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SPECIALITIES > Elderly - continence > Flashcards

Elderly - continence Flashcards

1
Q

what is the prevalence of urinary incontinence in different living situations

A

residential care - 25%
nursing home care - 40%
hospital care - 50-70%

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2
Q

is urinary incontinence more common in men or women

A

3x more common in women

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3
Q

what is incontinence

A

a symptom with many causes - uncontrolled leakage of urine

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4
Q

what are the two groups of causes for incontinence

A

extrinsic - environmental, habit, physical fitness, etc

intrinsic - problem with bladder or urinary outlet

BUT often caused by a mix of both

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5
Q

list some extrinsic factors

A 
Physical state and co-morbidities
Reduced mobility
Confusion (delirium or dementia)
Drinking too much or at the wrong time
Diuretics
Constipation
Home circumstances
Social circumstances
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6
Q

what does continence depend on

A

effective function of the bladder

integrity of local innervation and CNS connections

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7
Q

what are the functions of the bladder

A

urine storage

voluntary voiding

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8
Q

how does urine storage work

A

involves the detrusor muscle relaxing and filling to normal volume, combined with sphincter contraction

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9
Q

how does voluntary voiding work

A

voluntary relaxation of external sphincter
involuntary relaxation of internal sphincter
contraction of bladder

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10
Q

what are the three components of local innervation

A

parasympathetic
sympathetic
somatic

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11
Q

what is the parasympathetic innervation of the bladder/urethra and what does it do

A

S2-S4 - increases strength and frequency of contractions

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12
Q

what is the sympathetic innervation of the bladder/urethra and what does it do

A
  1. T10-L2
    - B-adrenorecepto: causes detrusor to relax
  2. T10-S2
    - a-adrenoreceptor: causes contraction of neck of bladder, and internal urethral sphincter
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13
Q

what is the somatic innervation of the bladder/urethra and what does it do

A

S2-S4 - contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter

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14
Q

what are the CNS components of urine storage

A

centres in the CNS inhibit parasympathetic tone - promote bladder relaxation = storage of urine

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15
Q

what are the CNS components of sphincter closure

A

sphincter closure mediated by reflex increase in a-adrenergic and somatic activity

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16
Q

what are the CNS components of voluntary voiding

A

pontine micturition centre normally exerts a “storage program” of neural connections until a voluntary switch to a “voiding program” occurs.

17
Q

what is stress incontinence/how does it occur

A

leakage of urine due to the bladder outlet being too weak

18
Q

what are characteristic features of stress incontinence

A

urine leak on movement, coughing, laughing, etc

weak pelvic floor muscles

common in women with children, esp after menopause

19
Q

what are the treatment options for stress incontinence

A

physiotherapy
- pelvic floor/kegal exercises, vaginal cones, biofeedback, pelvic floor stimulators
oestrogen cream, duloxetine

surgical - TVT/colposuspension

20
Q

what is overflow incontinence/how does it occur

A

urine leakage due to bladder outlet being too strong which leads to urinary retention

21
Q

what are characteristic features of urinary retention with overflow incontinence

A

poor urine flow, double voiding, hesitance, post micturition dribble

blockage to urethra

usually in older men with BPH

22
Q

what are the treatment options for urinary retention with overflow incontinence

A

alpha blockers (relaxes sphincter eg tamsulosin)

anti-androgens (shrinks prostate eg finasteride

surgery (TURP)

may need catheterisation, often suprapubic

23
Q

what is urge incontinence/how does it occur

A

urine leakage due to bladder muscle being too strong

24
Q

what are characteristic features of urge incontinence

A

detrusor contracts at low volumes of stored urine

leads to sudden urge to pass urine immediately

patients often know every public toilet

can be caused by bladder stones or stroke

25
Q

what are the treatment options for urge incontinence

A

anti-muscarinics (relax detrusor)
- eg oxybutinin, tolterodine, solifenacin

bladder re-training can sometimes be helpful

26
Q

SUMMARY: what are the main incontinence syndromes

A

overflow

  • urethral blockage
  • bladder unable to empty properly

stress

  • relaxed pelvic floor
  • increased abdominal pressure

urge

  • bladder oversensitivity
  • neurologic disorders
27
Q

SUMMARY: what are the main drugs used in incontinence

A

anti-muscarinics (URGE: relax detrusor)

B-3 adrenoreceptor agonists (URGE: relax detrusor)

A-blockers (OVERFLOW: relax sphincter, bladder neck)

Anti-androgens (OVERFLOW: shrink prostate)

28
Q

what is a neuropathic bladder

A

an underactive bladder

29
Q

what are the characteristic features of neuropathic bladder

A

“rare”

secondary to neurological disease, typically MS or stroke

**also secondary to prolonged catheterisation

no awareness of bladder filling resulting in overflow incontinence

30
Q

what are the treatment options for neuropathic bladder

A

medical treatments unsatisfactory BUT parasympathomimetics might help

catheterisation the only effective treatment

31
Q

how is incontinence assessed

A

careful history
- good social history for extrinsic factors

intake chart and urine output diaries

general exam including rectal and vaginal exams

urinalysis and MSSU

bladder scan for residual volume

32
Q

what are things to consider once incontinence is diagnosed

A

consider referral to incontinence clinical for further investigation in difficult cases

lifestyle/behavioural changes

stop unnecessary drugs

consider physio, medical treatment or surgical options

33
Q

when should an incontinent patient be referred to a specialist

A

after failure of initial management

- max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication

34
Q

what indications present at onset of incontinence call for immediate referral

A

Vesico-vaginal fistula

Palpable bladder after micturition/confirmed large residual volume

Disease of the CNS

Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)

Severe BPH or prostatic carcinoma

Patients with previous surgery for continence problems

Others in whom a diagnosis has not been made

35
Q

when should faecal incontinence be referred

A

Referral after failure of initial management:

Constipation or diarrhoea with normal sphincter

36
Q

what indications present at onset of faecal incontinence call for immediate referral

A

suspected sphincter damage

neurological disease

37
Q

if all other treatment options fail, what can be done

A

Incontinence pads

Urosheaths

Intermittent catheterisation

Long term urinary catheter

Suprapubic catheter

SPECIALITIES (23 decks)

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