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Geriatrics > Continence > Flashcards

Continence Flashcards

1
Q

What is the prevalence of incontinence?

A

34% in women
20-30% in young adults
30-40% in middle age
30-50% in older adults

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2
Q

Incontinence is a major cause of morbidity, what is it linked with?

A

Functional decline
Hospitalisation
Nursing home placement
Death

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3
Q

What is the prevalence of urinary incontinence in nursing homes?

A

70%

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4
Q

What percentage of people with dementia in institutional care are affected by incontinence?

A

84%

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5
Q

Why might the numbers of people with incontinence be inaccurate?

A

People can be embarrassed and unwilling to present to their doctor for help, so not everyone with incontinence will be known

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6
Q

What are the classifications of urinary incontinence?

A

Stress incontinence
Urge incontinence (overactive bladder)
Overflow incontinence
Mixed incontinence

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7
Q

What is urinary incontinence?

A

Unintentional passing of urine

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8
Q

What is bladder control dependent on?

A 
Functioning bladder 
Functioning sphincters 
Cognition 
Mobility 
Dexterity 
Environment
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9
Q

What is the musculature of the bladder/urinary tract?

A

Detrusor muscle - smooth muscle, involuntary
Internal urethral sphincter - smooth muscle, involuntary
External urethral sphincter - striated muscle, voluntary

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10
Q

What is the parasympathetic innervation of the bladder?

A

Muscarinic receptors
S2-S4
Cause detrusor muscle contraction

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11
Q

What is the sympathetic innervation of the bladder?

A

T10-L2, beta-2 adrenoceptors
Cause detrusor muscle relaxation

T10-S2, alpha adrenoceptors
Cause internal sphincter contraction

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12
Q

How does reflex urination occur (spontaneous)?

A

Stretch receptors in wall of bladder stimulated by expanding bladder
Feedback to spinal cord
Parasympathetic nerves stimulated
Detrusor muscle contracts

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13
Q

When does the internal urethral sphincter usually open?

A

When bladder is half full

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14
Q

How is urination controlled by higher centres?

A

Pontine micturition centre - blocks the parasympathetic actions and leads to detrusor relaxation, and so storage of urine
Frontal cortex exerts overall control, allowing voluntary voiding of urine

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15
Q

What is the typical presentation of stress incontinence?

A

Urine typically leaks with increased abdominal pressure e.g. laughing, coughing, sneezing, standing up

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16
Q

What are typically weak in stress incontinence?

A

Outlet from the bladder - weak external sphincter and weak pelvic floor muscles

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17
Q

In what sex is stress incontinence more common?

A

Women, particularly those who have had children and after menopause

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18
Q

What is the typical presentation of urge incontinence?

A

Incontinence associated with the sudden urge to pass urine which cannot be delayed
Frequency a common symptoms
Nocturnal incontinence common

19
Q

What happens to the detrusor muscle in urge incontinence?

A

Detrusor muscle instability leading to bladder overactivity

20
Q

When does the bladder contract in urge incontinence?

A

With low urine volumes

21
Q

What is urge incontinence due to?

A

Upper motor neurone lesion or detrusor muscle disorder

22
Q

What is the typical presentation of overflow incontinence?

A

Urine is retained in the bladder with subsequent overflow
Hesitancy
Reduced stream
Post-micturition dribbling

23
Q

What is often the cause of overflow incontinence?

A

Bladder outlet obstruction e.g. prostatic hypertrophy, tumour

24
Q

What is important in the history of a patient with incontinence?

A

Type of incontinence (allows you to direct the management)
Any contributing factors, intrinsic and extrinsic
How the symptoms affect the patient
Drug history e.g. anticholinergics, diuretics, alpha-adrenergic blockers

25
Q

For how long should a bladder diary be taken in an incontinent patient?

A

For 3 days, over working and non-working days, or over various days in patients who are not working
Volume of fluid taken in
Volume of urine excreted
Any episodes of incontinence

26
Q

What examination may be necessary in a patient with incontinence?

A 
Abdominal
Vaginal 
Rectal
Determine strength of pelvic floor muscles
Assess for constipation 
Assess for prolapse 
Assess size of prostate
27
Q

What investigations, other than history and physical examination, might be necessary in a patient with incontinence?

A

Urinalysis
MSSU
Bladder scan - check residual volume, pre and post-void
Urodynamics - cystometry, uroflowmetry

28
Q

What is the general management of incontinence?

A 
Weight control 
Fluid control - volume and type
Reduce bladder irritants e.g. caffeine, fruit juice, alcohol 
Pelvic floor exercises
Bladder retraining
29
Q

When should pads be used?

A

Should not be used as a treatment, but may have a place as a coping strategy

30
Q

What pelvic floor exercises should be recommended for stress incontinence treatment?

A

Minimum of 8 contractions, 3 times a day

Fast (1 second) and slow (10 second) contractions

31
Q

How long should pelvic floor exercises for stress incontinence be done?

A

Will take 3 months to work initially but should be continued lifelong

32
Q

What can be used as aids in pelvic floor exercises?

A

Biofeedback
Vaginal cones
Electrical stimulation (where patient cannot actively contract pelvic floor muscles)

33
Q

What surgery can be done for stress incontinence treatment?

A

Colposuspension

TVT tape

34
Q

What is the first line treatment for urge and mixed incontinence?

A

Bladder retraining programme

Prompted, regular toileting

35
Q

How long should a bladder retraining programme for urge incontinence be done for?

A

Minimum of 6 weeks

36
Q

What medications can be used to treat urge incontinence?

A

Anticholinergics e.g. oxybutynin, tolderodine, solifenacin

Beta-3 adrenoceptor agonist e.g. mirabegron

37
Q

What are the potential side effects of anticholinergics?

A 
Cognitive impairment 
Dry mouth 
Constipation 
Blurred vision 
Postural hypotension
Drowsiness
Urinary retention
38
Q

What specific treatments are there for urge incontinence?

A 
Bladder retraining programme
Prompted, regular toileting
Medications
Botulinum toxin 
Sacral nerve stimulation
39
Q

How does botulinum toxin help urge incontinence?

A

Relaxes detrusor muscle

40
Q

What are the specific treatments for overflow incontinence?

A

Relieve the obstruction
Relax the sphincter
Bypass the obstruction

41
Q

What can be done to relieve an obstruction causing overflow incontinence?

A

Anti-androgen to shrink prostate e.g. finasteride

TURP

42
Q

What can be given to relax the sphincter in overflow incontinence?

A

Alpha-blocker e.g. tamsulosin, doxazocin

43
Q

When should urinary catheters be used?

A

As a last resort

Criteria;
Symptomatic urinary retention
Bladder outflow tract obstruction, otherwise unable to clear
Undue stress caused by alternative management in the elderly, frail or dying

44
Q

What is preferred, in terms of catheterisation, especially with urge incontinence?

A

Intermittent self-catheterisation

Geriatrics (6 decks)

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