Prevalence INCONTINENCE What can Wee do about it? High risk groups Myths Aetiology Assessment-History Assessment-Drugs Assessment- Examination & Tests
INCONTINENCE What can wee do about it? Treatment-First steps Treatment-Stress incontinence Treatment-Urge Incontinence or Overactive Bladder Treatment-Drugs used Treatment-Overflow incontinence
INCONTINENCE What can wee do about it? Treatment- Environmental factors Treatment- Incontinence in the elderly Treatment-Assisted incontinence Treatment-surgical options
PREVALENCE OF INCONTINENCE 1 Affects over 800,000 adult Australians In excess of 100,000 children wet the bed each night Women are 7-8 times more likely to be afflicted than men More prevalent & severe in the elderly
PREVALENCE OF INCONTINENCE 2 Over 50% of men & women in nursing homes are incontinent Less than 40% of incontinent people ever seek professional help
PREVALENCE OF INCONTINENCE 3 Why? - Too embarrassed Ashamed Think its normal with ageing or childbirth Too busy with new baby Think nothing can be done Frightened of surgery Problem not bad enough to warrant surgery
PREVALENCE OF INCONTINENCE Why? - GP thinks its not a serious enough problem to ask about What do you expect at your age? approach Just women s troubles and only to be expected
HIGH RISK GROUPS Pregnant or after childbirth-especially primi with big headed baby Diabetic Bedwetter as a child Wet at school as a child Four or more children Recurrent UTI Over 75 years of age Locomotor problems Neurological disorders Parkinson s Multiple sclerosis C.V.A. Dementia
COMMON MYTHS ABOUT INCONTINENCE 1 Incontinence is a normal part of ageing Incontinence is never normal Age-related changes may predispose to it but incontinence may be treatable once the actual cause is identified
COMMON MYTHS ABOUT INCONTINENCE 2 Nothing can be done for incontinence Most incontinence can be cured or significantly alleviated.
COMMON MYTHS ABOUT INCONTINENCE 3 Holding onto the urine is bad for you Voluntary deferment of micturition is crucial to adult bladder control.
COMMON MYTHS ABOUT INCONTINENCE 4 Prolapse causes incontinence in women Both incontinence and prolapse are common. They are not causally related.
COMMON MYTHS ABOUT INCONTINENCE 5 Surgery is the only way to treat incontinence Incontinence can often be overcome by conservative programmes
COMMON MYTHS ABOUT INCONTINENCE 6 Fluid restriction is a good idea in managing incontinence Fluid restriction compromises bladder capacity and is best avoided
COMMON MYTHS ABOUT INCONTINENCE 7 The treatment of incontinence requires hospitalisation Most incontinence can be treated in the community
COMMON MYTHS ABOUT INCONTINENCE 8 An indwelling catheter will be an end to the problem Catheters create more problems than they solve and should be a last resort
AETIOLOGY Types of Incontinence 1 Stress Leaks with cough,sneeze,lifting or with physical exertion Cause of problem - Sphincter weakness
AETIOLOGY Types of Incontinence 2 Urge Leaks on the way to the toilet with urgent desire to void Cause of problem- Unstable bladder or Overactive Bladder (OAB)
Enuresis Wets bed during sleep Cause of problem- Unstable bladder AETIOLOGY Types of Incontinence 3
Giggle Wets pants AETIOLOGY Types of Incontinence 4 when giggling/ laughing Cause of problem- Unstable bladder
AETIOLOGY Types of Incontinence 5 Overflow Frequency, nocturia, UTI, dribbling+/- stress +/- urge incontinence Cause of problem- Incomplete emptying
Dribble Quiet leakage without warning or provocation Cause of problem- Sphincter weakness +/- unstable bladder or overflow AETIOLOGY Types of Incontinence 6
Continuous Never dry. Leaks all the time day and night Cause of the problem- Fistula, ectopic ureter, patulous urethra AETIOLOGY Types of Incontinence 7
Post-micturition dribble A few drops dribble out of the penis after voiding Cause of the problem- Bulbous urethral pooling of urine AETIOLOGY Types of Incontinence 8
