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Specialities > Geriatrics: incontinence > Flashcards

Geriatrics: incontinence Flashcards

1
Q

Which sex is urinary incontinence more common in?

A

Women

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2
Q

Where is there a prevalence of urinary incontinence?

A

Institutions: residential care, nursing home care, hospital care

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3
Q

What is the main objective in treating incontinence?

A

Identify causes and treat

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4
Q

What are the main causes of incontinence?

A

Extrinsic to urinary system: environment, habit, physical fitness
Intrinsic to urinary system: problem with bladder/urinary outlet
Both

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5
Q

What are extrinsic factors which lead to incontinence?

A 
Physical state and co-morbidities
Reduced mobility
Confusion
Drinking too much or wrong time
Medications e.g. diuretics
Constipation
Home circumstances
Social circumstances
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6
Q

What does continence depend on?

A

Effective function of bladder and integrity of neural connections which bring it under voluntary control:

  • bladder and urethra
  • local innervation
  • CNS connections
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7
Q

What is the function of the bladder?

A

Urine storage

Voluntary voiding

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8
Q

What parts of the bladder are smooth muscle?

A

Detrusor

Internal urethral sphincter

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9
Q

What parts of the bladder are striated muscle?

A

External urethral sphincter

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10
Q

What does urine storage of the bladder involve?

A

Detrusor muscle relaxation with filling to normal volume 400-600ml with sphincter contraction

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11
Q

What does voluntary voiding of the bladder involve?

A

Voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder

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12
Q

What does parasympathetic innervation do for voiding?

A

Increases strength and frequency of contractions

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13
Q

What nerve roots are parasympathetic?

A

S2-4

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14
Q

What nerves are parasympathetic (S2-4) to bladder?

A

Pelvic splanchnic nerves

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15
Q

What does sympathetic (T10-L2) innervation do for voiding?

A

B-adrenoreceptors cause detrusor to relax

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16
Q

What does sympathetic (T10-S2) innervation do for voiding?

A

A-adrenoreceptors causes contraction of neck of bladder and internal urethral sphincter

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17
Q

What does somatic (S2-@$) innervation do for bladder voiding?

A

Contraction of pelvic floor muscle and external urethral sphincter

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18
Q

How do CNS connections aid bladder storage?

A

Centres within CNS inhibit parasympathetic tone and promote bladder relaxation - hence storage of urine

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19
Q

How is sphincter closure mediated?

A

Reflex increase in a-adrenergic and somatic activity

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20
Q

What does the pontine micturation centre do?

A

Normally exerts storage program of neural connections until voluntary switch to voiding program occurs

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21
Q

What happens to the intrinsic factors in incontinence?

A

Bladder and outlet either too weak/too strong

22
Q

What is the physiology in stress incontinence?

A

Bladder outlet too weak

23
Q

What happens in stress incontinence?

A

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

24
Q

What are the treatments for stress incontinence?

A

Physiotherapy: pelvic floor exercises, pelvic floor stimulators/Kegel exercisers, vaginal cones
Oestrogen cream
Duloxetine

25
Q

What are the surgical options for stress incontinence?

A

TVT/colposuspension

26
Q

What is the physiology in urinary retention with overflow incontinence?

A

Bladder outlet too strong

27
Q

What happens in overflow incontinence?

A

Poor urine flow, double voiding, hesitancy, post micturition dribbling
Blockage to urethra

28
Q

Who is usually affected in overflow incontinence?

A

Older men with BPH

29
Q

How is overflow incontinence treated?

A

Alpha blocker - relaxes sphincter (tamsulosin)
Anti-androgen - shrinks prostate (finasteride)
Surgery - TURP
Catheterisation - suprapubic

30
Q

What are different types of incontinence?

A

Stress
Overflow
Urge

31
Q

What is the physiology in urge incontinence?

A

Bladder muscle too strong

32
Q

How is urge incontinence treated?

A

Anti-muscarinics - relax detrusor (oxybutinin, tolterodine, solifenacin)

33
Q

What happens in urge incontinence?

A

Detrusor contracts at low volumes

Sudden urge to urinate immediately

34
Q

What can cause urge incontinence?

A

Bladder stones

Stroke

35
Q

Summarise the 3 main syndromes of incontinence

A

Overflow: urethral blockage and bladder unable to empty properly
Stress: Relaxed pelvic floor, increased abdominal pressure
Urge: bladder oversensitivity from infection, neurologic disorders

36
Q

What are the main drugs used in incontinence?

A

Antimuscarinics - relax detrusor
Beta-3 adrenoceptor agonists - relax detrusor
Alpha blockers - relax sphincter and bladder neck
Anti-androgen drugs - shrink prostate

37
Q

How do antimuscarinics act in incontinence?

A

Relax detrusor

38
Q

How do beta-3 adrenoceptor agonists act in incontinence?

A

Relax detrusor

39
Q

How do alpha-blockers act in incontinence?

A

Relax sphincter and bladder neck

40
Q

How do anti-androgen drugs act in incontinence?

A

Shrink prostate

41
Q

Give an example anti-androgen drug

A

Finasteride

42
Q

Give an example alpha-blocker used in incontinence

A

Tamsulosin

43
Q

Give an example antimuscarinic used in incontinence

A

Oxybutinin

44
Q

Give an example beta-3 adrenoceptor agonist used in incontinence

A

Mirabegron

45
Q

What is a neuropathic bladder?

A

Underactive bladder

46
Q

When does neuropathic/underactive bladder typically occur?

A

Secondary to neurological disease e.g. MS/stroke

Or prolonged cathertarisation

47
Q

What happen in neuropathic/underactive bladder?

A

No awareness of bladder filling resulting in overflow incontinence

48
Q

What are the treatments for underactive bladder?

A

Parasympathomimetics?

Catheterisation

49
Q

How do you assess incontinence?

A 
Hx
SHx - ?extrinsic factors
Intake chart and urine output
General exam w/rectal/vaginal
Urinalysis and MSSU
Bladder scan for residual volume
Incontinence clinic
Lifestyle/behavioural changes
Medication changes
Physio, medical treatment & surgical options
50
Q

When should you refer incontinence to specialist?

A

Failure of initial management (max 3mo physio/medication)
Vesico-vaginal fistula
Disease of CNS
Gynae conditions
Palpable bladder after micturition/confirmed large residual volume
Severe BPH or prostate cancer
Previous surgery for incontinence problems
Faecal incontinence

51
Q

What are options for untreatable incontinence?

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

Specialities (14 decks)

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