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Systems: Specialities AB > Geriatrics: Continence > Flashcards

Geriatrics: Continence Flashcards

1
Q

Why is incontinence so important to learn about?

A
  • Common
  • Stigmatising
  • Disabling
  • Treatable
  • Most doctors not good at treating it
  • Often becomes permanent if untreated
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2
Q

What is the prevalence of incontinence?

A
  • Increases with age
  • Women 3x more likely
  • High rates in hospital, nursing homes and care homes
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3
Q

How should incontinence be viewed?

A

As a symptoms with many causes

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4
Q

What are the 2 classes of causes of incontinence?

A

Extrinsic to the urinary system
-Environment, habit, physical fitness

Intrinsic to the urinary system
-Problem with bladder or urinary outlet

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5
Q

Give examples of extrinsic factors that can lead to incontinence

A
  • 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
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6
Q

What does continence depend on?

A

Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control

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7
Q

What are the 2 functions of the bladder?

A
  • Voluntary voiding

- Urine storage

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8
Q

Describe the muscle of the bladder and the sphincters.

A
  • Detrusor is smooth muscle
  • Internal urethral sphincter is smooth muscle
  • External urethral sphincter is striated muscle
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9
Q

How does urine storage occur in the bladder?

A

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

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10
Q

How does voluntary voiding occur in the bladder?

A

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

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11
Q

What local innervation is there at the bladder?

A
  • Parasympathetic
  • Sympathetic
  • Somatic
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12
Q

What is the parasympathetic action on the bladder?

A

S2-S4

-Increases strength and frequency of contractions

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13
Q

What is the sympathetic action on the bladder?

A

T10-L2
-B-adrenoreceptor: causes detrusor to relax

T10-S2
-A-adrenorecptor: causes contraction of the neck of the bladder and internal urethral sphincter

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14
Q

What is the somatic action on the bladder?

A

S2-S4

-Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter

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15
Q

What CNS connections are there to the bladder?

A

Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.

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16
Q

What is sphincter closure mediated by?

A

Reflex increase in a-adrenergic and somatic activity.

17
Q

What role does the pontine micturition centre play?

A

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

18
Q

Apart from the pontine micturition centre, what other parts of the CNS is involved in the storage of urine?

A
  • Frontal cortex

- Caudal part of the spinal cord

19
Q

What are the 4 physiological problems that can result in incontinence?

A
  • Bladder too weak
  • Bladder too strong
  • Outlet too weak
  • Outlet too strong
20
Q

What type of incontinence occurs when the bladder outlet is too weak?

A

Stress incontinence

21
Q

What are the features of stress incontinence?

A
  • Urine leak on movement, coughing, laughing, squatting etc.
  • Weak pelvic floor muscles
  • Common in women with children, especially after menopause
22
Q

What are the treatments for stress incontinence?

A
  • Physiotherapy
  • Oestrogen cream
  • Duloxetine
  • TVT/colosuspension (90% cure at 10 years)
23
Q

What exercises can help strengthen the pelvic floor?

A

Kegel exercises

24
Q

What type of incontinence occurs when the bladder outlet is too strong?

A

Urinary retention with overflow incontinence

25
Q

What are the features of overflow incontinence?

A
  • Poor urine flow, double voiding, hesitancy, post micturition dribbling
  • Blockage to urethra
  • Common in older men with BPH
26
Q

How is overflow incontinence treated?

A
  • Alpha blockers
  • Anti-androgen
  • TURP surgery
  • May require catheterisation, often suprapubic
27
Q

What type of incontinence occurs when the bladder muscle is too strong?

A

Urge incontinence

28
Q

What are the features of urge incontinence?

A
  • Detrusor contracts at low volumes
  • Sudden urge to pass urine immediately
  • Patients often know every public bathroom
29
Q

What can cause urge incontinence?

A
  • Bladder stones
  • Stroke
  • Infection
30
Q

How is urge incontinence treated?

A
  • Anti-muscarinic (relax detrusor)

- Bladder retraining

31
Q

What are the main drugs used in incontinence?

A

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

32
Q

What problem is associated with a neuropathic bladder?

A

Underactive bladder

33
Q

What happens in an underactive bladder?

A
  • It is rare
  • Secondary to neurological disease or prolonged catheterisation
  • No awareness of bladder filling resulting in overflow incontinence
34
Q

How is a neuropathic bladder treated?

A
  • Medical treatments rarely work but parasympathomimetics may work
  • Catheterisation
35
Q

How is incontinence assessed?

A
  • 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
36
Q

When is it indicated that urinary incontinence be referred to specialists?

A

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

37
Q

When is a referral for urinary incontinence required at its onset?

A
  • 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
38
Q

When should faecal incontinence be referred?

A

Referral after failure of initial management
-Constipation of diarrhoea with normal sphincter

Referral necessary at onset:

  • Suspected sphincter damage
  • Neurological disease
39
Q

What options are there for managing incontinence when all else fails?

A
  • Incontinence pads
  • Urosheaths
  • Intermittent catheterisation
  • Long term urinary catheter
  • Suprapubic catheter

Systems: Specialities AB (19 decks)

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