AP401+Urinary+Incontinence

= AP401 Urinary Incontinence =

Resources
Sample Questions: 2008 [|2007] Sample Answers: 2008 2007
 * **Subject** || **Lecture Notes** || **mp3** ||
 * Incontinence || [|2008] [|2007] || [|2008] [|2007] ||

Outline
Date: Friday, September 28 Handouts: [|Incontinence - Handout] Slides: Incontinence - Slides Audio: [|Incontinence] Note: The lecture audio for this presentation is posted in mp3 format and provided for the purpose of revision support only At the end of this lecture students should be able to:
 * Urinary Incontinence: Stefan Kowalski**

Urinary incontinence is the inability to control urination which results in unintended urinary flow or leakage
 * • Define urinary incontinence and the main factors contributing to it**

//Potentially reversible causes?//
 * D** - Delirium (confusion)
 * I** - Infection (UTI)
 * A** - Atrophic vaginitis or urethritis (hormone treatment)
 * P** - Pharmaceuticals
 * P** - Psychological disorders
 * E** - Endocrine disorders (diabetes insipidus, increased Calcium/PTH)
 * R** - Restricted mobility (arthritis?)
 * S** - Stool impaction (constipation)

//Medications that may cause incontinence//

-  Diuretics -  Caffeine -  Anticholinergics (if overflow problem) // - antihistamines, antipsychotics, antidepressants // -  Sedatives/hypnotics (less likely to reach toilet - oversedation) -  Alcohol (diuretic and sedative)  - <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial-BoldMT','sans-serif'; mso-bidi-font-family: Arial-BoldMT">Narcotics (as with sedatives) <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial-BoldMT','sans-serif'; mso-bidi-font-family: Arial-BoldMT">α-adrenergic agonists/antagonists (depending on type of incontinence, use agonists in stress, antagonists in overflow) <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial-BoldMT','sans-serif'; mso-bidi-font-family: Arial-BoldMT">Lithium (polyuria) <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial-BoldMT','sans-serif'; mso-bidi-font-family: Arial-BoldMT">Verapamil (constipation) - ACEi (may induce coughing) //Prevalence// <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri"> - <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">Prevalence increases with age (but it is not a part of normal aging) <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">25-30% of community dwelling older women <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">10-15% of community dwelling older men <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">50% of nursing home residents
 * • Discuss the prevalence of urinary incontinence and its importance in particular settings**

//Importance// <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">Social stigma <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">leads to restricted activities and depression <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">Medical complications <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">skin breakdown <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">urinary tract infections

<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">Institutionalization <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">second leading cause of nursing home placement //<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'">urge incontinence //<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Arial"> - <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'"> storage failure due to uninhibited contraction of the bladder (detrusor instability)
 * • Contrast the types of urinary incontinence**

//<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'">stress incontinence //<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Arial"> - <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'"> impaired urethral support and/or poor urethral closure

//<span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'Arial','sans-serif'">overflow incontinence // <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri; mso-bidi-font-family: Calibri">- <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: Wingdings-Regular; mso-bidi-font-family: Wingdings-Regular"> <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">emptying failure caused by outlet obstruction (eg BPH), or inability to contract the detrusor <span style="FONT-SIZE: 10pt; LINE-HEIGHT: 115%; FONT-FAMILY: 'ArialMT','sans-serif'; mso-bidi-font-family: ArialMT">(eg neurogenic bladder)

//First-line interventions// - Pelvic Muscle Exercise (PME) - Bladder drills (scheduling toilet), diet etc. Medical Procedures - biofeedback and stimulation - drugs - surgery/injectables
 * • Describe a typical hierarchy of treatment options for urinary incontinence**

- most common cause of incontinence >75 years of age || hypermotility of bladder neck and urethra or intrinsic sphincter problems - most common type in women <75 years of age || emptying failure caused by outlet obstruction (e.g. BPH), or inability to contract the detrusor (e.g. neurogenic bladder) || - idiopathic - related to aging (unclear mechanism) - decreased cortical inhibition (CVA/stroke, Parkinson's disease, Alzheimer's disease, brain tumour) - bladder irritation (UTI, bladder cancer, stones) || hypermotility of bladder neck and urethra (85% of cases) - associated with aging, hormonal changes (menopause), traume of childbirth or pelvic surgery intrinsic sphincter problems (15% of cases) - due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes || overdistention of bladder bladder outlet obstruction - stricture, BPH, cystocele (herniation of the bladder into the vagina), fecal impaction (opioids - pressure from faeces on bladder) non-contractile bladder (hypoactive detrusor or atonic bladder) - diabetes, MS, spinal injury, medications || - propantheline - imipramine (used low dose in children) - oxybutynin (tablet, 2x weekly patch available) - tolterodine - solifenacin - darifenacin
 * • Contrast pharmacotherapies suitable for various types of urinary incontinence**
 * || **Urge Incontinence** || **Stress Incontinence** || **Overflow Incontinence** ||
 * **Definition** || abrupt desire to void cannot be suppressed (voiding of urine before you can reach the toilet)
 * **Anatomical cause** || inappropriate contraction of detrusor muscle during bladder filling
 * **Autonomic pharmacological rationale for drug treatment** || medications to relax the bladder (more bladder specific as you go down)

last two are M3 receptor antagonists - responsible for emptying, contraction and involuntary contractions that can cause UTI (used 3rd line) - atropine would cause CNS effects (not bladder-selective)

//do not use medications used in stress incontinence, as it may lead to overflow incontinence (trouble emptying the bladder)// || medications to tighten the tap - drug treatment usually secondary (try pelvic floor exercises) - phenylpropanolamine (not used much) - oestrogen (orally, transdermally or transvaginally) to help strengthen the bladder outlet in post-menopausal women, limited evidence (if atrophic vagina related to oestrogen deficiency || medications to loosen the tap - use an alpha-1 blocker such as prazosin or tamsulosin (Flomax)

//do not use an anticholinergic, as this will make the bladder relax and fill up more, worsening overflow - do not use medications used in stress incontinence, as this will further restrict flow// ||


 * Practice Questions:** [|Sample Questions (Incontinence)]