Makindo Medical Notes.com

Always check none of the medications are making continence worse.

About

• Urinary incontinence is defined as the involuntary loss of urine, sufficiently severe to cause a social or hygiene problem
• It is frequently precipitated by acute illness in old age and is commonly multifactorial

Aetiology

• Physical changes to the bladder and pelvic floor with weakness
• Mutifactorial and common with any illnesses with reduced mobility

Types and management

• Stress incontinence: physical causes that cause raises in intravesical pressure and leakage with coughing, laughing, straining. There may be a gynaecological history or obesity. Usually, a mechanical cause and may need surgery. Duloxetine may be used.
• Urge Incontinence: detrusor muscle is unstable and contracts and causes instant overwhelming desire need to pass urine. Can be managed with bladder retraining, pelvic floor exercises and medications such as antimuscarinics which relax bladder smooth muscle. Trial for 4-6 weeks and regular review. Mirabegron is a new agent sometimes used when antimuscarinics have failed.
• Mixed: Both stress and urge can co-exist
• Overflow incontinence: most commonly seen in elderlymen with prostatic enlargement, which obstructs bladderoutflow. Urinary catheterisation and surgery may be needed.

Clinical

• Take a clear history. May be due to poor communications, mobility, new medications e.g. diuretics, old birthing injuries, gynaecological disease, lack of oestrogen.
• Stress: Stress incontinence usually due to dysfunction of the urethral sphincter, is common in women and uncommon in men. There is urine leakage with coughing and anything that increases intra-abdominal and therefore intravesical pressure. Patients may be obese. Often multiple births and damage to the pelvic floor, menopause and gynaecological surgery. Kegel exercises may be useful, but surgery is considered the most effective intervention.
• Urge: Often unexpected and sudden need to pass urine. Detrusor overactivity. Usually larger amounts of urine. Oxybutynin and bladder training exercises are sometimes effective for urge incontinence, which is more common in men. Alpha-adrenergic blockers and 5-alpha reductase inhibitors are used for prostate hypertrophy in men.
• Mixed: quite possible that two can coexist

Drugs that worsen Incontinence

• Alcoholic drinks: volume and diuresis of alcohol
• Alpha agonists e.g. nasal decongestants. Can tighten the urinary sphincter; can cause containing urine to be retained in the bladder and pseudoephedrine uncontrollable leakage of small amounts of urine (overflow incontinence)
• Alpha blockers Doxazosin, Prazosin, Relax the urinary sphincter and urethra; Tamsulosin, Terazosin can cause incontinence when coughing, straining, sneezing, lifting heavy objects, or putting any other pressure on the abdomen (stress incontinence)
• ACEI: Can cause cough and worsen stress converting incontinence
• Antidepressants Amitriptyline, Interfere with bladder contraction and Desipramine, worsen constipation; can cause urine to Nortriptyline be retained in the bladder and overflow incontinence
• Antihistamines Chlorpheniramine, Interfere with bladder contraction and diphenhydramine worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
• Antipsychotics Haloperidol, Can slow mobility and cause abrupt Risperidone urge to urinate followed by Thioridazine, uncontrollable loss of urine (urge thiothixene incontinence)
• Caffeine Coffee, cola, tea, some Increases urination by increasing urine non-prescription production headache remedies
• Calcium channel Diltiazem, verapamil Interfere with bladder contraction and blockers worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
• Diuretics: Furosemide, thiazides Increase urination by increasing urine production
• Opioids Morphine Interfere with bladder contraction and worsen constipation; can cause urine to be retained in the bladder and overflow incontinence
• Sedatives Diazepam, flurazepam, Can slow mobility and worsen urge lorazepam incontinence

Investigations

• FBC, U&E, Glucose, CRP
• Urine frequency volume chart
• Urinalysis: exclude a UTI
• Abdominal USS may be useful if concerns of structural renal disease
• Urodynamics: may see sudden surges in intravesical pressure with urge incontinence.

