Elderly Continence

Question 1

is incontinence more common in men or women and by how much?

Answer 1

women 3 x

Question 2

in what situations is incontience more prevalent?

Answer 2

those in institutions
residential care - 25%
nursing home - 40%
hospital 50-70

Question 3

causes of incontinence

Answer 3

• Extrinsic to the urinary system
o Environment, habit, physical fitness etc
• Intrinsic to the urinary system
o Problem with bladder or urinary outlet
• Often a bit of both

Question 4

extrinsic factors of incontinence

Answer 4

physical state and comorbidities
• Reduced mobility
• Confusion (delirium or dementia)
• Drinking too much or at the wrong time
• Diuretics
• Constipation
• Home circumstances
• Social circumstances

Question 5

what is continence dependent on?

Answer 5

Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control:

1. Bladder and urethra
2. Local innervation
3. CNS connections

Question 6

innervation of the bladder

Answer 6

• Parasympathetic S2-4
o Increases strength and frequency of contractions
• Sympathetic T10-L2
o B-adrenoreceptor causing detrusor relaxation
• Sympathetic T10-S2
o A-adrenoreceptor causing contraction of the neck of the bladder and IUS
• Somatic S2-4
o Contraction of pelvic floor muscle (urogenital diaphragm) and EUS

Question 7

intrinsic factors of incontinence

Answer 7

bladder outlet too week or too strong.

Question 8

cause of stress incontience

Answer 8

bladder outlet too week

Question 9

characteristic features of stress incontinence

Answer 9

• Urine leak on movement, coughing, laughing, squatting etc
• Weak pelvic floor muscles
• Common in women with children, especially after menopause
o Premenopause oestrogen keeps vaginal tone
• Treatments include PT, oestrogen cream and duloxetine
o Oestrogen cream over vulva helpful if atrophy – itchy, excoriated. Often need
oestrogen pessary
o Duloxetine is an SSRI
• Surgical option
o TVT/colposuspension 90% cure at 10 years

Question 10

causes of urinary retention with overflow incontinence

Answer 10

bladder outlet too strong

Question 11

characteristic features of urinary retention with overflow incontinence

Answer 11

• Poor urine flow, double voiding, hesitancy, post micturition dribbling
• Blockage to urethra
• Older men with BPH
• Treat with alpha blocker (relaxes sphincter e.g. Tamsulosin) or anti-androgen (shrinks prostate
e.g. finasteride) or surgery (TURP)
• May need catheterisation, often suprapubic

Question 12

cause of urge incontinence

Answer 12

too strong bladder muscle

Question 13

characteristic features of urge incontinence

Answer 13

• Detrusor contracts at low volumes
• Sudden urge to pass urine immediately
• Patients often know every public toilet
• Can be caused by bladder stones or stroke
• Treat with anti-muscarinics (relax detrusor)
o E.g. oxybutynin, tolterodine, solifenacin
• Bladder re-training sometimes helpful

Question 14

main drugs used for teatment of incontinence

Answer 14

• Anti-muscarinics (relax detrusor)
o Oxybutynin, tolterodine, solifenacin, trosium
• Beta-3 adrenoceptor agonists (relax detrusor)
o Mirabegron
• Alpha-blockers (relax sphincter, bladder neck)
o Tamsulosin, terazosin, indoramin)
• Anti-androgen drugs (shrink prostate)
o Finasteride, Dutasteride

Question 15

characteristic features of neuropathic bladder

Answer 15

• Rare
• Secondary to neurological disease, typically MS or stroke
• Also secondary to prolonged catheterisation
• No awareness of bladder filling resulting in overflow incontinence
• Medical treatments unsatisfactory but parasympathomimetics might help
• Catheterisation is only effective treatment
• Iatrogenic
• Bladder lost innervation

Question 16

indications for referral in incontinence

Answer 16

• Referral after failure of initial management (max 3 months of pelvic floor exercises, cone
therapy, habit retraining and/or appropriate medication)
• Referral necessary at onset:
o Vesico-vaginal fistula
o Palpable bladder after micturition or confirmed large residual volume of urine after
micturition
o Disease of the CNS
o Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
o Severe benign prostatic hypertrophy or prostatic carcinoma
o Patients who have had previous surgery for continence problems
o Others in whom a diagnosis has not been made
• Faecal incontinence
o Referral after failure of initial management
§ Constipation or diarrhoea with normal sphincter
o Referral necessary at onset
§ Suspected sphincter damage
§ Neurological disease