8 - Incontinence and Constipation Flashcards
What is the epidemiology of urinary incontinence?
F > M
2 in 5 F over 60 have UIc
What maintains continence?
Bladder
Urethra
Pelvic floor muscles
Nervous system
Continence is maintained as long as uretheral pressure > bladder pressure
How does voiding of the bladder occur?
Voluntary relaxation of the striated muscle around the urethra
AND
Increase in bladder pressure - due to contraction of detrusor muscle via PSS
What is the most important thing regarding elderly patients and bowel opening?
Whether they can pass motions easily - not frequency of defecation.
What things can cause constipation in elderly Ps?
Faulty habits (poor diet, low fluid intake, lack of exercise, holding on)
Poor appetitie
Immobility
Drugs
Metabolic disease (DM, hypothyroid, hypercalcaemia, hypokalaemia, hypomagnesaemia)
Psychiatric causes - depression, dementia
IBS
Pain (piles, fissures)
Neurological issues (Parkinsons, spinal cord injury, MS and cerebrovascular disease)
How do you manage constipation in the elderly?
Identify nature and duration
Look for any cause
DRE
If impaction - enema
If not impacted - think stimulant (Senna) or osmotic laxative (mag sulphate)
ST - ensure adequate fluids & mobilise
What can you prescribe for small hard stools in association with opioids?
One of:
Co-danthrusate / Co-danthramer
Macrogols
Liquid paraffin
Magnesium hydroxide emlulsion
How can you treat severe constipation in bed bound Ps?
Manual evacuation
What can you prescribe for long-term treatment?
Macrogol or ispaghula husk
When is lactulose used? (Expensive!)
Hepatic encephalopathy
What are the potential complications of constipation in the elderly?
Faecal impaction
Overflow diarrhoea
Obstruction
Perforation
Megacolon -> sigmoid volvulus or rectal prolapse
Urinary retention –> Delirium
Which group of elderly Ps have the highest incidence of faecal incontinence? Patients who are in:
- Community-dwelling
- Residential homes
- Nursing homes
Nursing home residents
What do you need to ask a P with faecal incontinence?
Examine their fluid and food intake
Hx of GI or neurological disease?
Medications
PSHx - especially obstetric or rectal
How can you treat faecal incontinence in Ps with disinhibition or dementia?
Bulking preparations and regular toileting
Treat underlying cause if possible
What medical Tx can be given for faecal incontinence in frail older Ps?
Codeine phosphate (to cause constipation) with enemas at regular intervalsYou
Anal plugs to block rectum for short periods
What obstetric issues can cause faecal incontinence?
Third degree tear
Instrumental delivery
Damage to pudendal nerve
What colorectal diseases can cause weakness of the internal anal sphincter
Rectal prolapse
Haemorrhoids
IBD
Tumour
What neurological issues can cause faecal incontinence?
Parkinsons
Stroke
Spinal cord injury
Diabetic autonomic neuropathy
What percentage of prostates have hyperplasia by the age of
- 60
- 85
60 = 50%
85 = 90%
What causes cellular proliferation in the prostate?
5 α reductase - converts testosterone to dihydrotestosterone (DHT) - which causes cellular proliferation in the prostate
Which symptoms count as LUTS?
Frequency
Urgency
Dysuria
Nocturia
Poor stream
Hesitancy
Dribbling
Incomplete Voiding
Overflow incontinence
Which type drugs can be used in men to treat urinary obstruction caused by BPH?
Why is this class used?
α-adrenoreceptor antagonists
Muscle in the bladder which prevents micturition is controlled by α adrenoreceptors. Using a blocker of these receptors allows the muscle to relax to allow micturition.
Name a drug which is an α adrenoreceptor antagonist?
Tamsulosin
Doxazosin
Terazosin
What is the difference between tamsulosin AND doxazosin/terazosin?
Tamsulosin = more alpha1 specificity - thus causes less orthostatic hypotension
Which treatment is the mainstay treatment for symptomatic BPH?
TURP = transurethral prostatectomy
What complications can arise from a TURP procedure?
Perioperative haemorrhage
Absorption of irrigative fluids - can cause electrolyte imbalances
Urethral strictures
Incontinence
What is stress incontinence?
When urine leaks from the bladder due to higher pressures than the pelvic muscles are able to contain - e.g. on coughing, laughing etc
What is urge incontinence?
What are the symptoms?
When the P feels the need to urgently empty the bladder when it is not actually full. P is unable to prevent involuntary bladder contractions.
