Continence: Global Perspective on Causes and Management

Continence 200 million worldwide 14% women, 6% men at ALL ages Assoc with increased risk of falls & # Incontinence = involuntary loss of urine which is objectively demonstrated and a social/hygienic problem Impact Embarrassment Fear Restriction of fluid (à dehydration) Limited social life Affects sex life Costs of management Anatomy of Continence Frontal cortex = Voluntary control Pontine micturition centre = co-ordination Sacral cord roots à detrussor muscle = parasympathetic Pudendal nerve à bladder outlet = sympathetic Storage = sympathetic (T2-L3) à high urethral pressure Voiding = parasympathetic (S2-4) à high detrussor pressure In the elderly 10% have detrussor instability Decreased capacity Increased residual volume (>100ml à infection à irritation) Increased prostatism in men à residual volume Insults (pathological, physiological, psychological, pharmacological) Type of Incontinence Urge incontinence – profound urge to void associated with nocturia & frequency. Due to detrussor overactivity (instability) = spasms – Can occur if bladder fills too fast that decending control to detrussor is not sufficient to prevent contraction (e.g. due to diuretics or DM à osmotic diuresis). If drug related can be reversible Can be idiopathic, neural damage, outlet obstruction à residual vol à irritation à contraction Relative urge incontinence is due to immobility issues where the descending control cannot hold long enough to allow patient to reach toilet Reversible causes can be treated by improving mobility, reviewing medications etc Stress incontinence - Outlet weakness / Sphincter malfunction – involuntary loss when bladder stable & non contractile due to transient increases in intraabdominal pressure (e.g. cough). Common post partum / post prostatectomy / prolapse due to mal-position of the sphincter Reversible causes include Alpha-blockers (prazosin, doxazosin) Overflow / Retention = prostatic hypertrophy (retention) or neuropathic bladder (detrusor failure). Once bladder capacity reached then urine will overflow Reversible (transient) causes include anticholinergics, Ca2+ channel blockers and faecal impaction Irreversible causes include prostate enlargement (rx with surgery), strictures from previous instrumentation and vulval / cervical cancers. Detrusor failure can be due to nervous damage (e.g. DM neuropathy) Rx by relieve obstruction / catheterise if neuropathic bladder Fistulae = often to bowel / vagina Transient incontinence (DIAPERS) should be treatable (30% community, 50% hospital) Delerium Infection Atrophy (vagina) Pharmaceutical (diuretic, anticholinergic, antipsychotic, antidepressant, sedative, narcotic, A-blocker, A-agonist, Ca2+ blocker, ACE Inhibitor, Alcohol) Excess UO (DI, DM, diuretic) Restricted mobility Stool impaction (presses on bladder) History Include – sexual, O&G, pelvic/abdo surgery, DH, Functional, Social, Mental Frequency/Volume chart (input = what, when, how much, output = continent/hr) Examination Full clinical, genital, digital rectal (for prostate), vaginal Investigations Urinalysis – MSU/CSU (via catheter) Uroflowmetry (wee into bucket) / Urodynamics (pressure/contrast) Management Conservative • Check fluids (Vol, caffeine, alcohol), fluid habits (timings), diet (no curry) & toileting • Review existing meds (consider laxatives, reduce sedatives) • Check and treat any UTI • If transient – treat cause Urge Incontinence (Detrussor Instability) • Bladder Training to extend times between toileting, works well if motivated • Antimuscarinic drugs – SE include confusion, more selective = less SE 1. oxybutinin 2. tolterodine • Botox injections to the bladder neck • Cystoplasty with a piece of intestine will reduce contraction force • Urinary diversion / urostomy = last resort Stress Incontinence (sphincter failure) • Barrier methods if only small volume • Pelvic floor exercises (limited use in elderly people) +/- vaginal cones to check technique, +/- electrical stimulation of pelvic floor muscles to assist with training • SNRI (selective noradrenalin reuptake inhibitor) e.g. duloxetine • Surgery – TFVT Overflow Incontinence • Clean intermittent self catheterisation for neuropathic bladder • Queens square stimulator • A-blockers / 5 A-reductase inhibitors to reduce prostate size • NB: avoid long term catheter wherever possible as à infection, atrophy of bladder & loss of self continence. Also inconvenient and predictive factor for entry to nursing home. Use Flip-Flow valve to maintain voiding cycle & bladder volume – no bag and easier to wean patient off.