Elderly Continence

Question 1

Why is incontinence important?

Answer 1

It is common
Stigmas around it
Disabling
Treatable 
Becomes permanent if untreated

Question 2

What is the prevalence of incontinence in the elderly?

Answer 2

3 x more common
Residential care: 25%
Nursing home: 40%
Hospital care: 50-70%

Question 3

What is the main objective for incontinence?

Answer 3

To identify cause(s) and treat it

Question 4

What are the causes of incontinence?

Answer 4

Extrinsic factors: environment, habit, physical fitness

Intrinsic factors: problem with bladder/ urinary outlet

Question 5

What are the extrinsic factors contributing to incontinence?

Answer 5

Physical state and co-morbidities
Reduced mobility
Confusion
Drinking too much/ at wrong time
Diuretics
Constipation
Home/ social circumstances

Question 6

What are the three things allowing voluntary control and continence?

Answer 6

Bladder and urethra
Local innervation
CNS connections

Question 7

What is the function of the bladder and describe its muscular structure

Answer 7

Urine storage (400-600ml)
and voluntary voiding 

Detrusor + internal urethral sphincter = smooth muscle
External urethral sphincter = striated muscle

Question 8

What are the types of local innervation contributing to continence?

Answer 8

S2-S4 parasympathetic = increases strength of contractions
Sympathetic = causes detrusor to relax (T10-L2)
Sympathetic (T10-S2) = causes contraction of bladder and internal urethral sphincter
Somatic S2-S4 = contraction of pelvic floor muscles

Question 9

What CNS connections are there?

Answer 9

centres in CNS inhibit parasympathetic tone + promote bladder relaxation (storage)

sphincter closure is mediated by reflex increase by somatic activity

Question 10

What are the issues of intrinsic factors contributing to incontinence?

Answer 10

Too weak/ too strong

• outlet
• bladder

Question 11

What are the features of stress incontinence?

Answer 11

Bladder outlet too weak

urine leak on movement
weak pelvic floor muscles

Question 12

Who is at risk to stress incontinence?

What is the treatment?

Answer 12

common in women with children + after menopause

Tx= physiotherapy, oestrogen cream, surgery (colosuspension)

Question 13

What can help improve strength of pelvic floor muscles?

Answer 13

Kegel - pelvic floor exercises
Vaginal cones
Pelvic floor stimulaters Biofeedback

Question 14

What are the features of Overflow incontinence?

What is it caused by

Answer 14

Associated with urinary retention
Bladder outlet too strong
Blockage to urethra- Poor urine flow, double voiding, hesitancy, post micturition dribbling
Older men with BPH

Question 15

What is the treatment for overflow incontinence?

Answer 15

Treat blockage to urethra
In older men with BPH:
alpha blocker (relax sphincter)
anti-androgen (shrink prostate)
Surgery (TURP)

May need catheterisation, often suprapubic

Question 16

What are the features of urge incontinence?

What can it because by?

Answer 16

Bladder muscle too strong
Detrusor contracts at low volumes
Sudden urge to pass urine immediately

Can be caused by bladder stones or stroke

Question 17

What is the treatment for urge incontinence?

Answer 17

Anti-muscarinics to relax detrusor muscle

Bladder re-training can be helpful

Question 18

What are the features of neuropathic bladder?

How is it caused?

Answer 18

underactive bladder
it is rare + secondary to neurological disease (MS or stroke) or prolonged catheterisation

No awareness of bladder filling - results in overflow incontinence

Question 19

What is the treatment for neuropathic bladder?

Answer 19

Catheterisation = only effective treatment

Medical treatments unsatisfactory

Question 20

How do you assess incontinence?

Answer 20

Careful history
intake chart + urine output
Examination - rectal and vaginal
Urinalysis + MSSU
Bladder scan for residual volume

Question 21

What are the indications for referral to a specialist?

Answer 21

Failure of initial management (after 3 months of medication/ PF exercises)

Or referral at onset if:
Fistula
Palpable bladder after micturition/ large residual volume
Disease of CNS
BPH/ cancer
Previous continence surgery

Question 22

What management strategies are there for those with incontinence?

Answer 22

Suggest lifestyle/ behavioural changes
Stop unnecessary drugs
Improve pain relief
make toilet more accessible

Consider specific treatments- physiological, medical treatment or surgical options

Question 23

If all treatment methods fail, what are the options?

Answer 23

Incontinence pads
Urosheaths
Long term catheterisation/ suprapubic catheterisation

Question 24

What are the features of faecal incontinence?

Answer 24

Refer after failure of initial management

Referral at onset if suspected sphincter damage or neurological disease