Geriatrics: incontinence

Question 1

Which sex is urinary incontinence more common in?

Answer 1

Women

Question 2

Where is there a prevalence of urinary incontinence?

Answer 2

Institutions: residential care, nursing home care, hospital care

Question 3

What is the main objective in treating incontinence?

Answer 3

Identify causes and treat

Question 4

What are the main causes of incontinence?

Answer 4

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

Question 5

What are extrinsic factors which lead to incontinence?

Answer 5

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

Question 6

What does continence depend on?

Answer 6

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

• bladder and urethra
• local innervation
• CNS connections

Question 7

What is the function of the bladder?

Answer 7

Urine storage

Voluntary voiding

Question 8

What parts of the bladder are smooth muscle?

Answer 8

Detrusor

Internal urethral sphincter

Question 9

What parts of the bladder are striated muscle?

Answer 9

External urethral sphincter

Question 10

What does urine storage of the bladder involve?

Answer 10

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

Question 11

What does voluntary voiding of the bladder involve?

Answer 11

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

Question 12

What does parasympathetic innervation do for voiding?

Answer 12

Increases strength and frequency of contractions

Question 13

What nerve roots are parasympathetic?

Answer 13

S2-4

Question 14

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

Answer 14

Pelvic splanchnic nerves

Question 15

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

Answer 15

B-adrenoreceptors cause detrusor to relax

Question 16

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

Answer 16

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

Question 17

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

Answer 17

Contraction of pelvic floor muscle and external urethral sphincter

Question 18

How do CNS connections aid bladder storage?

Answer 18

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

Question 19

How is sphincter closure mediated?

Answer 19

Reflex increase in a-adrenergic and somatic activity

Question 20

What does the pontine micturation centre do?

Answer 20

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

Question 21

What happens to the intrinsic factors in incontinence?

Answer 21

Bladder and outlet either too weak/too strong

Question 22

What is the physiology in stress incontinence?

Answer 22

Bladder outlet too weak

Question 23

What happens in stress incontinence?

Answer 23

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

Question 24

What are the treatments for stress incontinence?

Answer 24

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

Question 25

What are the surgical options for stress incontinence?

Answer 25

TVT/colposuspension

Question 26

What is the physiology in urinary retention with overflow incontinence?

Answer 26

Bladder outlet too strong

Question 27

What happens in overflow incontinence?

Answer 27

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

Question 28

Who is usually affected in overflow incontinence?

Answer 28

Older men with BPH

Question 29

How is overflow incontinence treated?

Answer 29

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

Question 30

What are different types of incontinence?

Answer 30

Stress Overflow Urge

Question 31

What is the physiology in urge incontinence?

Answer 31

Bladder muscle too strong

Question 32

How is urge incontinence treated?

Answer 32

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

Question 33

What happens in urge incontinence?

Answer 33

Detrusor contracts at low volumes | Sudden urge to urinate immediately

Question 34

What can cause urge incontinence?

Answer 34

Bladder stones | Stroke

Question 35

Summarise the 3 main syndromes of incontinence

Answer 35

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

Question 36

What are the main drugs used in incontinence?

Answer 36

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

Question 37

How do antimuscarinics act in incontinence?

Answer 37

Relax detrusor

Question 38

How do beta-3 adrenoceptor agonists act in incontinence?

Answer 38

Relax detrusor

Question 39

How do alpha-blockers act in incontinence?

Answer 39

Relax sphincter and bladder neck

Question 40

How do anti-androgen drugs act in incontinence?

Answer 40

Shrink prostate

Question 41

Give an example anti-androgen drug

Answer 41

Finasteride

Question 42

Give an example alpha-blocker used in incontinence

Answer 42

Tamsulosin

Question 43

Give an example antimuscarinic used in incontinence

Answer 43

Oxybutinin

Question 44

Give an example beta-3 adrenoceptor agonist used in incontinence

Answer 44

Mirabegron

Question 45

What is a neuropathic bladder?

Answer 45

Underactive bladder

Question 46

When does neuropathic/underactive bladder typically occur?

Answer 46

Secondary to neurological disease e.g. MS/stroke | Or prolonged cathertarisation

Question 47

What happen in neuropathic/underactive bladder?

Answer 47

No awareness of bladder filling resulting in overflow incontinence

Question 48

What are the treatments for underactive bladder?

Answer 48

Parasympathomimetics? | Catheterisation

Question 49

How do you assess incontinence?

Answer 49

``` 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 ```

Question 50

When should you refer incontinence to specialist?

Answer 50

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

Question 51

What are options for untreatable incontinence?

Answer 51

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