had not developed it in childhood
Red flags in urinary Hx?
- microscopic haematuria in women aged 50 and older
- visible haematuria
- recurrent or persisting UTI with haematuria in women over 40
- Sx associated with pelvic pain and abdo swelling
- weight loss and night sweats
- suspected malignant mass arising from the urinary tract
Dx tests for urinary incontinence?
- dipstick and culture (careful in elderly)
- blood tests
- U+Es, calcium, glucose, CRP
- bedside US / bladder scan
(pre and post void volumes) - patient diaries of fluid intake and toileting habits
- urodynamic studies
Reversible causes of incontinence?
DIAPPERS:
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders, polydipsia
- Endocrine disorders
- Restricted mobility
- Stool impaction
Drugs that may cause incontinence?
- Diuretics
- Anticholinergics, antihistamines, antidepressants, antipsychotics
- Sedatives and muscle relaxants
- Alcohol
- Opioid based pain killers
- alpha-adrenergic antagonists/ agonists
- CCBs
Management of incontinence?
And for each of the types?
Treat reversible causes.
Dementia: regular toileting
Lifestyle: reduce about or timing of fluid intake, avoid bladder stimulants
Medications: use diuretics judiciously and not just before bed
Weight loss if high BMI
Reduce physical barriers to toilet (use bedside commode)
Urge: bladder retraining, anticholinergic/oestrogen cream. Botox injection, nerve therapy.
Stress: pelvic floor exercise, prolapse then a pessary. Invasive options available.
Overflow: BPH (tamsulosin, finasteride, TURP), intermittent self catheterisation
What is faecal incontinence?
Faecal incontinence is unintentional loss of solid or liquid stool.
3-10% of over 65s have it.
Common reason for entering long term care.
Physiology of bowel control?
- controlled by anal sphincter pressure, rectal storage capacity and rectal sensation
- intraabdominal pressure
- innervation from the pudendal nerve, mixed motor/sensory nerves S2-S4
- sphincter muscles stretched, weakened, not strong enough
Factors for normal bowel function?
- hydration
- dietary fibre
- mobility
(and not stressed)
Loss of faecal continence causes?
Poor anal tone / dysfunction
- haemorrhoids or skin tags
- fistulae
Altered bowel physiology
- IBD
- infections
- laxatives
- faecal impassion
- radiation enteritis
- coeliac disease
- bacterial overgrowth
Altered neurology
- MS/CVA
- PD
- diabetes
- alcohol
Mechanical disruption
- damage to sphincters / nerve/ tissue
- can be iatrogenic, surgical or traumatic
What is runniest on the Bristol stool chart?
Type 7 running
Type 1 hard
Medication that can cause faecal incompetence/ constipation?
- opiates
- metallic ions (iron, calcium)
- CCBs
- antispasmodics
- anticholinergics
- dopamine agonist
- diuretics
Ix for faecal incompetence?
Hb, ferritin, U+Es, bone profile, TFT
stool sample
AXR and bowel visualisation
Management of faecal incompetence?
Address underlying cause
Factors, dehydration /in-mobility
Bowel training
Use of laxatives
Skin protection
Carer training
What are the types of laxatives and name some from each group?
- Poor data on efficacy
- bulking agents (psyllium husk)
- osmotic (lactulose, macrogol, phosphate enema, glycerol enema)
- stimulant (Senna, bisacodyl)
- softener (docusate)
