Incontinence Flashcards
what is the significance of incontinence in the elderly?
incontinence is one of the major factors leading older people to fall + require 24h care
- 30% in own home and 50% of those in care homes have this but is NOT part of natural ageing
- significant impact on mental health and wellbeing
what features will you focus on in a urinary incontinence history?
- Urine leakage on increased abdominal pressure
- Urgency
- Any pain on urination
- Urinary frequency
- Dribbling
- Medications
- Bowel habits
- Neurological disease
- any signs of infection, confusion
how might you examine and investigate urinary incontinence?
- review bladder and bowel diary
- abdominal exam
- urine dipstick and MSU
- PR examination - prostate assessment, assess pelvic floor
- external genitalia review - atrophic vaginitis
- post micturition bladder scan
- urodynamic testing
what causes stress incontinence?
weakness of pelvic floor → RF: post-partum, obesity, constipation, pelvic surgery etc
*leakage with increased intra-abdominal pressure
how is stress incontinence managed?
pelvic floor muscle training 3m, duloxetine for stronger urethral contractions, tension-free vaginal tape, colposuspension
how does urge incontinence occur?
detrusor hyperactivity, uninhabited bladder contraction → can be neurogenic, infection, malignancy, idiopathic, cholinesterase inhibitor meds
how is urge inconitnence investigated?
urodynamic assessment - checks of intravesicular, intra-abdominal pressures with detrusor pressure
Urine dip, MSU - infection
CT abdomen and pelvis - malignancy
Medication reviews
Bladder diaries
what is the management of urge incontinence?
lifestyle changes like caffeine, fluids etc anti-muscurinic drugs like oxybutynin to inhibit detrusor contraction
*solifenacin and mirabegron for elderly
bladder training 6w minimum
botulium toxin A injections
what is overflow incontinence?
complication of chronic urinary retention, progressive stretching of bladder → efferent fibre damage, loss of bladder sensation
*prostatic hyperplasia
how is overflow incontinence managed?
*urodynamics for flow rate etc
BPH management, doxazosin to relax muscle at base of urethra, bladder training
what is functional incontinence?
comorbid physical conditions impair ability to get to bathroom on time → dementia, sedation meds, ambulation
*optimise cause and consider catheterisation?
what is oxybutynin and what are the side effects?
antimuscurinic for urge
s/e: constipation, dizzy, drowsy, dry mouth
*FALLS in elderly frail
(avoided in ‘frail older women’)
what is solifenacin and s/e?
anticholinergic for frequency, urgency
s/e: constipation, dizzy, drowsiness, dry mouth
what is mirabegron and what are the s/e?
beta-3-adrenergic receptor agonist for overactive bladder
s/e: arrhythmia, constipation, diarrhoea, headache
*useful in elderly if anticholinergic burden concern
what is tolterodine and what are the s/e?
immediate release anticholinergic
s/e: constipation, dizziness, drowsiness, dry mouth etc
what is tamsulosin and what are the s/e?
alpha adrenergic receptor antagonist
*relax bladder neck muscles
s/e: dizziness, sexual dysfunction
what is the pathophysiology of faecal incontinence?
- faecal impaction with overflow diarrhoea (50% of faecal inc.)
- second neurogenic
- age and sphincter gape due to haemorrhoids, chronic constipation
- medications: antibiotics, muscle relaxants, PPI, metformin
how might you assess faecal incontinence?
- DRE - assess sphincter function, impaction
- perianal sensation
- stool type and charts assessed
- signs of infections, other spinal pathology
- abdominal exam - distention, hard faeces
how is faecal loading managed?
- check urinary retention!
- abdominal examination
- mx: enemas for rectal loading (won’t work on hard stool), stool softeners, stimulants
- manual evacuation → difficult, risk of perforation outweighed
- older patients → co-prescribe laxative with any meds causing constipation
how is chronic diarrhoea managed?
- bowel imaging, stool culture
- exclude impaction
- mx: regular toileting, dietary review, low dose loperamide
how is faecal incontinence managed?
- perianal exercises - sphincter weakness
- surgical anal sphincter repair
- steroids, GTN gel
- bowel training
- diarrhoea and constipation mx
- MDT care and psychological help
