Continence / osteoporosis

Question 1

Outline the management options for urge urinary incontience (esp. in elderly)

Answer 1

Conservative:
- Reduce fluid intake, esp. close to bedtime
- Reduce caffeine intake
- Reduce alcohol intake
- Smoking cessation
- Manage any constipation
- Contience pads

Medical:
- Referral to continence team
- Bladder re-training
- Anticholinergic drugs e.g. Mirabegron (best in elderly)

Surgical:
- Botulinum toxin A injection to the bladder wall
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty
- Urinary diversion

Question 2

Outline the management options for stress urinary incontience (esp. in elderly)

Answer 2

Conservative:
- Reduce fluid intake, esp. close to bedtime
- Reduce caffeine intake
- Reduce alcohol intake
- Smoking cessation
- Manage any constipation
- Contience pads

Medical:
- Referral to continence team
- Pelvic floor exercises

Surgical:
- Mid urethral sling insertion

Question 3

List some investigations to do for a patient with urinary incontinence

Answer 3

B - baseline obs (temp, BP), calculate BMI, CBG, DRE, urine dipstick and MC&S, consider bladder diary, examine external genetalgia (atrophic vaginitis)

L - FBC, CRP U&Es, LFTs, TFTs, HbA1c, calcium and phosphate

I - post-void bladder scan

P - invasive urodynamics, cystoscopy

Question 4

List some investigations to do for a patient with faecal incontinence

Answer 4

B - baseline obs (temp, BP), DRE, stool culture, consider stool diary, FIT test if older

L - FBC, CRP, U&Es, LFTs, TFTs, HbA1c

I - post-void bladder scan (resultant urine retention from consitpation)

P -

Question 5

Outline the management options for faecal incontience (esp. in elderly)

Answer 5

Conservative:
- Incontience pads
- High fibre diet
- Increase fluid intake

Medical:
- Loperamide (once ruled out other causes)
- Pelvic floor exercises
- Bowel retraining

Surgical:
- Sphincteroplasty
- Sacral nerve stimulation
- Injectable bulking agents e.g. silicone into anal muscles
- Rarely: colostomy

Question 6

List some risk factors for pressure sores

Answer 6

Non-modifiable:
- Increased age

Modifiable:
- Immobility e.g. paralysis
- Incontinence
- Recent surgery
- Low BMI
- Poor nutrition (slow healing)
- Comorbidities e.g. diabetes, HF

Question 7

Outline general management for pressure ulcers / sores

Answer 7

Conservative:
- Good documentation and regualar reviews
- General good diet and hydration
- Avoid additional pressure on ulcer, repositioning and pressure redistirubtion equipment
- Regularly dressings to aid wound healing

Question 8

Outline how to prevent pressure sores from developing

Answer 8

• Firstly identify those at risk
• Regular repositioning every 4-6 hours
• Keep skin dry and clean (esp. for incontinence)
• Consider use of pressure redistribution systems e.g. mattress

Question 9

Outline how osteoporosis is managed

Answer 9

Conservative:
- Increase activity levels + weight-bearing exercises
- Good dietary intake calcium/vit D
- Maintain normal BMI
- Smoking cessation
- Reduce alcohol intake

Medical:
- Calcium and vitamin D (Adcal D3)
- Oral bisphosphonate e.g. Alendronic acid (review after 5 years)

Question 10

List some risk factors for osteoporosis

Answer 10

Non-modifiable:
- Increased age
- Female / post-menopausal

Modifiable:
- Poor diet
- Smoking
- Alcohol
- Immobility / prolonged bed rest
- Obesity
- Medications e.g. steroids
- Hyperthyroidism
- Malabsorption conditions e.g. Crohn’s

Question 11

Outline what is involved in a bone health assessment

Answer 11

B - calculate FRAX score

L - U&Es, calcium, phosphate, ALP, TFTs

I - DXA scan for those with high FRAX score (assess bone mineral density)

P - x

Question 12

For the bristol stool chart, state what 1 and 7 mean (which end of the scale is which)

Answer 12

Stool - 1 = very solid seperate blobs

Stool - 7 = very watery stool

Question 13

State what is a normal post-void bladder scan volume and when to suspect urinary retention

Answer 13

Generally < 200 mL = ‘normal’
Over 400 mL = urinary retention

Between 200-400 suggests incomplete emptying

Question 14

List some causes of urinary retention

Answer 14

T: post-surgery
I: UTI, prostatitis, cystitis, local abscess
N: cauda equina syndrome / MSCC, spinal cord injury, Parkinson’s, MS, Fowler’s syndrome + BPH / prostate cancer
D: anticholingerics, antihistamines, botox injections to bladder
E: B12/folate deficiency,
V: stroke
I: failure of TWOC
C: phimosis, vesicoureteral reflux
A:

Question 15

List some containment products that can be used for urinary incontience

Answer 15

• Incontience pads and pants
• Skincare / hygiene products
• Specially adapted clothing and swimwear
• Bed / chair protection
• Catheters / penile sheaths

Bladder & Bowel UK gives independent advice on products that can help manage bladder and bowel problems

Question 16

List some containment products that can be used for faecal incontience

Answer 16

• Incontience pads and pants
• Skincare / hygiene products
• Bed / chair protection

Bladder & Bowel UK gives independent advice on products that can help manage bladder and bowel problems

Question 17

List some contributing factors for an older person developing foecal incontinence

Answer 17

Underlying constipation (overflow diarrhoea) = most common

Others:
- Neurogenic dysnfunction (reduced anal tone)
- Haemorrhoids
- Reduced ability to exer intra-abdominal pressure to empty bowels on time

Question 18

Outline how constipation can be managed

Answer 18

• Stool softeners
• Phosphate enema (if loaded stool)
• Manual evacuation (last line)