Bowel and bladder problems in the elderly Flashcards
Physiology of bladder control
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
Control of the bladder outlet
Internal sphincter - A-adrenergic stimulation causes muscle contraction preventing flow of urine
External sphincter - striated muscle under voluntary control contracts to prevent flow
Changes in bladder function with age
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
Prevalence of urinary incontience
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
Types of urinary incontinence
Acute or transient incontinence Functional incontinence Overflow incontinence Stress incontinence Urge Incontinence/Detrusor instability
Causes of Acute or transient incontinence
DIAPPERS - delirium, infection, atrophic vaginitis, pharmacological, psychological, excess urine, reduced mobility, stool impaction
Causes of Functional incontinence
Physical disability or mental health disability/illness
Stroke or dementia –> they could control it but they dont
Causes of Overflow incontinence
outlet blockage causing increasing pressure and leaking
BPH, stricture, constipation or neuropathology of the bladder (DM, spinal cord disease or trauma)
Causes of Stress incontinence
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)
Causes of Urge Incontinence/Detrusor instability
Bladder over-sensitivity due to infection or neurological disorders (PD or stroke) - also age
Symptoms of Acute or transient incontinence
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
Symptoms of Functional incontinence
Unable/unaware/unmotivated to get to the toilet in time
May be combined with faecal incontience
Treat with MDT assessment and living aids
Symptoms of Overflow incontinence
Hesitancy and straining when voiding, Incomplete evacuation, Frequent UTIs
Post-vid residual volume > 150ml
Treatment of Overflow incontinence
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
Symptoms of stress incontinence
Leaks with sneezing, coughing and movement No nocturia (lying down)
Treatment of stress incontinence
Pelvic floor exercises, vaginal cones or pessaries
Weight loss, oestrogen creams. Surgery
Drugs –> Dloxetine - SNRI
Treatment of Urge Incontinence/Detrusor instability
Anticholinergic drugs - Detrusitol or oxybutinin
Bladder retraining classes - 85% success in the community
Solifenacin (vesicare) – anti-muscarinic anti-cholinergic
Caffine irritates the bladder
Symptoms of Urge Incontinence/Detrusor instability
Nocturia, increased frequency and urgency
Pharmacological causes of urinary incontinence
Diuretics Sedatives
Anticholinergics (amitryptilline) ETOH
a-blockers (Doxazocin) CCBs
ACE inhibitors via cough
Urodynamics in urinary incontinence
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
Types of Urinary Catheters
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
Colonic movement
Colon is constantly mobile to promote water reabsorption
Mass peristalsis occurs 2-3/day stimulated by gastrocolic reflex and physical exercise
Physiology of bum control
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
Changes of lower gut function with age
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
Prevalence of faecal incontinence
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
Types of faecal Incontinence
Overflow incontinence Dementia-related incontinence
Anorectal incontinence Symptomatic incontinence
History of overflow faecal incontinence
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)
History of anorectal faecal incontinence
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
History of Dementia-related faecal incontinence
Due to lack of central inhibition of the anal sphincters – will pass 1-3 formed stools/day generally after eating
Assessment and treatment of overflow faecal incontinence
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
Assessment and treatment of anorectal faecal incontinence
On exam — prolapse and loss of tone on DRE
Treat – pelvic floor exercises, Loperamide (if not constipated), assess for surgery
Treatment of Dementia-related faecal incontinence
Prompted or scheduled toileting - carer education and support
Careful skincare
Consider Pads
Causes of Symptomatic incontinence
Caused by colorectal disease - will be acute with associated urgency
May be due gastroenteritis, CDT, IBD, lactose intolerance
