Elderly Incontinence

Question 1

What nerves control the pelvic floor and external urethral sphincter?

Answer 1

Somatic (voluntary) fibres from S2-4

Question 2

What nerves relax the detrusor and how?

Answer 2

Sympathetic nerves from T10-L2

Via B-adrenoreceptors

Question 3

What nerves contract the bladder neck and internal urethral sphincter and how?

Answer 3

Sympathetic nerves from T10-L2

Via alpha-adrenoreceptors

Question 4

What nerves relax the internal urethral sphincter and contract the bladder when you want to pee?

Answer 4

Parasympathetic nerves from S2-4

Question 5

Incontinence is often the result of a mixture of extrinsic and intrinsic factors. What extrinsic things can cause incontinence in the elderly?

Answer 5

• Co-morbidities
• Confusion
• Drinking to much
• Diuretics
• Constipation
• Home circumstances
• Social Circumstances

Question 6

Intrinsic causes of incontinence can be split into 4 syndromes

Answer 6

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)

Question 7

Describe how stress incontinence occurs?

Answer 7

Weak pelvic floor muscles lead to leakage of urine on stress e.g. movement, coughing or laughing

Question 8

Who gets stress incontinence?

Answer 8

Mostly women who’ve had children and/or are menopausal

Question 9

How do we treat stress incontinence?

Answer 9

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

Question 10

What surgical treatments are there for stress incontinence?

Answer 10

Tension-free vaginal tape or more invasively colposuspension.
To basically raise the bladder outlet as a substitute for muscles

Question 11

Describe what happens in overflow incontinence?

Answer 11

Urethra is blocked (most common is BPH) leading to urinary retention which eventually overflows causing:

• Poor flow
• Double voiding
• Hesitancy
• Post-micturition dribbling

Question 12

How do we treat overflow incontinence (Considering most cases are BPH)?

Answer 12

• Alpha-1-adrenoreceptor Antagonist to relax sphincter
• Anti-androgen to shrink prostate
• Surgery i.e. TURP
  Potentially catheterisation

Question 13

Give an example of an alpha-blocker and an anti-androgen?

Answer 13

Alpha blocker e.g. tamsulosin

Anti-androgen e.g. Finasteride

Question 14

Describe how urge incontinence occurs?

Answer 14

The detrusor contracts excessively/at low volumes –> Sudden urge to micturate

Question 15

What causes urge incontinence?

Answer 15

Can be due to stroke or bladder stones mostly

Question 16

How would we treat urge incontinence?

Answer 16

Bladder Re-training

Medically we can relax the detrusor with:

• Anti-muscarinics e.g. oxybutinin
• beta3 adrenoreceptor agonists e.g. mirabegron

Question 17

What is a neuropathic bladder?

Answer 17

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

Question 18

How can we treat neuropathic bladders?

Answer 18

The only effective treatment is catheterisation

Question 19

An old man woman presents to you complaining of incontinence, what do you want to do?

Answer 19

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)

Question 20

What treatments (other than those mentioned specifically) can be important to incontinence?

Answer 20

Medication review

Lifestyle changes such as alcohol & exercise

Question 21

When would we refer an incontinence patient to a specialist?

Answer 21

After failure of initial management

Question 22

What criteria would warrant immediate referral to a specialist?

Answer 22

• 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

Question 23

If all else fails what devices do we have for the incontinent?

Answer 23

In order of “Severity”:

• Incontinence pads
• Urosheath (men)
• Intermittent Catheterisation
• Long term catheter
• Suprapubic catheter

Question 24

When to refer immediately for faecal referral

Answer 24

At onset
• Suspected sphincter damage
• Neurological disease