Geriatrics: Continence Flashcards
Why is incontinence so important to learn about?
- Common
- Stigmatising
- Disabling
- Treatable
- Most doctors not good at treating it
- Often becomes permanent if untreated
What is the prevalence of incontinence?
- Increases with age
- Women 3x more likely
- High rates in hospital, nursing homes and care homes
How should incontinence be viewed?
As a symptoms with many causes
What are the 2 classes of causes of incontinence?
Extrinsic to the urinary system
-Environment, habit, physical fitness
Intrinsic to the urinary system
-Problem with bladder or urinary outlet
Give examples of extrinsic factors that can lead to incontinence
- 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
What does continence depend on?
Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control
What are the 2 functions of the bladder?
- Voluntary voiding
- Urine storage
Describe the muscle of the bladder and the sphincters.
- Detrusor is smooth muscle
- Internal urethral sphincter is smooth muscle
- External urethral sphincter is striated muscle
How does urine storage occur in the bladder?
Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction.
How does voluntary voiding occur in the bladder?
Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder
What local innervation is there at the bladder?
- Parasympathetic
- Sympathetic
- Somatic
What is the parasympathetic action on the bladder?
S2-S4
-Increases strength and frequency of contractions
What is the sympathetic action on the bladder?
T10-L2
-B-adrenoreceptor: causes detrusor to relax
T10-S2
-A-adrenorecptor: causes contraction of the neck of the bladder and internal urethral sphincter
What is the somatic action on the bladder?
S2-S4
-Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter
What CNS connections are there to the bladder?
Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.
What is sphincter closure mediated by?
Reflex increase in a-adrenergic and somatic activity.
What role does the pontine micturition centre play?
The pontine micturition centre normally exerts a “storage program” of neural connections until a voluntary switch to a voiding program occurs.
Apart from the pontine micturition centre, what other parts of the CNS is involved in the storage of urine?
- Frontal cortex
- Caudal part of the spinal cord
What are the 4 physiological problems that can result in incontinence?
- Bladder too weak
- Bladder too strong
- Outlet too weak
- Outlet too strong
What type of incontinence occurs when the bladder outlet is too weak?
Stress incontinence
What are the features of stress incontinence?
- Urine leak on movement, coughing, laughing, squatting etc.
- Weak pelvic floor muscles
- Common in women with children, especially after menopause
What are the treatments for stress incontinence?
- Physiotherapy
- Oestrogen cream
- Duloxetine
- TVT/colosuspension (90% cure at 10 years)
What exercises can help strengthen the pelvic floor?
Kegel exercises
What type of incontinence occurs when the bladder outlet is too strong?
Urinary retention with overflow incontinence
What are the features of overflow incontinence?
- Poor urine flow, double voiding, hesitancy, post micturition dribbling
- Blockage to urethra
- Common in older men with BPH
How is overflow incontinence treated?
- Alpha blockers
- Anti-androgen
- TURP surgery
- May require catheterisation, often suprapubic
What type of incontinence occurs when the bladder muscle is too strong?
Urge incontinence
What are the features of urge incontinence?
- Detrusor contracts at low volumes
- Sudden urge to pass urine immediately
- Patients often know every public bathroom
What can cause urge incontinence?
- Bladder stones
- Stroke
- Infection
How is urge incontinence treated?
- Anti-muscarinic (relax detrusor)
- Bladder retraining
What are the main drugs used in incontinence?
Anti-muscarinic (relax detrusor)
-Oxybutin, tolterodine, solifenacin, trospium
Beta-3-adrenoreceptor agonists (relax detrusor)
-Mirabegron
Alpha blockers (relax sphincter, bladder neck) -tamsulosin, terazosin, indoramin
Anti-androgen drugs (shrink prostate)
-Finasteride, dutasteride
What problem is associated with a neuropathic bladder?
Underactive bladder
What happens in an underactive bladder?
- It is rare
- Secondary to neurological disease or prolonged catheterisation
- No awareness of bladder filling resulting in overflow incontinence
How is a neuropathic bladder treated?
- Medical treatments rarely work but parasympathomimetics may work
- Catheterisation
How is incontinence assessed?
- History
- Social history (impact)
- Intake chart and urine output diaries
- General exam
- Urinalysis and MSSU
- Bladder scan for residual volume
- Referral to incontinence clinic
- Suggest lifestyle changes and stop unnecessary drugs
- Consider treatment options
When is it indicated that urinary incontinence be referred to specialists?
-Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
When is a referral for urinary incontinence required at its onset?
- Vesico-vaginal fistula
- Palpable bladder after micturition or confirmed large residual volume of urine
- Disease of the CNS
- Certain gynaecological conditions (fibroids, procidentia, rectocele, cystocele)
- Severe BPH or prostatic carcinoma
- Patients who have had previous surgery for continence concerns
- Other in whom a diagnosis has not been made
When should faecal incontinence be referred?
Referral after failure of initial management
-Constipation of diarrhoea with normal sphincter
Referral necessary at onset:
- Suspected sphincter damage
- Neurological disease
What options are there for managing incontinence when all else fails?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheter
- Suprapubic catheter