AETIOLOGY Causes of Detrusor Instability(OAB) Physiological Neurological disorders Parkinson s disease, M.S., C.V.A., Dementia, Spinal injury Bladder outlet obstruction Severe Intravesical inflammation IC., CIS., Radiation cystitis Idiopathic
AETIOLOGY Causes of Sphincter Weakness Congenital Pregnancy Childbirth trauma to muscles or nerve supply Trauma-penetrating or surgical Obesity Chronic constipation Senile atrophy Oestrogen depletion Drug induced
ASSESSMENT Taking a History Direct approach is the best Onset/Precipitating event Fluid intake Drugs Constipation Locomotor problems Neurological symptoms Other urological symptoms Environmental factors
DRUGS WHICH CAUSE OR AGGRAVATE INCONTINENCE Make sure you are not prescribing INCONTINENCE Alpha blocking agents Phenoxybenzamine, Prazosin, Labetolol, Doxazocin, Indoramin Causes sphincter relaxation and STRESS INCONTINENCE
DRUGS WHICH CAUSE OR AGGRAVATE INCONTINENCE Make sure you are not prescribing INCONTINENCE Bladder Relaxants Anticholinergics agents, Tricyclic antidepressants Promote incomplete emptying and cause OVERFLOW INCONTINENCE
DRUGS WHICH CAUSE OR AGGRAVATE INCONTINENCE Make sure you are not prescribing INCONTINENCE Bladder stimulants Cholinergic agents, Caffiene, Acidifiers Enhance detrusor excitability and cause URGE INCONTINENCE or OVERACTIVE BLADDER
DRUGS WHICH CAUSE OR AGGRAVATE INCONTINENCE Make sure you are not prescribing INCONTINENCE Sedatives Antihistamines, Antidepressants, Antipsychotic agents, Tranquillisers & Hypnotics Cloud consciousness - less aware of bladder sensation and cause URGE INCONTINENCE
DRUGS WHICH CAUSE OR AGGRAVATE INCONTINENCE Make sure you are not prescribing INCONTINENCE Miscellaneous Alcohol-lowers central inhibition Loop diureticsincrease bladder filling rate Lithium-polydipsia Cause URGE INCONTINENCE /ENURESIS
ASSESSMENT EXAMINATION OF THE PATIENT CNS Abdomen Vaginal Rectal Urine culture Micturition chart Other investigations
FIRST STEPS IN THERAPY Micturition chart Urinalysis & culture Drug intake/fluid intake Constipation Teach pelvic floor exercises/deferment techniques Encourage fluid intake 2L/d & bladder training Check patient s motivation Consider onward referral if you fail
TREATMENT OF STRESS Conservative Weight loss Pelvic Floor exercises Electrostimulation Oestrogen Surgical Colposuspension Needle suspension Sling operation Collagen injection Artificial urinary sphincter INCONTINENCE
TREATMENT OF URGE INCONTINENCE Primary/Conservative Exclude infection Bladder training Drugs Secondary/Surgical Transvesical phenol Bladder transection Clam ileocystoplasty Replacement cystoplasty Diversion
DRUGS USED TO TREAT INCONTINENCE Urge Incontinence Anticholinergics Probanthine 15-30mg QID, Donnatabs 1 TID, Atrobel 1TID, Oxybutynin 5mg TID, Oxytrol Patches twice a week Competitive muscarinic acetylcholine receptor antagonist - Vesicare (Solifenacin) 5 mg or 10 mg od. Tricyclic antidepressants Imipramine 25-75mg nocte Calcium Channel Blocker Terodiline 12.5-25mg BD Miscellaneous Flavoxate 2 QID
DRUGS USED TO TREAT STRESS INCONTINENCE Oestrogens Topical or oral Alpha adrenergic agents Ephedrine/Pseudoephe drine 30 mg TID, Phenylpropanol-amine 50 mg TID, Mazindol 1mg BD & Midodrine
TREATMENT OF OVERFLOW INCONTINENCE Consider cause Bladder outlet Detrusor contractile dysfunction - Neurogenic, Myogenic, Psychogenic & Pharmacological. Confirm diagnosis by UDS Remove any outlet obstruction Alter any drug regimen if appropriate Manage voiding dysfunction - CIC/ IDC Review regularly
ENVIRONMENTAL FACTORS Distance to toilet- Urinal/Bedside commode Access to toiletcommode Need for assistance Never forget a UTI Timed toileting
DRUGS IN INCONTINENCE DRUGS THAT CAUSE INCONTINENCE * URINARY * FAECAL * BOTH DRUGS THAT CURE INCONTINENCE
DRUGS WHICH CAN CAUSE INCONTINENCE Drugs which can cause or contribute to incontinence are categorised under urinary, faecal and either/both. Make sure you are not prescribing INCONTINENCE.
