Geriatrics: Continence

Question 1

What are the causes of incontinence that are extrinsic to the urinary system?

Answer 1

• Environment, habit, physical fitness, etc.​
• 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​

Question 2

What are the causes of incontinence intrinsic to the urinary system?

Answer 2

• Problem with bladder or urinary outlet​
• Bladder and/ or outlet
  Too weak and/ or too strong

Question 3

True or false: In frail individuals, the cause of incontinence is extrinsic to the urinary system?

Answer 3

False: it is often a bit of both

Question 4

What is stress incontinence?

Answer 4

The bladder outlet is too weak

Question 5

What are the charecteristic features of stress incontinence?

Answer 5

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

Question 6

What are the management option for stress incontinence?

Answer 6

• Treatments include physiotherapy, oestrogen cream and duloxetine​
• Surgical option – TVT/colposuspension 90% cure at 10 years

Question 7

What is urinary retention with overflow incontinence?

Answer 7

The bladder outlet is too strong

Question 8

What are the charecteristic features of urinary retention with overflow incontinence?

Answer 8

• Poor urine flow, double voiding,​
• hesitancy, post micturition dribbling​
• Blockage to urethra​
• Older men with BPH​

Question 9

What are the management options for urinary retention with overflow incontinence?

Answer 9

• 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​

Question 10

What is urge incontinence?

Answer 10

The bladder muscles are too strong

Question 11

What aree the charecteristoc features of urge incontinence?

Answer 11

• 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​

Question 12

What are the management options for urge incontinence?

Answer 12

• Treat with anti-muscarinics (relax detrusor) ​
  □ e.g. oxybutinin, tolterodine, solifenacin ​
• Bladder re-training sometimes helpful​

Question 13

What are the main drugs used in incontinence?

Answer 13

○ 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​

Question 14

What is neuropathic bladder?

Answer 14

Underactive bladder

Question 15

What are the charecteristic featurtes of a neuropathic bladder?

Answer 15

• “Rare”​
• Secondary to neurological disease, typically multiple sclerosis or stroke​
• ALSO SECONDARY TO PROLONGED CATHETARISATION​
• No awareness of bladder filling resulting in overflow incontinence​

Question 16

What are the management options for an underactive bladder?

Answer 16

• Medical treatments unsatisfactory but parasympathomimetics might help​
• Catheterisation is only effective treatment

Question 17

How should you assess incontinence?

Answer 17

○ 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​

Question 18

When sould you refer the patient to the incotinence clinic?

Answer 18

• Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/ or appropriate medication)
• 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​
  □ Referral after failure of initial management:​
  ® Constipation or diarrhoea with normal sphincter​
  □ Referral necessary at onset:​
  ® Suspected sphincter damage​
  ® Neurological disease​

Question 19

What are the options if everything else fails?

Answer 19

○ Incontinence pads​
○ Urosheaths ​
○ Intermittent catheterisation ​
○ Long term urinary catheter​
○ Suprapubic catheter