Symptoms = frequency, urgency and nocturia (always rule out UTI)
How is urge incontinence managed?
Conservative measures - avoiding irritants including dehydration, and bladder training.
Can use antimuscarinics.
What are the side effects of antimuscarinics?
Dry mouth, dry eyes, constipation, confusion.
Β-3 agonists (mirabegron) can be used as second line therapy for urge incontinence. What is the potential adverse effect of these?
Accelerated hypertension
What are the symptoms of overflow incontinence?
Difficulty initiating micturition
Poor stream
Terminal dribbling
What are the potential complications of overflow incontinence?
Renal failure due to obstructive uropathy
What is functional incontinence?
P is unable to reach the toilet in time, rather than there being a primary urogenital problem.
Which nervous systems control micturition?
Somatic and autonomic nervous systems
Which park of the brain provides voluntary control of micturition?
Frontal cortex
What coordinates detrusor contraction with urethral relaxation? Where is this found?
Pontine micturition centre
Found in the midbrain
Which nervous system mediates bladder contraction?
Where do these nerves originate from?
PSS
Originate from sacral plexus (S2-S4)
Which nervous system mediates bladder filling?
Where do these nerves arise from?
SS
Nerves arise from T11 - L2 - innervate smooth muscle of bladder neck and proximal urethra = contraction
Excitation of which nerve causes contractions of the external urethral sphincter (= voluntary control)
Pudendal nerve
What are the causes of urge incontinence?
Idiopathic (most common)
Neurogenic
Infective
Bladder outlet obstruction
Which neurological conditions can cause urge incontinence?
MS
Parkinsons
Stroke
Spinal cord injury
What are the RF for stress incontinence?
F
Age
Childbirth
Previous pelvic surgery
Neurological disease
UTI
Post-menopausal
Post-hysterectomy
Bladder outlet obstruction
What is mixed incontinence?
A combination of urge and stress
What is outflow obstruction?
Obstruction of the ureter preventing voiding of the bladder. Can have residual urine in the bladder after voiding.
What are the causes of outflow obstruction?
Phimosis
BPH
Stricture
Trauma
Blood clot
Calculi
Cancer
STIs
How do the following drugs put you at risk of urinary continence issues?
Diuretics
Anticholinergics
Sedatives
Alpha blockers
Alpha agonists
ACEi
Cholinesterase inhibitors
Ca channel blockers
Oestrogen deficiency
Diuretics – increase volume of urine
Anticholinergics – may precipitate poor bladder emptying or retention
Sedatives – may reduce awareness of need to pass urine and increase confusion
Alpha blockers – relax bladder outlet, may worsen SI
Alpha agonists – urinary retention, may lead to overflow
ACEi – chronic cough (bradykinin) may worsen SI
Cholinesterase inhibitors – increase bladder contraction
Ca channel blockers – decrease smooth muscle contractility
Oestrogen deficiency – very common in elderly women, causes urinary urgency
How can you treat vaginal atrophy?
Topical oestrogens
What are red flag symptoms for LUTS?
Haematuria
Persistent UTI
Constitutional symptoms
Poor renal function
Abnormal neurology including saddle anaesthesia
Recent back trauma or pelvic surgery
What type of urinary symptoms are these?
Hesitancy
Poor stream
Intermittent flow
Incomplete emptying (with associated frequency)(
Postvoid dribbling
Overflow incontinence
Obstructive / Voiding symptoms
What type of urinary symptoms are these?
Frequency
Nocturia
Urgency
Urgency incontinence
Storage symptoms
How is pelvic floor muscle strength assessed during a DRE?
Oxford classification of strength and function scale of 0 - 5
0 – no contraction
1 – flicker
2 – weak
3 – moderate
4 – good
5 – strong contraction
How can you test the following nerves to make sure that they aren’t affecting micturition?
S3
L1-2
S1
S3 = dorsiflexion of foot and sensation of posterior thigh
L1-2 = perianal sensation
S1 = sensation of sole of the foot
What do we need to rule out with imaging in Ps struggling with incontinence?
Chronic retention
Causes of renal failure / recurrent UTI
Masses, renal stones
How much of your urine is produced at night?
1/3
What is the definition of polyuria?
> 2500 pls per day
What things do we look for with urinalysis?
Glucose (diabetes)
Protein (primary kidney pathology)
Blood(stones or malignancy)
Leucocytes/nitrites (infection, although this is less sensitive in the elderly)
With continence problems - what do we look for in the bloods?