DRUGS WHICH CAUSE/AGGRAVATE URINARY INCONTINENCE Alpha Blocking Agents such as Prazosin, Labetolol, Doxazocin, Indoramin and Phenoxybenzamine cause SPHINCTER RELAXATION and STRESS INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Polysynaptic inhibitors, Directacting skeletal muscle relaxants decrease SPHINCTER RESISTANCE and cause STRESS INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Centrally acting muscle relaxants cause a decrease in SPHINCTER RESISTANCE & /OR BLADDER CONTRACTILITY, OVERSEDATION - cause STRESS &/or OVERFLOW INCONTINECE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Acetylcoline-like agents, anticholinesterases, Prostaglandin E-2,F2 alpha cause INCREASED BLADDER CONTRACTILITY and URGE INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Atropine-like agents, Ganglionic blocking agents and Musculotropic relaxants decrease bladder contractility and cause OVERFLOW INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Calcium antagonists, Antihistamines, Theophylline, Phenothiazines, Phenytoin, Narcotics and Tricyclic antidepressants decrease bladder contractility and cause OVERFLOW INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Alpha adrenergic agonists, L-Dopa and Amphetamines increase sphincter resistance and cause OVERFLOW INCONTINENCE.
DRUGS THAT CAUSE/AGGRAVATE URINARY INCONTINENCE Caffiene causes diuresis and detrusor instability and causes URGE INCONTINENCE. Alcohol causes sedation and diuresis and causes URGE, NOCTURIA & RETENTION.
DRUGS THAT CAUSE FAECAL INCONTINENCE Narcotics, Analgesics, Anticholinergics cause constipation and result in IMPACTION WITH OVERFLOW. Chemotherepeutic drugs cause diarrhoea and result in URGE & FAECAL INCONTINENCE.
DRUGS THAT CAUSE & AGGRAVATE URINARY & OR FAECAL INCONTINENCE Sedatives cause NOCTURNAL ENURESIS, Tranquilisers cause URGE INCONTINENCE and hypnotics cause FAECAL INCONTINENCE.
DRUGS THAT TREAT INCONTINENCE Anticholinergic agents Probanthine 15-30 mg QID, Donnatabs 1 TID, Atrobel 1 TID & Oxybutynin 5mg TID or Oxytrol patches twice a week treat URGE INCONTINENCE. Anticholinergic agents are to be taken on an empty stomach to aid absorption. Dosage reduction may be necessary in the elderly and in neurogenic bladder dysfunction especially Multiple Sclerosis. Competitive muscarinic acetylcholine receptor antagonist - Vesicare (Solifenacin) 5 mg or 10 mg od.
DRUGS THAT TREAT INCONTINENCE Tricyclic Antidepressants like Imipramine 25-75mg nocte, Calcium channel blockers like Terodiline 12.5-25mg BD can be used to treat URGE INCONTINENCE.
DRUGS THAT TREAT INCONTINENCE Oestrogens - Oral and Topical and Alpha adrenergic agents such as Ephedrine/Pseudoephe drine 30mg TID, Phenylpropanolamine 50mg TID and Mazindol 1mg BD treat STRESS INCONTINENCE.