Elderly Continence Flashcards
Why is incontinence important?
It is common Stigmas around it Disabling Treatable Becomes permanent if untreated
What is the prevalence of incontinence in the elderly?
3 x more common
Residential care: 25%
Nursing home: 40%
Hospital care: 50-70%
What is the main objective for incontinence?
To identify cause(s) and treat it
What are the causes of incontinence?
Extrinsic factors: environment, habit, physical fitness
Intrinsic factors: problem with bladder/ urinary outlet
What are the extrinsic factors contributing to incontinence?
Physical state and co-morbidities Reduced mobility Confusion Drinking too much/ at wrong time Diuretics Constipation Home/ social circumstances
What are the three things allowing voluntary control and continence?
Bladder and urethra
Local innervation
CNS connections
What is the function of the bladder and describe its muscular structure
Urine storage (400-600ml) and voluntary voiding
Detrusor + internal urethral sphincter = smooth muscle
External urethral sphincter = striated muscle
What are the types of local innervation contributing to continence?
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
What CNS connections are there?
centres in CNS inhibit parasympathetic tone + promote bladder relaxation (storage)
sphincter closure is mediated by reflex increase by somatic activity
What are the issues of intrinsic factors contributing to incontinence?
Too weak/ too strong
- outlet
- bladder
What are the features of stress incontinence?
Bladder outlet too weak
urine leak on movement
weak pelvic floor muscles
Who is at risk to stress incontinence?
What is the treatment?
common in women with children + after menopause
Tx= physiotherapy, oestrogen cream, surgery (colosuspension)
What can help improve strength of pelvic floor muscles?
Kegel - pelvic floor exercises
Vaginal cones
Pelvic floor stimulaters Biofeedback
What are the features of Overflow incontinence?
What is it caused by
Associated with urinary retention
Bladder outlet too strong
Blockage to urethra- Poor urine flow, double voiding, hesitancy, post micturition dribbling
Older men with BPH
What is the treatment for overflow incontinence?
Treat blockage to urethra In older men with BPH: alpha blocker (relax sphincter) anti-androgen (shrink prostate) Surgery (TURP)
May need catheterisation, often suprapubic
What are the features of urge incontinence?
What can it because by?
Bladder muscle too strong
Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Can be caused by bladder stones or stroke
What is the treatment for urge incontinence?
Anti-muscarinics to relax detrusor muscle
Bladder re-training can be helpful
What are the features of neuropathic bladder?
How is it caused?
underactive bladder
it is rare + secondary to neurological disease (MS or stroke) or prolonged catheterisation
No awareness of bladder filling - results in overflow incontinence
What is the treatment for neuropathic bladder?
Catheterisation = only effective treatment
Medical treatments unsatisfactory
How do you assess incontinence?
Careful history intake chart + urine output Examination - rectal and vaginal Urinalysis + MSSU Bladder scan for residual volume
What are the indications for referral to a specialist?
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
What management strategies are there for those with incontinence?
Suggest lifestyle/ behavioural changes
Stop unnecessary drugs
Improve pain relief
make toilet more accessible
Consider specific treatments- physiological, medical treatment or surgical options
If all treatment methods fail, what are the options?
Incontinence pads
Urosheaths
Long term catheterisation/ suprapubic catheterisation
What are the features of faecal incontinence?
Refer after failure of initial management
Referral at onset if suspected sphincter damage or neurological disease