Bloods:
FBC – leucocytosis (infection)
U&Es – assess renal function
Glucose/HbA1c – assess for diabetes
Calcium – hypercalcaemia can cause constipation and confusion; both transient causes of incontinence
What is a USS abdomen used for with urinary problems?
To evaluate kidney size (?renal failure) and look for signs of obstructive uropathy
What is a CT urography / IV urogram used for?
Identifying the presence of renal stones
What is a CT abdomen used for?
Excluding abdominal or pelvic masses if there is a clinical suspicion.
What is uroflowmetry?
Used for measuring urinary flow rate - measured total voided volume against flow time.
Can be used to diagnose bladder outlet obstruction
What does cystometry do?
Measures bladder pressure, sensation, capacity and compliance during filling and voiding.
- Detrusor contractions at low volumes = urge incontinence
Voiding on increase in abdominal pressure = stress incontinence
What are the 4 types of management for urinary issues?
Lifestyle advice / education
MDT - non-pharmalogical
Pharmacological
Surgical
How can stress incontinence be managed?
Lifestyle:
Smoking cessation
Weight reduction
Managing constipation
Reduce alcohol and caffeine intake
Surgical:
Mid-urethral sling insertion
Colposuspension
MDT
Continence advisor referral
Pelvic floor exercises
Vaginal cone
Medical:
Duloxetine (can be offered as second line if preferred to, or patient not suitable for surgical treatment)
How can urge incontinence be managed?
Lifestyle:
Reduced fluid intake (especially in evening)
Reduce caffeine and alcohol
Weight reduction
Manage constipation
Medical:
Anticholinergics (antimuscarinics)
Intravaginal oestrogens
MDT:
Community continence advisor
Bladder retraining
Pelvic floor exercises
Surgical:
Sacral nerve stimulation
Botulinum toxin (injected into detrusor muscle to decrease contractility)
How do anti-muscarinic drugs affect the bladder?
They act on M3 receptors in the detrusor muscle to reduce contraction
How can anticholinergic drugs (antimuscarinic) affect the elderly?
They can precipitate falls and increase confusion
What re the side effects of antimuscarinics?
Brain – cognitive impairment, hallucinations
Eyes – blurred vision
Salivary glands – dry mouth
Heart – tachycardia
GI tract – nausea, constipation
Urinary system – urinary retention
What type of medications are these:
oxybutynin, tolterodine, solifenacin, trospium
Antimuscarinics
What are the two types of medical treatment for BPH?
Α blockers (doxazosin, tamsulosin) reduces smooth muscle tone in the prostate
5-α reductase inhibitors - finasteride (reduces prostate volume by preventing conversion of testosterone to DHT)
Name two types of surgical procedures for BPH
TURP - transurethral resection of the prostate
HoLEP - transurethral laser enucleation
How long must symptoms be present for to qualify as chronic constipation?
3 months
Which medications can cause constipation?
Antacids (that contain Al and Ca)
Anticholinergics
Antispasmodics
Anticonvulsants
Ca Channel Blocerks
Diuretics
Iron Supplements
PD meds
Opioids
What is the definition of constipation?
BO < 3x per week +/- associated with excessive straining, abdominal pain / discomfort / distension / bloating
What can be signs of constipation in elderly Ps?
confusion, delirium
functional decline
nausea / anorexia
overflow diarrhoea
urinary retention
What are red flags for constipation?
Sudden change in bowel habit
Rectal bleeding / blood in stools
Weight loss
Abdo pain
Iron deficiency anaemia
When examining a patient with constipation - what do you look for in a DRE?
Fissures
Haemorrhoids
Skin tags
Prolapse
Rectocele
Skin erythema / excoriation
Leakage of stool
Tone of anus
What blood tests do you need to look at with constipation?
Bloods for anaemia, hypothyroidism, hypercalcaemia, coeliac disease
What investigations can you order for constipation?
Stool sample
Colonoscopy / flexible sigmoidoscopy
CT AP
How can you manage constipation?
Inc fluids and fibre
Inc mobilisation
Sort out impaction if present
Name a drug for the following:
- Bulk forming laxative
- Osmotic laxative
- Stimulant laxative
- Stool softener
Bulk forming - Ispaghula hulk
Osmotic - Macrogol, Lactulose
Stimulant - Senna
Softener - Sodium docusate
What type of laxative should you consider for opioid-induced constipation?
What should you NOT give?
Give osmotic and stimulant laxatives
Do not give bulk-forming!
What can you consider giving if at least 2 laxatives from different classes have been tried at highest recommended dose for at least 6m, but have failed to relieve the constipation?
Prucalopride
What is special about the trigone area?
