Elderly Incontinence - Part 3

Question 1

Indications for referral to specialists - when would you refer someone for Urinary incontinence

Answer 1

Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)

Defined as 3 months of non-pharmacological treatment

Some situations where you would refer to a specialist right away

Question 2

Indications for referral to specialists - when would you refer someone for urinary incontinence right awta?

Answer 2

• Vesico-vaginal fistula
• Palpable bladder after micturition or confirmed large residual volume of urine after micturition
• Disease of the CNS
• Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
• Severe benign prostatic hypertrophy or prostatic carcinoma
• Patients who have had previous surgery for continence problems
• Others in whom a diagnosis has not been made

Question 3

Indications for referral to specialists - when would you refer someone for Faecal incontinence?

Often has more obvious cause than urinary

Answer 3

Referral after failure of initial management:

•Constipation or diarrhoea with normal sphincter

Referral necessary at onset:

• Suspected sphincter damage
• Neurological disease

Question 4

If all else fails…

If we cant help incontinence (in most cases we can) then there is multiple containment options that can make a difference between someone being independent or not

what are the options?

Answer 4

• Incontinence pads (some wearable like nappy others go over beds or chairs)
• Urosheaths (only used in males, not that reliable but main used in patients who are immobile)
• Intermittent catheterisation (much safer than a long time catheter)
• Long term urinary catheter
• Suprapubic catheter

Question 5

Summary:

• Incontinence is ________ and _______
• It can almost always be ______
• Consider _______ factors (true for all geriatric syndromes)
• Urinary system disease can be divided into _______ and ______ over and under-activity – each has characteristic features and specific treatment
• Many have ________ factors contributing to incontinence
• Careful ________ can identify strategies to promote continence
• If all else fails there are still measures that can promote ___________

Incontinence is multifactorial so management plan cant have ___ thing to it

Answer 5

common

disabling

helped

extrinsic

bladder

outlet

multiple

assessment

independence

one

Question 6

Case Study

Answer 6

Is her conditions well controlled or not? Is her medications affecting her?

OA – does she have problems with mobility

CCF – maybe too breathless or too tired or diuretics ay be affecting her

Type 2 diabetes – get hypoglycaemia, polyuria, thirst

COPD – does she cough a lot, leak when she coughs?, is she too breathless

Hydrocodenia is very constipating

lots of her medications have different effects that may be causing it

We haven’t spoken to her yet, just read the letter but already thinking of possible target for incontinence

Question 7

What are some possible strategies (dependent on history / examination)?

Huge amount of targets for intervention, they wont all work but some will

Answer 7

• Improve pain relief
• Increase COPD medications
• Increase diuretics or other CCF medications
• Stop furosemide
• Improve diabetic control (up or down)
• Minimise risk of syncope
• Use cough suppressant
• Stop constipating medications
• Stop anticholinergic and sedative medications
• Mobility aids
• Make toilet more accessible e.g. stair-lift, commode
• Lifestyle changes (e.g. restrict fluid)
• Bladder exercises
• Specific treatments (e.g. tolterodine)
• Use containment strategies, etc, etc… a lot can normally be done!