Geriatrics: Continence Flashcards
What are the causes of incontinence that are extrinsic to the urinary system?
- 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
What are the causes of incontinence intrinsic to the urinary system?
- Problem with bladder or urinary outlet
- Bladder and/ or outlet
Too weak and/ or too strong
True or false: In frail individuals, the cause of incontinence is extrinsic to the urinary system?
False: it is often a bit of both
What is stress incontinence?
The bladder outlet is too weak
What are the charecteristic 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 management option for stress incontinence?
- Treatments include physiotherapy, oestrogen cream and duloxetine
- Surgical option – TVT/colposuspension 90% cure at 10 years
What is urinary retention with overflow incontinence?
The bladder outlet is too strong
What are the charecteristic features of urinary retention with overflow incontinence?
- Poor urine flow, double voiding,
- hesitancy, post micturition dribbling
- Blockage to urethra
- Older men with BPH
What are the management options for urinary retention with overflow incontinence?
- 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
What is urge incontinence?
The bladder muscles are too strong
What aree the charecteristoc features of urge incontinence?
- 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
What are the management options for urge incontinence?
- Treat with anti-muscarinics (relax detrusor)
□ e.g. oxybutinin, tolterodine, solifenacin - Bladder re-training sometimes helpful
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 bladder?
Underactive bladder
What are the charecteristic featurtes of a neuropathic bladder?
- “Rare”
- Secondary to neurological disease, typically multiple sclerosis or stroke
- ALSO SECONDARY TO PROLONGED CATHETARISATION
- No awareness of bladder filling resulting in overflow incontinence
What are the management options for an underactive bladder?
- Medical treatments unsatisfactory but parasympathomimetics might help
- Catheterisation is only effective treatment
How should you assess incontinence?
○ 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
When sould you refer the patient to the incotinence clinic?
- 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
What are the options if everything else fails?
○ Incontinence pads ○ Urosheaths ○ Intermittent catheterisation ○ Long term urinary catheter ○ Suprapubic catheter
