Elderly Incontinence - Part 1

Question 1

Why learn about incontinence?

Answer 1

• Common
• Stigmatising
• Disabling
• Treatable
• Most doctors not good at treating it
• Often becomes permanent if untreated

Question 2

what is the Prevalence of Urinary Incontinence? is it more common in females or males? and what places is it higher in?

Answer 2

• 3x more common in women
• Prevalence in those living in institutions:
• Residential care 25%
• Nursing home care 40%
• Hospital care 50-70%

2 peaks – after menopause and then in old age

Still pretty common in younger people

Question 3

• Incontinence is a _________ with many _______
• Main objective is to identify the _____(s) and treat the _____(s).

Answer 3

symptom

causes

cause

cause

Pleural is very deliberate – all geriatric syndromes are often multifactorial

Question 4

what are the causes of incontinence?

Answer 4

• 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

This is the scheme recommended to use to try and figure out the cause of incontinence

Question 5

what are some extrinsic factors that may be the cause of incontinence?

Answer 5

• Physical state and co-morbidities
• Reduced mobility
• Confusion (delirium or dementia)
• Drinking too much or at the wrong time
• Medications, e.g. diuretics (Diuretics don’t give you much warning when they strike)
• Constipation (Rectum is right beside the bladder so incontinence may be caused by constipation)
• Home circumstances
• Social circumstances

Question 6

Anatomy and Physiology:

•Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control - what are they?

Answer 6

1 : Bladder and Urethra

2 : Local Innervation

3 : CNS Connections

Key to this is our autonomic nervous system

Often medications we use to fix some dysfunction in the bladder will have effects on the parasympathetic and sympathetic NS so will have a wide range of side effects across all of these

Question 7

what are the functions of the bladder?

Answer 7

Urine storage

Voluntary voiding

Question 8

what is the structure of the bladder and urethra and what are the key parts of them?

Answer 8

• Detrusor is smooth muscle (Detrusor, like any other muscle, needs to be used to avoid atrophy)
• Internal urethral sphincter is smooth muscle (autonomic control)
• External urethral sphincter is striated muscle (voluntary)

Question 9

one function of the bladder is storage of urine, how is it done?

Answer 9

Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction

Bladder holds around 500ml of urine

When you get to 250ml of urine you start to get an awareness and at 400ml it becomes quite urgent

Overtime you can stretch detrusor muscle

Question 10

one function of the bladder is voluntary voiding, how is this done?

Answer 10

Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder

Should empty completely but allow upto 100ml left but be concerned if still have 250ml as probably have problem with urinary retention

Question 11

2. local innervation:

what is the local innervation of the blader?

(watch again)

Answer 11

• (S2-S4) : Parasympathetic - Increases strength and frequency of contractions
• (T10-L2) : Sympathetic - ß - adrenoreceptor : causes detrusor to relax
• (T10-S2) : Sympathetic - a - adrenoreceptor : Causes contraction of neck of bladder, and internal urethral sphincter
• (S2-S4) : Somatic - Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter

Question 12

CNS Connections:

• Centres within the ___ inhibit parasympathetic tone, and promote bladder _________ and hence storage of urine
• Sphincter closure is mediated by reflex increase in a-adrenergic and _______ activity

Answer 12

CNS

relaxation

somatic

If you lose consciousness then loss of inhibitory tone and the bladder empties

e.g. KO or have a fit

Question 13

The pontine micturition centre normally exerts a “storage program” of neural connections until a ________ switch to a voiding program occurs

Other areas involved include:

• Frontal cortex
• Caudal part of spinal cord

If damage to the PONs then you have a person that is permanently __________

Answer 13

voluntary

incontinent