Elderly Incontinence Flashcards

1
Q

What nerves control the pelvic floor and external urethral sphincter?

A

Somatic (voluntary) fibres from S2-4

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2
Q

What nerves relax the detrusor and how?

A

Sympathetic nerves from T10-L2

Via B-adrenoreceptors

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3
Q

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

A

Sympathetic nerves from T10-L2

Via alpha-adrenoreceptors

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4
Q

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

A

Parasympathetic nerves from S2-4

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5
Q

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

A
  • Co-morbidities
  • Confusion
  • Drinking to much
  • Diuretics
  • Constipation
  • Home circumstances
  • Social Circumstances
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6
Q

Intrinsic causes of incontinence can be split into 4 syndromes

A

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)

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7
Q

Describe how stress incontinence occurs?

A

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

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8
Q

Who gets stress incontinence?

A

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

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9
Q

How do we treat stress incontinence?

A

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

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10
Q

What surgical treatments are there for stress incontinence?

A

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

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11
Q

Describe what happens in overflow incontinence?

A

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

  • Poor flow
  • Double voiding
  • Hesitancy
  • Post-micturition dribbling
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12
Q

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

A
  • Alpha-1-adrenoreceptor Antagonist to relax sphincter
  • Anti-androgen to shrink prostate
  • Surgery i.e. TURP
    Potentially catheterisation
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13
Q

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

A

Alpha blocker e.g. tamsulosin

Anti-androgen e.g. Finasteride

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14
Q

Describe how urge incontinence occurs?

A

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

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15
Q

What causes urge incontinence?

A

Can be due to stroke or bladder stones mostly

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16
Q

How would we treat urge incontinence?

A

Bladder Re-training

Medically we can relax the detrusor with:

  • Anti-muscarinics e.g. oxybutinin
  • beta3 adrenoreceptor agonists e.g. mirabegron
17
Q

What is a neuropathic bladder?

A

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

18
Q

How can we treat neuropathic bladders?

A

The only effective treatment is catheterisation

19
Q

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

A

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)

20
Q

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

A

Medication review

Lifestyle changes such as alcohol & exercise

21
Q

When would we refer an incontinence patient to a specialist?

A

After failure of initial management

22
Q

What criteria would warrant immediate referral to a specialist?

A
  • 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
23
Q

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

A

In order of “Severity”:

  • Incontinence pads
  • Urosheath (men)
  • Intermittent Catheterisation
  • Long term catheter
  • Suprapubic catheter
24
Q

When to refer immediately for faecal referral

A

At onset
• Suspected sphincter damage
• Neurological disease