Bowel and bladder problems in the elderly

Question 1

Physiology of bladder control

Answer 1

Frontal lobe inhibition ensures bladder fills with sphincter closed – when inhibition stops the detrusor contracts due to input from stretch receptors in the bladder wall via sacral nerve roots and the pudendal nerve

Question 2

Control of the bladder outlet

Answer 2

Internal sphincter - A-adrenergic stimulation causes muscle contraction preventing flow of urine
External sphincter - striated muscle under voluntary control contracts to prevent flow

Question 3

Changes in bladder function with age

Answer 3

Bladder capacity falls and residual volume increases. Increased urine production at night and more uninhibited detrusor contractions —> decrease in internal sphincter tone in post-menopausal women
Women get weakness in pelvic floor and men get outflow obstruction by the prostate

Question 4

Prevalence of urinary incontience

Answer 4

Increases with age but women show an early peak at 45-49 and higher overall levels — varies with general health of the patient - Long term care>acute inpatients>community dwelling patients

Question 5

Types of urinary incontinence

Answer 5

Acute or transient incontinence
Functional incontinence
Overflow incontinence 
Stress incontinence
Urge Incontinence/Detrusor instability

Question 6

Causes of Acute or transient incontinence

Answer 6

DIAPPERS - delirium, infection, atrophic vaginitis, pharmacological, psychological, excess urine, reduced mobility, stool impaction

Question 7

Causes of Functional incontinence

Answer 7

Physical disability or mental health disability/illness

Stroke or dementia –> they could control it but they dont

Question 8

Causes of Overflow incontinence

Answer 8

outlet blockage causing increasing pressure and leaking

BPH, stricture, constipation or neuropathology of the bladder (DM, spinal cord disease or trauma)

Question 9

Causes of Stress incontinence

Answer 9

Weakness of the pelvic floor and/or the internal sphincter
Due to increased abdominal pressure (obesity or coughing) or weakness: weakness (multiparity or age) or sphincter dysfunction (post-menopausal)

Question 10

Causes of Urge Incontinence/Detrusor instability

Answer 10

Bladder over-sensitivity due to infection or neurological disorders (PD or stroke) - also age

Question 11

Symptoms of Acute or transient incontinence

Answer 11

May be none - Especially in older patients UTIs may not present with dysuria so incontinence may be the only sign – treatment is to treat underlying illness

Question 12

Symptoms of Functional incontinence

Answer 12

Unable/unaware/unmotivated to get to the toilet in time
May be combined with faecal incontience
Treat with MDT assessment and living aids

Question 13

Symptoms of Overflow incontinence

Answer 13

Hesitancy and straining when voiding, Incomplete evacuation, Frequent UTIs
Post-vid residual volume > 150ml

Question 14

Treatment of Overflow incontinence

Answer 14

TURP or other surgery if prostate aetiology
Drug therapy – including laxatives if constipated
Alpha blockers if due to BPH (tamsulosin/doxazosin)
Catheterisation - long term or intermittent

Question 15

Symptoms of stress incontinence

Answer 15

Leaks with sneezing, coughing and movement
No nocturia (lying down)

Question 16

Treatment of stress incontinence

Answer 16

Pelvic floor exercises, vaginal cones or pessaries
Weight loss, oestrogen creams. Surgery
Drugs –> Dloxetine - SNRI

Question 17

Treatment of Urge Incontinence/Detrusor instability

Answer 17

Anticholinergic drugs - Detrusitol or oxybutinin
Bladder retraining classes - 85% success in the community
Solifenacin (vesicare) – anti-muscarinic anti-cholinergic
Caffine irritates the bladder

Question 18

Symptoms of Urge Incontinence/Detrusor instability

Answer 18

Nocturia, increased frequency and urgency

Question 19

Pharmacological causes of urinary incontinence

Answer 19

Diuretics Sedatives
Anticholinergics (amitryptilline) ETOH
a-blockers (Doxazocin) CCBs
ACE inhibitors via cough

Question 20

Urodynamics in urinary incontinence

Answer 20

Normal in stress UI. Overflow UI - enlarged bladder capacity (>500ml), poor detrusor contractions, high post-void residual (PVR). Poor force and calibre of urine stream. Urge UI - uncontrolled detrusor contractions at low bladder volumes but normal PVR

Question 21

Types of Urinary Catheters

Answer 21

Short term - acute illness (<4/7), decompression in overflow UI or to avoid pressure sores with indwelling Cs. Intermittent - neuropath bladder (better than LT Cs). Chronic/LT - where retention causes renal damage/UTIs or pesistent overflow. In the terminally ill

Question 22

Colonic movement

Answer 22

Colon is constantly mobile to promote water reabsorption

Mass peristalsis occurs 2-3/day stimulated by gastrocolic reflex and physical exercise

Question 23

Physiology of bum control

Answer 23

Frontal lobe controls relaxation of external sphincter
As the rectum fills and when allowed by the cortex the rectal smooth muscle contracts while the internal and external sphincters relax

Question 24

Changes of lower gut function with age

Answer 24

Little necessary change with age – transit time is defined by level of activity and varies greatly
External sphincter may become weaker in older multiparous women

Question 25

Prevalence of faecal incontinence

Answer 25

Increases with age and health of the patient
3-10% of over 65yos — commonest reason for people to move LT care
80yr olds: 18% in community, 30% acute in-patients, 60% in residential care

Question 26

Types of faecal Incontinence

Answer 26

Overflow incontinence Dementia-related incontinence
Anorectal incontinence Symptomatic incontinence

Question 27

History of overflow faecal incontinence

Answer 27

Impacted stool and colon and/or rectum – commonest in the elderly
History – semi-solid, watery stool leaking - very frequency
New onset - may be related to opiates/loperamide/iron (wow)

Question 28

History of anorectal faecal incontinence

Answer 28

Pudendal nerve or external sphincter damage –> surgery, children, prolapse. Internal sphincter dyfunction – DM or spinal cord disease, being over 80. History of multiple small several times a day

Question 29

History of Dementia-related faecal incontinence

Answer 29

Due to lack of central inhibition of the anal sphincters – will pass 1-3 formed stools/day generally after eating

Question 30

Assessment and treatment of overflow faecal incontinence

Answer 30

DRE and abdominal exam – any signs of PD, CVA, DM, hypothyroid and dehydration – can use AXR if stool not palpable – colonoscopy or Ba enema if worried about Ca
Treat by removing stool impaction and treat underlying cause. Mobilise and increase fluid/fibre intake

Question 31

Assessment and treatment of anorectal faecal incontinence

Answer 31

On exam — prolapse and loss of tone on DRE

Treat – pelvic floor exercises, Loperamide (if not constipated), assess for surgery

Question 32

Treatment of Dementia-related faecal incontinence

Answer 32

Prompted or scheduled toileting - carer education and support
Careful skincare
Consider Pads

Question 33

Causes of Symptomatic incontinence

Answer 33

Caused by colorectal disease - will be acute with associated urgency
May be due gastroenteritis, CDT, IBD, lactose intolerance