Incontinence (short)

• Issues
  • Impaired ability or willingness to reach a toilet
  • Illness, injury, or restraint that interferes with mobility
  • Irritation or inflammation in or around lower urinary tract
    • Urinary tract infection (symptomatic with frequency, urgency, sudden onset, or worsening of continence, unexplained fever, or decline in functioning)
    • Atrophic vaginitis or urethritis Oral or topical estrogen
    • Stool impaction
  • Increased urine production
    • Metabolic (hyperglycemia, hypercalcemia)
    • Excess fluid intake 
    • Volume overload
• Stress urinary incontinence
  • Usually due to dysfunction urethral sphincter
  • Involuntary leakage due to increases in intra-abdominal pressure on effort or exertion (eg on laughing, sneezing, coughing and lifting)
  • Patient can usually predict which activities will cause leakage
  • In severe cases, it occurs with minimal activity (eg walking, standing from sitting) and limited awareness of leakage
  • Risks
    • prostatectomy
    • TURP
    • pelvic trauma
    • Childbirth
    • Obesity
    • Post-prostatectomy
• Urge urinary incontinence/ overactive bladder
  • Frequency and nocturia
  • hyperexcitability, increased nerve activity
  • Risks
    • neurological conditions
    • parkinsons
    • stroke
    • inflammatory
    • ageing
    • stressors
  • Rule out UTI, stones, carcinoma in situ
• Overflow (urinary retention)
  • Involuntary leakage with loss of fullness sensation from an overdistended bladder
  • Associated with obstructive symptoms such as dribbling, hesitancy and poor stream
  • Patient often feels that there is incomplete bladder emptying
  • Tends to occur with post-void residual volumes of >300 mL
  • Due to
    • Overdistention of the bladder from impaired detrusor contractility or bladder outlet obstruction
  • Etiology
    • anticholinergic agents
    • Benign prostatic hyperplasia
    • Pelvic organ prolapse
    • Diabetes mellitus
    • Multiple sclerosis
    • Spinal cord injuries
    • Faecal impaction
    • Prostatomegaly or pelvic mass

• Work out type of incontinence

Workup

• Functional status
• Impact of incontinence on quality of life 
• Abdominal/pelvic/ PR exam/ neuro
• urine MCS
• USS kUB, Measure post void residual
• Bladder diary
• Check renal function, fasting glucose

Indications for specialist

• Haematuria
• Suspected pelvic mass or urogenital fistulae
• Symptomatic prolapse
• Palpable bladder after voiding
• Persistent pelvic pain
• Suspected neurological disease
• Voiding difficulty
• Previous continence surgery or pelvic cancer surgery
• Poor response to conservative management
• Unclear type/diagnosis of incontinence

Treatment

• Aim: first-line treatment for urinary incontinence and can improve urinary symptoms and QoL

“feeling dry, being natural, not causing embarrassment, being easy and not resulting in dependence”

Pharmacological

• Mixed/ OAB
  • try antimuscarinics – treats overactive detrusor
  • Micrabegron
  • Botox injection
• Anticholinergic agents
  • Oxybutynin/ditropan – 5mg TDS
    • Non selective- more SE’s – dry mouth, constipation, blurred vision, drowsiness, delirium
    • Caution drug interactions
    • Contraindicated glaucoma
    • Can try patches – less systemic side effects – skin can react though
  • Avoid Anticholinergics (e.g. Oxybutynin) in stress incontinence
  • Not effective in Stress Incontinence (and may worsen symptoms)
  • can cause confusion
  • can interfere with the positive effects of cholinesterase inhibitors used for the treatment of dementia
• alpha or beta adrenoceptor agonists
  • mirabegron
    • Upregulates sympathetic activity – reduces destrusor
    • Caution if HTN or long QT
    • Can combine with anti-cholinergic
• serotonin–norepinephrine reuptake inhibitors
  • duloxatine
• botulinum toxin A
• For women:
  • intravaginal topical oestrogen
• For men:
  • alpha adrenoceptors antagonists  ( if BPH present)
    • Tamsulosin (Flomax)
  • 5-alpha reductase inhibitors
• Asymptomatic bacteriuria (ASB)
  • is a common occurrence in RACFs and antimicrobial therapy does not result in improved outcomes.
  • there is potential for harm from side effects of antimicrobials and the development of resistant organisms, thus treatment of ASB (unlike true UTIs) is not recommended

Non-pharm

• Bladder training
  • prompted or scheduled voiding
• Physical therapies
  • Pelvic floor muscle training and vaginal cones
• caffeine reduction
• managing fluid intake
• treating constipation (given the complex interplay between bladder and bowel function)
• minimising medications that incontinence (eg diuretics, calcium channel blockers, alpha-adrenoceptor antagonists, antipsychotics, benzodiazepines, antidepressants and hormone replacement therapy)
• Weight loss
• Cease smoking
• Passive containment
  • Continence products – Continence Aids Payment Scheme
  • Bedpans

continence management plan 

• bladder training program
• continence products such as pads, catheters or condom drainage
• advice on how to keep your bladder and bowel healthy
• trip planner/toilet map app provides:
  • locations of toilets
  • opening hours
  • accessibility for people with disabilities
  • Master Locksmith Access Key (MLAK) access
  • details of other nearby toilets.

• For stress – often need surgery
  • For women: sling procedures, colposuspension, urethropexy
  • For men: prostatectomy, artificial urinary sphincter, male sling