Management Urge Incontinence

• Pelvic floor exercises help to hold your bladder and bowel in position, also the uterus in women. They prevent leakage from bladder and bowel, only relaxing when your bladder or bowel is emptying.
• Drink adequately 1-2 litres (6 - 8 large cups or glasses). Concentrated urine can irritate the bladder.
• Reduce Caffeine which may be an irritant to your bladder and may increase your frequency of visits to the toilet. Avoid caffeinated drinks, fizzy drinks, grapefruit juice, alcohol. stronger brands of tea that contain more tea and tannins, spicy food. tomatoes.
• Try to avoid becoming constipated by eating a healthy diet with plenty of fruit and vegetables.
• Assessment fill in a 'frequency volume chart' for at least 3 full days (if possible 3 days in a row), to check how often you go to the toilet and how much urine you pass.
• Bladder retraining: retrain the bladder to hold a greater amount of urine. This should reduce the number of times you need the toilet. You should only go to the toilet when you really need to. Regaining control of your bladder is a gradual process.
• Pelvic floor exercises can help pelvic floor muscles prevent leakage from your bladder and bowel. Simple exercises carried out for 3 - 6 months can improve your muscle tone (strength) and help you to hold on longer. Your nurse or continence adviser will explain these exercises and give you a leaflet, 'How to do pelvic floor exercises.
• Further treatments can include medication to reduce your urgency and assist with your bladder retraining, nerve stimulation, physiotherapy or surgery.

Management of Stress Incontinence

• Pelvic floor muscle exercises. Your doctor or physical therapist can help you learn how to do Kegel exercises to strengthen your pelvic floor muscles and urinary sphincter. Just like any other exercise routine, how well Kegel exercises work for you depends on whether you perform them regularly.
• Fluid consumption. Your doctor may recommend how much and when you should consume fluids during the day and evening. However, don't limit what you drink so much that you become dehydrated. Follow as for urge continence.
• Again avoid caffeinated, carbonated and alcoholic beverages, which may irritate and affect bladder function in some people. If you find that using fluid schedules and avoiding certain beverages significantly improve leakage, you'll have to decide whether making these changes in your diet are worth it.
• Quitting smoking, losing excess weight or treating a chronic cough will lessen your risk of stress incontinence and improve your symptoms.
• Bladder training may help if mixed incontinence. More frequent voiding of the bladder may reduce the number or severity of urge incontinence episodes.
• Duloxetine and is used for the treatment of stress incontinence in Europe. Nausea is the most common side effect that makes people stop taking the medication.
• Devices to help control stress incontinence, including:
  • Vaginal pessary. A specialized urinary incontinence pessary, shaped like a ring with two bumps that sit on each side of the urethra, is fitted and put into place by your doctor or nurse. It helps support your bladder base to prevent urine leakage during activity, especially if your bladder has dropped (prolapsed). This is a good choice if you wish to avoid surgery. A pessary will require routine removal and cleaning. Pessaries are used mostly in people who also have pelvic organ prolapse.
  • Urethral inserts. This small tampon-like disposable device inserted into the urethra acts as a barrier to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day. Urethral inserts can be worn for up to eight hours a day. Urethral inserts are generally used only for heavy activity, such as repeated lifting, running or playing tennis.
• Surgery: Bladder neck suspension procedure or Sling procedures. Surgical interventions to treat stress incontinence are designed to improve the closure of the sphincter or support the bladder neck. Surgical options include:
• Sling procedure: a common procedure performed in women with stress urinary incontinence. The surgeon creates with the patient's own tissue, synthetic material (mesh), or animal or donor tissue to create a sling or hammock that supports the urethra. Slings are also used for men with mild stress incontinence. The technique may ease symptoms of stress incontinence in some men.
• Injectable bulking agents. Synthetic polysaccharides or gels may be injected into tissues around the upper portion of the urethra. These materials bulk up the area around the urethra, improving the closing ability of the sphincter.
• Retropubic colposuspension. This surgical procedure uses sutures attached to ligaments along the pubic bone to lift and support tissues near the bladder neck and upper portion of the urethra. This surgery can be done laparoscopically or by an incision in the abdomen.
• Inflatable artificial sphincter. This surgically implanted device is used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum.

Overflow incontinence