Elderly - Incontinence

Question 1

Causes of incontinence

Answer 1

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

Question 2

Extrinsic factors which may cause incontinence

Answer 2

• Reduced mobility
• Confusion (delirium or dementia)
• Drinking too much or at the wrong time
• Medications, e.g. diuretics
• Constipation
• Social circumstances

Question 3

Stress incontinence characteristic features

Answer 3

• Bladder outlet too weak
  
  • Urine leak on movement, coughing, laughing, squatting, etc.
  • Weak pelvic floor muscles
    
    • Common in women with children, especially after menopause

Question 4

Stress incontinence treatment

Answer 4

• physiotherapy, oestrogen cream and duloxetine
• surgical option - TVT/colposuspension
  
  • 90% cure at 10 years

Question 5

Non surgical treatments for pelvic floor weakness

Answer 5

• Kegel exercises
• Vaginal cones
• Biofeedback
• Pelvic floor stimulators

Question 6

Urinary retention with overflow incontinence pathophysiology

Answer 6

• Bladder outlet too strong
• Blockage to urethra
• Older men with BPH

Question 7

Urinary retention with overflow incontinence symptoms

Answer 7

• poor urine flow
• double voiding
• hesitancy
• post micturition dribbling

Question 8

Urinary retention with overflow incontinence treatment

Answer 8

• alpha blocker (relaxes sphincter, e.g. tamsulosin)
• anti-androgen (shrinks prostate, e.g. finasteride)
• surgery (TURP)
• may need catheterisation, often suprapubic

Question 9

Urge Incontinence pathophysiology

Answer 9

• Bladder muscle “too strong”
• Detrusor contracts at low volumes
• Can be caused by bladder stones or stroke

Question 10

Urge Incontinence symptoms

Answer 10

• Sudden urge to pass urine immediately
• Patients often know every public toilet

Question 11

Urge Incontinence treatment

Answer 11

• Treat with anti-muscarinics (relax detrusor)
• Bladder re-training sometimes helpful

Question 12

Main drugs used for incontinence

Answer 12

• Antimuscarinics (relax detrusor)
  
  • oxybutinin, tolterodine
• Beta-3 adrenoceptor agonists (relax detrusor)
  
  • mirabegron
• Alpha-blockers (relax sphincter, bladder neck)
  
  • tamsulosin
• Anti-androgen drugs (shrink prostate)
  
  • finasteride, dutasteride

Question 13

Neuropathic Bladder pathophysiology

Answer 13

• Underactive bladder
• Rare
• Secondary to neurological disease, typically multiple sclerosis or stroke
• Also secondary to prolonged catheterisation
• No awareness of bladder filling resulting in overflow incontinence

Question 14

Neuropathic Bladder treatment

Answer 14

• Medical treatments unsatisfactory but parasympathomimetics might help
• Catheterisation is only effective treatment

Question 15

Assessing incontinence

Answer 15

• Good social history to assess impact of incontinence and identify ‘extrinsic’ factors
• Intake chart and urine output diaries
• General examination to include rectal and vaginal examination
• Urinalysis and MSSU
• Bladder scan for residual volume

Question 16

Incontinence - measures to promote independence if all else fails

Answer 16

• Incontinence pads
• Urosheaths
• Intermittent catheterisation
• Long term urinary catheter
• Suprapubic catheter