Case 1 - Constipation and incontinence - WB and Case Flashcards
Common causes of constipation - general
- Lack exercise
- Lack fibre
- Dehydration
- Post-op pain
- IBS
- Old age
- Hospital environment - decreased privacy
Exam for constipation?
- Abdominal exam
- DRE - fissures, haemorrhoids anal sphincter tone prolapse?
Investigations for constipation
- FBC, ESR, U&E, Ca2+, TFT
- Colonoscopy if suspected malignancy
- Abdo X-ray - suspect obstruction?
- Threshold decreases with age for investigations
Causes of constipation anorectal disease
- Fissues
- Haemorrhoids
- Rectal prolapse
- Anal/rectal cancer
- Pelvic muscle dysfunction/levator ani syndrome
Causes of constipation obstruction
- Intestinal carcinoma
- Strictures eg Crohns
- Diverticulosis
Metabolic causes constipation
- Hypercalcaemia
- Hypokalaemia
- Hypothryoidism
- Lead poisioning
Drugs which can cause constipation
- Opiates
- Anticholinergics
- Iron supplements
- Antacids (eg with aliminium)
- Diuretics - furosemide
- CCBs
Management of severe constipation
- Stimulant such as senna ± a bulking agent is more effective
- 1st line NICE CKS = bulking eg Isphagula husk
- Add or switch to osmotic (eg macrogol or lactulose) if hard stool
- Add stimulant eg Bisacodyl/senna if soft
Factors contributing to incontinence
- Immobility
- Previous pregnancies/childbirth
- Overweight
- Post menopause
- Stroke/other neurological causes
- Constipation
3 most common types of incontinence
- Urge - urgency followed by leakage, can be complete or partial emptying of bladder
- Stress - when intrabdominal pressure rises, urine leaks, inadequate sphincter
- Functional - eg due to immobility or unfamiliar surroundings
Urgency incontience precipitated by…
- arriving home (latchkey incontinence a conditioned reflex);
- cold
- the sound of running water;
- caffeine
- obesity.
Medications that contribute to incontinence
- ACEi
- Diuretics
- Antidepressants
- HRT
- Sedatives
Medications that cause urinary retention
- Anticholinergics
- Opioids
- Anaesthetics
- Alpha agonists
- CCBs
- NSAIDs
- Benzodiazepines
Non pharmacological interventions for urinary incontinence
- Modify fluid intake
- Reduce caffeine intake
- Weight loss
- Stop smoking
- Avoid constipation
- Pelvic floor exercises - stress I
- Bladder training - urge
Common drugs used for urge incontinence and their class
- Oxybutynin, Solifenacin - Antimuscarinics
- Mirabegron - B3 agonist
- Intravaginal oestrogen
- Desmopressin - off label
Common drugs used to treat stress incontinence and class
- Duloxetine - SNRI
What is the type of incontinence that occurs with retention?
Overflow incontinence
Exams required for incontinence presentation
- Bladder and bowel diary review
- Abdo exam
- Urine dip and MSU
- PR exam - inc prostate assessment in males
- External genitalia review esp looking for atrophic vaginitis
- Post micturition bladder scan
What pharmacological drug is not good in older patients for incontinence
Antimuscarinics - Oxybutynin
Side effect of many drugs used to treat incontinence
Postural hypotension = increased falls risk
What kind of stool can cause impaction?
Hard and soft
Where can impaction occur?
Most often rectum but can be above
If clinical signs fit and rectum empty - be suspicious
What to do if patient is found to have full bladder on scan ie retention?
PR exam - assess for impacted rectum +/- large prostate
Examination of constipation
Abdo exam - faeces can sometimes be palpated
Risk of constipation
- Stercoral perforation
- Ischaemic bowel
Management constipation overall
- Enemas for rectal loading
- Stool softners
- Stimulants
- If stool hard - use softner
Some enemas do fall out if stool is hard
When is manual evacuation performed?
- Difficult cases and risk of perforation is outweighed by positive impact on patient sympotms and wellbeing
What should happen with all drugs that can cause constipation in elderly patinets?
Co-prescribe laxative!!
Why does faecal impaction occur more commonly in elderly?
- Anal sphincter can gape because of haemorrhoids and chronic constipation
- Cannot exert same intrabdominal pressure
When is it normal to have faeces in rectum?
Never - unless passing stool
Red flags for faecal incontinence
- Loss anal tone and sensation
- Suggests cord compression
Most common cause faecal incontinence
- Faecal impaction wiht overflow diarrhoea
- 2nd cause is neurogenic dysfunction
Exam for faecal incontinence
PR exam - rectum, prostate, anal tone and sensation
Visual inspection around anus too
Assess stool type if in rectum
Investigations chronic diarrhoea
- Bowel imaging
- Stool culture
- Rule out faecal impaction
Management chronic diarrhoea
Low dose loperamide (paeds doses) can be trialled
Then constipating and enema regimes can be used
