Geriatric Incontinence Flashcards
Why learn about incontinence?
- Common
- Stigmatising
- Disabling
- Treatable
- Most doctors not good at treating it
- Often becomes permanent if untreated
With which gender is incontinence more common?
3x more common in Women.
What are the causes of incontinence?
- 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.
Extrsinsic Factors are?
- Physical state and co-morbidities
- Reduced mobility
- Confusion (delirium or dementia)
- Drinking too much or at the wrong time
- Diuretics
- Constipation
- Home circumstances
- Social circumstances
Generally outline the anatomy and physiology of continence?
Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control:
- Bladder and Urethra
- Local Innervation
- CNS connection
Function of the bladder and urethra? What type of muscle is the detrusor, internal urethral sphincter and external urethral sphincter?
- Function:
- Urine storage
- Voluntary voiding
- Detrusor is smooth muscle
- Internal urethral sphincter is smooth muscle
- External urethral sphincter is striated muscle
Outline urine storage in the bladder?
Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction
Outline voluntary voiding in the bladder?
Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder.
What is the local innervation of the bladder?
- S2-S4 - [parasympathetic system]
- Increases strength and frequency of contractions.
- T10-L2 - [Sympathetic] - Beta-adrenoreceptor
- causes detrusor to relax.
- T10 -S2 - [Sympathetic] - Alpha adrenoreceptor -
- causes contraction of neck of bladder, and internal urethral sphincter.
- S2-S4 - [Somatic]
- Contraction of pelvic floor muscle (urogential diaphragm) and extrnal urethral sphincter.
Outline the CNS connections of the bladder.
- Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.
- Sphincter closure is mediated by reflex increase in a-adrenergic and somatic activity.
- The pontine micturition centre normally exerts a “storage program” of neural connections until a voluntary switch to a voiding program occurs.
- Other areas involved include:
- Frontal cortex
- Caudal part of spinal cord
What are the intrinsic factors of incontinence?
- Bladder issue
- Outlet issue
- Too weak
- Too strong
Outline stress incontinence.
Bladder outlet too weak
Characteristic features: -
- Urine leak on movement, coughing, laughing, squatting, etc. -
- Weak pelvic floor muscles -
- Common in women with children, especially after menopause
- Treatments include physiotherapy, oestrogen cream and duloxetine
- Surgical option
- TVT/colposuspension 90% cure at 10 years
What are the managemnt options for stress incontinence?
- Pelvic floor exercises or pelvic floor weights, stimulation etc.
- Vaginal cones
- Duloxetine - if non-pharmacological doesn’t work.
Outline urinary retention with overflow incontinence.
Bladder outlet is too strong.
Characteristic features:
- Poor urine flow, double voiding, hesitancy, post micturition dribbling
- Blockage to urethra
- Older men with BPH
- Treat with alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
- May need catheterisation, often suprapubic
Outline urge incontinence.
Bladder muscle too strong
Characteristic features:
- Detrusor contracts at low volumes
- Sudden urge to pass urine immediately
- Patients often know every public toilet
- Can be caused by bladder stones or stroke
- Treat with anti-muscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin
- Bladder re-training sometimes helpful
Summarise the three main incontnece syndromes.
- Overflow
- Urethral blockage
- Bladder unable to empty properly
- Stress
- Relaxaed pelvic floor
- Increased abdominal pressure
- Urge
- Bladder oversensitivity from infection.
- Neurologic disorders.
What are the main drugs used in incontinence?
- Antimuscarinics (relax detrusor) oxybutinin, tolterodine, solifenacin, trospium
- Beta-3 adrenoceptor agonists (relax detrusor) mirabegron
- Alpha-blockers (relax sphincter, bladder neck) tamsulosin, terazosin, indoramin
- Anti-androgen drugs (shrink prostate) finasteride, dutasteride
What is neuropathic baldder?
Underactive bladder
Characteristic features:
- “Rare”
- Secondary to neurological disease, typically multiple sclerosis or stroke
- ALSO SECONDARY TO PROLONGED CATHETARISATION -
- No awareness of bladder filling resulting in overflow incontinence
- Medical treatments unsatisfactory but parasympathomimetics might help
- Catheterisation is only effective treatment
How is incontinence assessed?
- Careful history – may need closed question
- 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
- Consider referral to incontinence clinic for further investigation in difficult cases
- Suggest lifestyle/behavioural changes and stopping unnecessary drugs
- Consider physio, medical treatment or surgical options
When should incontinece be refered to a specialist?
Referral after failure of initial management
- Max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
OR
Referral necessary at onset:
- 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 Faecal incontinence
OR
Faecal incontinene
- Referral after failure of initial management:
- Constipation or diarrhoea with normal sphincter
- Referral necessary at onset:
- Suspected sphincter damage
- Neurological disease
If all else fails in incontinece, what can be done for patients?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
