Elderly Incontinence Flashcards
What nerves control the pelvic floor and external urethral sphincter?
Somatic (voluntary) fibres from S2-4
What nerves relax the detrusor and how?
Sympathetic nerves from T10-L2
Via B-adrenoreceptors
What nerves contract the bladder neck and internal urethral sphincter and how?
Sympathetic nerves from T10-L2
Via alpha-adrenoreceptors
What nerves relax the internal urethral sphincter and contract the bladder when you want to pee?
Parasympathetic nerves from S2-4
Incontinence is often the result of a mixture of extrinsic and intrinsic factors. What extrinsic things can cause incontinence in the elderly?
- Co-morbidities
- Confusion
- Drinking to much
- Diuretics
- Constipation
- Home circumstances
- Social Circumstances
Intrinsic causes of incontinence can be split into 4 syndromes
1) Stress incontinence (i.e. Bladder outlet too weak)
2) Overflow Incontinence (I.e. Bladder outlet too strong)
3) Urge Incontinence (i.e. bladder too strong)
4) Neuropathic bladder (i.e. bladder too weak)
Describe how stress incontinence occurs?
Weak pelvic floor muscles lead to leakage of urine on stress e.g. movement, coughing or laughing
Who gets stress incontinence?
Mostly women who’ve had children and/or are menopausal
How do we treat stress incontinence?
You want to strengthen the pelvic floor though physio:
- Pelvic floor exercises
- Vaginal Cones
- Kegel exercisers & pelvic floor stimulators
Also oestrogen cream and duloxetine can be useful
What surgical treatments are there for stress incontinence?
Tension-free vaginal tape or more invasively colposuspension.
To basically raise the bladder outlet as a substitute for muscles
Describe what happens in overflow incontinence?
Urethra is blocked (most common is BPH) leading to urinary retention which eventually overflows causing:
- Poor flow
- Double voiding
- Hesitancy
- Post-micturition dribbling
How do we treat overflow incontinence (Considering most cases are BPH)?
- Alpha-1-adrenoreceptor Antagonist to relax sphincter
- Anti-androgen to shrink prostate
- Surgery i.e. TURP
Potentially catheterisation
Give an example of an alpha-blocker and an anti-androgen?
Alpha blocker e.g. tamsulosin
Anti-androgen e.g. Finasteride
Describe how urge incontinence occurs?
The detrusor contracts excessively/at low volumes –> Sudden urge to micturate
What causes urge incontinence?
Can be due to stroke or bladder stones mostly
How would we treat urge incontinence?
Bladder Re-training
Medically we can relax the detrusor with:
- Anti-muscarinics e.g. oxybutinin
- beta3 adrenoreceptor agonists e.g. mirabegron
What is a neuropathic bladder?
Quite rare.
It’s secondary to neuro diseases e.g. MS or prolonged catheterisation
The patient can’t feel the bladder filling so it overflows
How can we treat neuropathic bladders?
The only effective treatment is catheterisation
An old man woman presents to you complaining of incontinence, what do you want to do?
A comprehensive complaint & social history (remember to cover extrinsic factors that could contribute)
Intake chart & UO diary
General, rectal & Vaginal exam
Urinalysis & MSSU (kidney stones, UTI etc)
Bladder scan (tells you residual volume after micturition, good for urinary retention)
What treatments (other than those mentioned specifically) can be important to incontinence?
Medication review
Lifestyle changes such as alcohol & exercise
When would we refer an incontinence patient to a specialist?
After failure of initial management
What criteria would warrant immediate referral to a specialist?
- Vesico-vaginal fistula
- Large residual volume (i.e. still palpable after voiding)
- CNS disease
- Certain gynae conditions (fibroids, rectocele etc.) stuff for a gynaecologist
- Severe BPH or prostatic carcinoma
- Previous continence surgery
- Can’t diagnose
If all else fails what devices do we have for the incontinent?
In order of “Severity”:
- Incontinence pads
- Urosheath (men)
- Intermittent Catheterisation
- Long term catheter
- Suprapubic catheter
