L14 Urinary incontinence

1 in 4 New Zealanders live with incontinence.

Choose the incorrect statement.

Choose the incorrect statement.

Which of these is not a risk factor for incontinence?

Incontinence is under-diagnosed and under-treated despite the majority of urinary incontinence being easy to treat and resolve.

Why is Incontinence Important? It has: • Social stigma - which leads to [blank_start]restricted[blank_end] activities and [blank_start]depression[blank_end] • Medical complications - [blank_start]skin[blank_end] breakdown, increased urinary tract [blank_start]infections[blank_end] • Institutionalisation - UI is the second leading cause of [blank_start]nursing home[blank_end] placement

Red flags • [blank_start]haematuria[blank_end] (blood in the urine) • recurrent [blank_start]urinary tract infections[blank_end] (3 or more in last 6 months) • loin [blank_start]pain[blank_end] (pain in the lower back) • recurrent catheter [blank_start]blockages[blank_end] • hydro nephrosis or [blank_start]kidney stones[blank_end] on imaging • biochemical evidence of [blank_start]renal[blank_end] deterioration.

Micturition/urination: An autonomic spinal cord reflex controlled by higher brain centres(Pons - [blank_start]facilitates[blank_end]. Cerebral cortex – [blank_start]inhibits[blank_end].) Detrusor muscle constricts to expel urine, relaxes to allow filling. Has an internal sphincter which is [blank_start]involuntary[blank_end] and an external sphincter which is [blank_start]voluntary[blank_end] and deep in pelvic floor muscle. Stretch receptors send signals to the brain and sacral segment.

At 150-300mL you first have the urge to void urine and at about 700mL you can no longer suppress urination.

Potentially Reversible Causes of incontinence: D- [blank_start]Delirium[blank_end] I - [blank_start]Infection[blank_end] A- [blank_start]Atrophic[blank_end] vaginitis or urethritis P -[blank_start]Pharmaceuticals[blank_end] P - [blank_start]Psychological[blank_end] disorders E - [blank_start]Endocrine[blank_end] disorders R- [blank_start]Restricted mobility[blank_end] S - [blank_start]Stool[blank_end] impaction

Which of these is NOT a drug which may cause incontinence?

3 types of incontinence: 1. [blank_start]Overflow[blank_end] - urethral blockage 2. [blank_start]Stress[blank_end] - abdominal pressure and weak pelvic floor 3. [blank_start]Urge[blank_end] - oversensitivity from infection or neuro disorders

Overactive bladder (OAB) is defined as urgency that occurs with urgency UI and usually with frequency and nocturia.

Men are more likely to experience urge incontinence.

Stress Incontinence • Most common type in [blank_start]women < 75 years[blank_end] old • Occurs with increase in abdominal [blank_start]pressure[blank_end]; cough, sneeze, laughing, etc. • Hypermotility of bladder neck and urethra; associated with aging, hormonal [blank_start]changes[blank_end], trauma of [blank_start]childbirth[blank_end] or pelvic surgery (85% of cases) • [blank_start]Intrinsic[blank_end] sphincter problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

Urge Incontinence AKA detrusor [blank_start]hyperactivity[blank_end], detrusor instability, irritable bladder, spastic bladder. • Most [blank_start]common[blank_end] cause of UI >75 years of age • [blank_start]Abrupt[blank_end] desire to void cannot be suppressed • Usually [blank_start]idiopathic[blank_end] • Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

Overflow Incontinence • Over distention of bladder • Bladder outlet [blank_start]obstruction[blank_end]; stricture, BPH, cystocele, fecal [blank_start]impaction[blank_end] • Non-contractile bladder ([blank_start]hypoactive[blank_end] detrusor or atonic bladder); diabetes, MS, spinal injury, medications

Functional Incontinence does not involve the lower urinary tract and is the result of psychological, cognitive or physical impairment.

Lifestyle choices • Reduce or eliminate [blank_start]caffeine and alcohol[blank_end] • Drink 6 to 8 glasses of water daily • Quit [blank_start]smoking[blank_end] • [blank_start]Weight[blank_end] control • Follow a healthy diet high in [blank_start]fibre[blank_end] • Reduce physical [blank_start]barriers[blank_end] to toilet

Non-pharmacological Treatment Options: • Bladder [blank_start]training[blank_end] • Patient [blank_start]education[blank_end] • [blank_start]Scheduled[blank_end] voiding (Regular scheduled pattern of voiding where the intervals between voiding are gradually [blank_start]increased[blank_end], reduces irritability of the bladder, reverses bad [blank_start]habits[blank_end]) • Positive reinforcement • Pelvic floor exercises ([blank_start]Kegel Exercises[blank_end])

Pharmacological Interventions: • Anti[blank_start]cholinergics[blank_end]: These medications can calm an [blank_start]overactive[blank_end] bladder and may be helpful for urge incontinence. Examples include [blank_start]oxybutynin[blank_end], tolterodine • [blank_start]Alpha[blank_end] blockers: In men with urge or overflow incontinence, these medications [blank_start]relax[blank_end] bladder neck muscles and muscle fibres in the prostate and make it [blank_start]easier[blank_end] to empty the bladder. Examples include [blank_start]tamsulosin, doxazosin, terazosin[blank_end]. • Topical estrogen. For women, applying [blank_start]low[blank_end]-dose, topical estrogen in the form of a vaginal cream, ring or patch may help [blank_start]tone[blank_end] and rejuvenate tissues in the urethra and vaginal areas.

Interventional therapies: • Bulking material injections: A synthetic material is [blank_start]injected[blank_end] into tissue surrounding the urethra. The bulking material helps keep the urethra [blank_start]closed[blank_end]. • Botulinum toxin type A (Botox): Injections of Botox into the [blank_start]detrusor[blank_end] muscle may benefit people who have an overactive bladder. • Nerve stimulators: A device resembling a pacemaker is [blank_start]implanted[blank_end] under your skin to deliver painless [blank_start]electrical[blank_end] pulses to the nerves involved in bladder control (sacral nerves). Surgical Interventions: - [blank_start]Sling surgery[blank_end] is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after [blank_start]10[blank_end] years - [blank_start]Bladder neck suspension[blank_end] adds support to the bladder neck and urethra, reducing the risk of stress incontinence

Pessaries - • Urethral insert: a small, tampon-like [blank_start]disposable[blank_end] device inserted into the urethra before a specific [blank_start]activity[blank_end], such as tennis, that can trigger incontinence. The insert acts as a plug to prevent [blank_start]leakage[blank_end], and is removed before urination. • Pessary: a stiff ring that you insert into your vagina and wear all [blank_start]day[blank_end]. The device is typically used in someone who has a [blank_start]prolapse[blank_end] that is causing incontinence. The pessary helps hold up your bladder, which lies near the vagina, to prevent urine leakage.