Geriatrics: incontinence Flashcards
Which sex is urinary incontinence more common in?
Women
Where is there a prevalence of urinary incontinence?
Institutions: residential care, nursing home care, hospital care
What is the main objective in treating incontinence?
Identify causes and treat
What are the main causes of incontinence?
Extrinsic to urinary system: environment, habit, physical fitness
Intrinsic to urinary system: problem with bladder/urinary outlet
Both
What are extrinsic factors which lead to incontinence?
Physical state and co-morbidities Reduced mobility Confusion Drinking too much or wrong time Medications e.g. diuretics Constipation Home circumstances Social circumstances
What does continence depend on?
Effective function of bladder and integrity of neural connections which bring it under voluntary control:
- bladder and urethra
- local innervation
- CNS connections
What is the function of the bladder?
Urine storage
Voluntary voiding
What parts of the bladder are smooth muscle?
Detrusor
Internal urethral sphincter
What parts of the bladder are striated muscle?
External urethral sphincter
What does urine storage of the bladder involve?
Detrusor muscle relaxation with filling to normal volume 400-600ml with sphincter contraction
What does voluntary voiding of the bladder involve?
Voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder
What does parasympathetic innervation do for voiding?
Increases strength and frequency of contractions
What nerve roots are parasympathetic?
S2-4
What nerves are parasympathetic (S2-4) to bladder?
Pelvic splanchnic nerves
What does sympathetic (T10-L2) innervation do for voiding?
B-adrenoreceptors cause detrusor to relax
What does sympathetic (T10-S2) innervation do for voiding?
A-adrenoreceptors causes contraction of neck of bladder and internal urethral sphincter
What does somatic (S2-@$) innervation do for bladder voiding?
Contraction of pelvic floor muscle and external urethral sphincter
How do CNS connections aid bladder storage?
Centres within CNS inhibit parasympathetic tone and promote bladder relaxation - hence storage of urine
How is sphincter closure mediated?
Reflex increase in a-adrenergic and somatic activity
What does the pontine micturation centre do?
Normally exerts storage program of neural connections until voluntary switch to voiding program occurs
What happens to the intrinsic factors in incontinence?
Bladder and outlet either too weak/too strong
What is the physiology in stress incontinence?
Bladder outlet too weak
What happens in stress incontinence?
Urine leak on movement, coughing, laughing, squatting etc
Weak pelvic floor muscles
Common in women with children, esp after menopause
What are the treatments for stress incontinence?
Physiotherapy: pelvic floor exercises, pelvic floor stimulators/Kegel exercisers, vaginal cones
Oestrogen cream
Duloxetine
What are the surgical options for stress incontinence?
TVT/colposuspension
What is the physiology in urinary retention with overflow incontinence?
Bladder outlet too strong
What happens in overflow incontinence?
Poor urine flow, double voiding, hesitancy, post micturition dribbling
Blockage to urethra
Who is usually affected in overflow incontinence?
Older men with BPH
How is overflow incontinence treated?
Alpha blocker - relaxes sphincter (tamsulosin)
Anti-androgen - shrinks prostate (finasteride)
Surgery - TURP
Catheterisation - suprapubic
What are different types of incontinence?
Stress
Overflow
Urge
What is the physiology in urge incontinence?
Bladder muscle too strong
How is urge incontinence treated?
Anti-muscarinics - relax detrusor (oxybutinin, tolterodine, solifenacin)
What happens in urge incontinence?
Detrusor contracts at low volumes
Sudden urge to urinate immediately
What can cause urge incontinence?
Bladder stones
Stroke
Summarise the 3 main syndromes of incontinence
Overflow: urethral blockage and bladder unable to empty properly
Stress: Relaxed pelvic floor, increased abdominal pressure
Urge: bladder oversensitivity from infection, neurologic disorders
What are the main drugs used in incontinence?
Antimuscarinics - relax detrusor
Beta-3 adrenoceptor agonists - relax detrusor
Alpha blockers - relax sphincter and bladder neck
Anti-androgen drugs - shrink prostate
How do antimuscarinics act in incontinence?
Relax detrusor
How do beta-3 adrenoceptor agonists act in incontinence?
Relax detrusor
How do alpha-blockers act in incontinence?
Relax sphincter and bladder neck
How do anti-androgen drugs act in incontinence?
Shrink prostate
Give an example anti-androgen drug
Finasteride
Give an example alpha-blocker used in incontinence
Tamsulosin
Give an example antimuscarinic used in incontinence
Oxybutinin
Give an example beta-3 adrenoceptor agonist used in incontinence
Mirabegron
What is a neuropathic bladder?
Underactive bladder
When does neuropathic/underactive bladder typically occur?
Secondary to neurological disease e.g. MS/stroke
Or prolonged cathertarisation
What happen in neuropathic/underactive bladder?
No awareness of bladder filling resulting in overflow incontinence
What are the treatments for underactive bladder?
Parasympathomimetics?
Catheterisation
How do you assess incontinence?
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
When should you refer incontinence to specialist?
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
What are options for untreatable incontinence?
Incontinence pads Urosheaths Intermittent catheterisation Long term urinary catheter Suprapubic catheter
