Geriatrics - incontinence Flashcards
Causes of incontinence
extrinsic to the urinary system, intrinsic to the urinary system
Extrinsic factors
Physical state and co-morbidities, Reduced mobility, Confusion (delirium or dementia), Drinking too much or at the wrong time, Medications, e.g. diuretics, Constipation, Home circumstances, Social circumstances
simple way the nervous system works in urination
switch on parasympathetic system and switch off the sympathetic nervous system
what is the detrusor, internal and external urethral sphincter made of?
detrusor and internal - smoot muscle, ext- striated muscle.
how is urine stored in the bladder? In terms of detrusor and sphincter action…
Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction.
How is voluntary voiding carried out?
Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder.
explain using root values how the bladder is innervated and thhe action each provides.
(S2-S4) : Parasympathetic - Increases strength and frequency of contractions
(T10-L2) : Sympathetic - ß - adrenoreceptor : causes detrusor to relax.
(T10-S2) : Sympathetic - a - adrenoreceptor : Causes contraction of neck of bladder, and internal urethral sphincter.
(S2-S4) : Somatic - Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter.
how does the CNS interact with micturition?
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
high lesion
constant incontinence as te detrusor cannot relax
low lesion
lock the ability of the urethra to open - muscle cannot relax
4 types of incontinence
Stress incontinence/ Urinary retention with overflow incontinence/ Urge incontinence/ neuropathic bladder
Stress incontinence
bladder outlet too weak: Urine leak on movement, coughing, laughing, squatting, etc.
Weak pelvic floor muscles
Common in women with children, especially after menopause
Treatments include physiotherapy (Kegel, vaginal cones, biofeedbaack), oestrogen cream and duloxetine
Surgical option – TVT/colposuspension 90% cure at 10 years
Urinary retention with overflow incontinence
Bladder outlet is too strong, can have fibrosis of the urethra idiopathically in males and females - colposuspension more common in cervical cancer - tx with radiotherapy. Poor urine flow, double voiding,
hesitancy, post micturition dribbling
Blockage to urethra, on examination will feel a big smooth bladder.
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
Urge incontinecce
Bladder muscle too strong - overactive bladder - not full but still contracts, external sphincter does work but pressure on it.. Detrusor contracts at low volumes
Sudden urge to pass urine immediately, disabling. usually due to not drinking enough water
Patients often know every public toilet
Can be caused by bladder stones or stroke
Treat with anti-muscarinics (relax detrusor, blocks the parasympathetic system) - however: dry mouth, constipation, dizziness, side effects, need reveiwed in a week.
e.g. oxybutinin, tolterodine, solifenacin
Bladder re-training sometimes helpful- empty bladder every 2 hours even if you dont need to urinate, to desentitise the bladder from contraction
Neuropathic bladder
due to prolongued cateterisation or can occur randomly or secondary to a disease. Underactive 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
Medical treatments unsatisfactory but parasympathomimetics might help
Catheterisation is only effective treatment, parasympatomimetics are usually too toxic.
