Incontinence & Constipation

Question 1

What are 4 common symptoms associated with storage issues, like OAB?

Answer 1

• Increased frequency: >7x per day or <2h between voids during the day, or 4-5x per night
• Urgency
• Nocturia
• Pain

Question 2

What type of incontinence is associated with loss of pelvic floor integrity?

Answer 2

Stress UI

Question 3

___ incontinence is associated with stronger than physiologic detrusor muscles contraction in response to smaller urine volumes.

Answer 3

Urge

Question 4

What is a lifestyle intervention for incontinence related to body weight?

Answer 4

Weight loss of less than 7-8% body weight.

Question 5

Stress UI: definition

Answer 5

Incontinence due to loss of pelvic floor integrity → internal urethral sphincter insufficiency → pressure of detrusor muscles exceeds internal uretheral sphincter

Question 6

Nocturnal polyuria: definition

Answer 6

Voiding volume at night is >1/3 of the entire day

Question 7

Urge UI / OAB pharmacological management? List 2

Answer 7

• Mirabegron (beta 3 agonist)
• Anticholinergic (feso/tolterodine, dari/solifenacin, trospium)

Question 8

4 types of urinary incontinence

Answer 8

urge (OAB)
overflow
stress
functional
(mixed)

Question 9

What are 4 common symptoms associated with voiding issues?

Answer 9

• Slow stream
• Hesitancy
• Straining
• Feeling of incomplete emptying

Question 10

What behaviour interventions work for incontinence?

Answer 10

• weight loss
• OSA treatment
• balance hydration
• prompted voiding (better than timed voiding or habit retraining)
• pelvic muscle floor retraining (Kegels)
• bladder retraining for frequency (increase time between voids)



*Per guidelines: “No lifestyle interventions (such as fluid manipulation, caffeine, alcohol restriction, smoking cessation and weight loss) can be recommended.”

Question 11

Stress incontinence non-pharm treatment? List 2

Answer 11

• Pelvic Muscle Floor Retraining
• Bladder retraining (for frequency during the day)

Question 12

Most common cause of UI in persons with dementia?

Answer 12

Detrusor overactivity (urge UI / OAB)

Question 13

7 drug classes that can worsen UI?

Answer 13

ACEi (cough)

CCB (leg edema, urinary retention)
Lithium (DI)
psychotropics/sedative-hypnotics (sedation, anticholinergic)
SSRI (cholinergic??)
Gabapentin (impaired emptying, leg edema)
NSAIDs (leg edema)

Other obvious ones: diuretics, anticholinergics, ChEI

Question 14

3 adverse effects of mirabegron (beta 3 agonist)?

Answer 14

hypertension, nasopharyngitis, UTI

Question 15

Interventional management of UI? Indications? Advantages?

Answer 15

• miduretheral sling (MUS)
or transvaginal synthetic mesh (TSM)
• intravesical botox (urge/OAB)

Low morbidity (even less with MUS approach), high efficacy, high patient satisfaction, improved QoL. For stress UI - 40% conservative vs. 70-80% surgical success

Question 16

When do you refer for UI? 8 indications

Answer 16

• hx of pelvic floor rads or surgery
• recurrent UTI
• PVR >200
• new neurologic issues /weakness
• failed behavioural management
• pelvic pain
• can’t pass 14fr catheter
• hematuria

Question 17

6 drug classes that can cause incontinence via action on the detrusor muscle

Answer 17

• Cholinesterase inhibitors (increased ACh → urge incontinence/OAB)
• SSRIs (increased ACh transmission → urge incontinence/OAB)
• Calcium channel blockers (blocks L-type calcium channels in detrusor → inhibits bladder contraction and increases duration to reach maximal bladder pressure → LUTS)
• TCAs (anticholinergic → impaired detrusor relaxation → urinary retention)
• Antihistamines (anticholinergic → impaired detrusor relaxation → urinary retention)
• Antipsychotics (anticholinergic → impaired detrusor relaxation → urinary retention)
• Muscle relaxants (anticholinergic → impaired detrusor relaxation → urinary retention)
• Opioids (detrusor relaxation → urinary retention)

Question 18

4 drug classes for BPH

Answer 18

• alpha-1 antagonist (tamsulosin, silodosin, alfuzosin)
• 5-alpha reductase inhibitor (finasteride, dutasteride)
• 5-PDE inihibitor (tadalafil)
• anticholinergic

Question 19

7 reasons for urinary retention post-op?

Answer 19

• Anesthetic agents: Epidural, spinal blocks
• nerve injury secondary to surgery (less likely)
• Post-operative medications: opiates, blocks
• Constipation
• In-hospital UTI
• Tethers
• Post-op pain → increase ADH production → retention

Question 20

2 types of urge incontinence

Answer 20

Detrusor hyperreflexia (central cause like NPH)
Detrusor instability (local cause like UTI, atrophic vaginitis)

Question 21

4 types of fecal incontinence

Answer 21

Urge (yes awareness)
Overflow
Passive (no awareness)
Seepage (normal defecation then seepage after)

Question 22

4 adverse outcomes of using incontinence pads

Answer 22

psychosocial distress
functional decline
skin irritation / dermatitis
?UTI

Question 23

According to the ACG and AGA (Gastroenterology), what are the laxative recommendations by class?

Answer 23

Fiber
Osmotic: PEG -> MgO -> lactulose
Stimulant: bisacodyl -> senna
Secretagogues: lubiprostone etc.
5-HT4 agonist (prokinetic): prucalopride

Question 24

What are the 3 types of functional /primary constipation?

Answer 24

normal transit
slow transit
pelvic floor dyssynergia (outlet)

Question 25

Name 5 non-pharm options for constipation

Answer 25

psyllium fluids physical activity pelvic floor physio toiletting habits

Question 26

6 steps in management of constipation per CMAJ 2013 (Gandell) on chronic constipation in older adults

Answer 26

1. determine predominent symptoms 2. secondary causes? meds, disease states... 3. r/or fecal impaction with AXR 4. behavioural factors 5. diet 6. previously preferred laxative 7. PEG, lactulose 8. trial of another laxative or combo 9. referral