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19 Cards in this Set

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  • Back
What are the four basic categories of urinary incontinence?
1. Overflow
2. Stress
3. Urge
4. Functional

Keep in mind that mixed etiogies are common
What are the mechanisms and risk factors of OVERFLOW incontinence?
1. Outlet obstruction BPH or stricture
2. Decreased Bladder contractility
3. Diabetic neuropathy
What are the characteristic symptoms of OVERFLOW incontinence?
Hesitancy, dribbling, small-volume leakage

In this condition, patients never feel the urge to urinate, the bladder never empties, and small amounts of urine leak continuously. Overflow incontinence is prevalent in older men with an enlarged prostate and is rare in women.
What are treatments of OVERFLOW incontinence?
1. Avoid anticholinergic agents
2. For BPH, alpha-blockers, finasteride, saw palmetto, TURP
3. For stricture, urethral dilation.
What are the mechanisms and risk factors of STRESS incontinence?
1. Weak sphincter
2. Altered pelvic muscle strength
3. Multiple childbirth
4. Vaginal atrophy
What are the characteristic symptoms of STRESS incontinence?
1. Exacerbated by cough, laugh, bending
2. Small-volume leakage
What are the treatments for STRESS incontinence?
1. Pelvic muscle exercises
2. Pessary
3. Periurethral collagen injections
4. Surgery
5. alpha-agonists (imipramine effective by its alpha-agonist effect)
6. imipramine
7. estrogen (used historically, but recent data show little or no benefit)
What are the mechanisms and risk factors for URGE incontinence?
1. Detrusor hyperreflexia: Decreased CNS inhibition, Parkinson's, stroke

2. Detrusor overactivity: Increased bladder contraction, UTI, renal stone, outlet obstruction
What are the characteristic symptoms of URGE incontinence?
1. Sudden urge
2. Large-volume leakage
What are the treatments for URGE incontinence?
1. Avoid irritants (caffeine, alcohol)
2. Scheduled voiding
3. Anticholinergic agents (oxybutynin, imipramine)
4. Antispasmodic agents (dicyclomine, propantheline).
What are the mechanisms and risk factors for FUNCTIONAL incontinence?
1. Physical impairment
2. Cognitive impairment
What are the characteristic symptoms for FUNCTIONAL incontinence?
1. Inability to get to toilet
2. Large-volume leakage
What are the treatments for FUNCTIONAL incontinence?
1. Adapt environment
2. Commode, urinal, condom catheter
3. Schedule voiding
Remember reversible causes of incontinence with the mneumonic DRIP. These often occur suddenly and are usually treatable.
D: drugs, delirium
R: restricted mobility, retention
I: infection, fecal impaction
P: polyuric states, such as CHF, diabetes
Frequently implicated drugs that cause acute incontinence include:
1.
2.
3.
Frequently implicated drugs that cause acute incontinence include:
1. diuretics
2. anticholinergic agents that impair bladder contractility
3. narcotics
Isolated ______________ is often caused by volume overload states (CHF, lower extremity edema) due to the diuresis that occurs with recumbence.
Isolated NOCTURNAL INCONTINENCE is often caused by volume overload states (CHF, lower extremity edema) due to the diuresis that occurs with recumbence.
What is the best way to discern the cause of my patients incontinence?

Inquire about timing and volume of urine loss and about specific symptoms related to urge or stress incontinence, outlet obstruction, and functional problems.

If incontinence is new or suddenly worse, consider _____ causes.

Because the bladder control reflex arc is located at __________ , focus the examination on relevant neurologic evaluation of sacral dermatomes and lower extremity function. Perform rectal exam (atrophy, vaginitis, prolapse).

Assess for volume-over-load state, cognitive impairment and/or physical impairment.

Obtain urinalysis, glucose, BUN/creatine, and calcium.

Obtain postvoid residual (PVR) - greater than ______ is likely overflow (ie. outlet obstruction), whereas less than 100 mL is likely ____ or _______ incontinence.
What is the best way to discern the cause of my patients incontinence?

Inquire about timing and volume of urine loss and about specific symptoms related to urge or stress incontinence, outlet obstruction, and functional problems.

If incontinence is new or suddenly worse, consider DRIP causes.

Because the bladder control reflex arc is located at S2-S4, focus the examination on relevant neurologic evaluation of sacral dermatomes and lower extremity function.

Perform rectal exam (atrophy, vaginitis, prolapse).

Assess for volume-over-load state, cognitive impairment and/or physical impairment.

Obtain urinalysis, glucose, BUN/creatine, and calcium.

Obtain postvoid residual (PVR) - greater than 100 mL is likely overflow (ie. outlet obstruction), whereas less than 100 mL is likely URGE or STRESS incontinence.
What are common nonpharmacologic treatment approaches to incontinence?

More than 50% of patients are cured and most others are markedly improved with standard therapies.

Nonpharmacologic interventions include scheduled voids, bladder training (Kegel exercises to strengthen pelvic muscles as well as biofeedback and imagery to decrease urges), addressing mobility issues, and adult protective garments. Somtimes, surgery is helpful.

Refer to urology for _______, PVR greater than ______, prostate _______, uterine _______ , or unclear diagnosis after initial evaluation and/or empiric therapy fails.
What are common nonpharmacologic treatment approaches to incontinence?

More than 50% of patients are cured and most others are markedly improved with standard therapies.

Nonpharmacologic interventions include scheduled voids, bladder training (Kegel exercises to strengthen pelvic muscles as well as biofeedback and imagery to decrease urges), addressing mobility issues, and adult protective garments. Somtimes, surgery is helpful.

Refer to urology for HEMATURIA, PVR greater than 100 mL, prostate NODULE, uterine PROLAPSE, or unclear diagnosis after initial evaluation and/or empiric therapy fails.
What medicines work to improve urinary incontinence?

Medications for incontinence act at cholinergic receptor, which cause bladder ________ (overactive in those with urge and underactive for those with bladder overflow incontinence).

For urge incontinence, anticholinergics ________ and ________ block stimulation of the bladder muscle and have the best efficacy. Anticholinergic side effects (_______ , ________ ) may limit its use, especially in elderly patients. Other agents to try include dicyclomine, propantheline, and imipramine.

Imipramine may also improve sphincter tone by its alpha-agonist effect in patients with stress incontinence and is a reasonable agent to try for mixed stress and urge incontinence.

There are no medications that help overflow incontinence. Avoid anticholinergic medications that may decrease bladder tone and worsen obstruction.
What medicines work to improve urinary incontinence?

Medications for incontinence act at cholinergic receptor, which cause bladder CONTRACTION (overactive in those with urge and underactive for those with bladder overflow incontinence).

For urge incontinence, anticholinergics OXYBUTYNIN and TOLTERIDINE block stimulation of the bladder muscle and have the best efficacy. Anticholinergic side effects (DRY MOUTH, CONFUSION) may limit its use, especially in elderly patients. Other agents to try include dicyclomine, propantheline, and imipramine.

Imipramine may also improve sphincter tone by its alpha-agonist effect in patients with stress incontinence and is a reasonable agent to try for mixed stress and urge incontinence.

There are no medications that help overflow incontinence. Avoid anticholinergic medications that may decrease bladder tone and worsen obstruction.