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