Is from a different embryological origin to the rest of the bladder - contains nerves that are sensitive to stretch - gives the urge of the need to wee.
Histologically - why can some Ps be more prone to UTIs?
Their transition cell epithelium lining of the bladder may have a glycosaminoglycan (GAG) deficiency
Which nerves control micturition?
PSS via S2-4 = pudendal nerve
Somatic supply - S2-4 as well - controls urethral sphincter
Which nerve receptors are found in the bladder?
M3 receptors - for PSS and somatic supply - when stimulated they cause contraction of the bladder.
Β-3 receptors (NOR) - for SS - cause relaxation of the bladder. Found in the body of the bladder.
α receptors - found in neck of bladder and urethra - when stimulated they cause contraction.
Which anticholinergics can be used for the bladder?
Oxybutynin
Solifenacin
Name a drug that is a β 3 agonist for the bladder?
Mirabegron
Which drug is a nicotinic agonist for the external urethral sphincter that is used for leakage?
Duloxetine
Why do infections cause diarrhoea?
Basically - there is a loss of absorptive area - can be due to cell death (toxins, ion channel disruption), inflammatory response, inc permeability of epithelium –> fluid and electrolyte loss
When do you do stool microscopy on a P with diarrhoea?
If the Ps is very unwell, there is blood/pus in the stool, recent ABs, foreign travel or IC P.
What is lost in diarrhoea?
H20, Na, HCO3 and K
Can cause dehydration, hypokalaemia and acidosis.
What causes acidosis with diarrhoea?
AKI - less perfusion of kidney = HC03 loss
Which drugs can cause diarrhoea?
Metformin
ACEIs
Omeprazole
Laxatives
If the pancreas fails - how does this affect stools?
Can cause steatorrhea due to lack of absorption of fats from lack of bile salts
What are the causes of urinary incontinence?
Mixed (urge & stress)
Outflow obstruction
Abnormal communication of urinary tract
Overflow
Functional - inability to reach the toilet
Which medical conditions can cause urinary incontinence?
UTIs
Oestrogen deficiency
DM
Neurological - MS, stroke, cauda equina, previous pregnancy w/difficult delivery
Which medications can cause urinary incontinence?
What are transient causes of incontinence?
What are red flag Sx for incontinence?
Haematuria
Persistent UTI
Constitutional Sx
Poor renal function
Abnormal neurology - inc saddle anaesthesia
Recent back trauma or pelvic surgery
Which nerves allow bladder filling?
T11 - L2 (also responsible for perianal sensation)
Which nerves innervate detrusor muscle contraction?
S2-S4
How is stress incontinence managed?
Which medication can be given for stress incontinence?
Duloxetine
How is urge incontinence managed?
Which drug is used for urge incontinence?
Anti-cholinergics
E.g. Solifenacin
What are the SEs of solifenacin?
Cognitive impairment
Blurred vision
Dry mouth
Tachycardia
Nausea, constipation
Urinary retention
Which drugs are given for bladder outlet obstruction caused by BPH?
Doxazosin
Tamsulosin (both α blockers)
Finasteride (5-α reductase)
How do α blockers work for bladder obstruction?
Relax smooth muscle tone in the prostate
How does finasteride work for bladder obstruction?
5-α reductase inhibitor
Blocks conversion of testosterone to dihydrotestosterone - limiting growth of prostate.
What surgical procedures can be performed for BPH?
TURP
HoLEP
How long do Sx have to be present for chronic constipation?
3m
What conditions are associated with constipation?
Coeliac diease
Parkinsons
Spinal cord / brain injury
DM
Hypothyroid
Inflammation - diverticular disease
Intestinal obstruction
Which medications can cause constipation?
Antacids
Anticholinergics
Antispasmodics
Anticonvulsants
Ca Channel blockers
Diuretics
Iron supplements
PD meds
Opioids
What are the Sx of constipation?
What are the red flags for constipation?
SCIBH
Rectal bleeding / bloody stools
Weight loss
Abdo pain
IDA
What investigations can you do for constipation?
How is constipation managed?
What is first line laxative for constipation?
Ispaghula husk - BUT require adequate fluid intake which can be challenging in elderly Ps
In elderly Ps - what is often given first line for constipation?
Osmotic laxatives - Macrogol, Lactulose
If P finds stool difficult to pass, hard or incomplete emptying - what should be prescribed?
Senna (stimulant)
Sodium docusate (stool softener)
What should you give for opioid induced constipation?
Osmotic + Stimulant
NEVER bulk forming
