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Geriatrics > Incontinence > Flashcards

Incontinence Flashcards

1
Q

Why is incontinence an important topic?

A 
Common
Stigmatising
Disability
Treatable
Drs bad at treating it
If left untreated can often become permanent
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2
Q

In which groups of people is urinary incontinence most common?

A

3x more common in women

More common in those having hospital care, nursing home residents, those in residential care

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3
Q

Is incontinence a symptom or a diagnosis?

A

Symptom with many causes

Must find and treat the cause

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4
Q

What are the two groups of causes of incontinence?

A

Extrinsic to urinary system (environment, habit, physical fitness etc)

Intrinsic to urinary system (problem with urinary bladder/bladder outlet)

Often bit of both

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5
Q

What are the extrinsic factors contributing to urinary incontinence?

A 
Physical state and comorbs 
Reduced mobility
Confusion (delirium, dementia)
Drinking too much or at the wrong time
Diuretics
Constipation
Home or social circumstances
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6
Q

Continence depends on the effective function of what three things?

A

Bladder and urethra
Local innervation
CNS connections

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7
Q

What are the functions of the bladder?

A

Storage of urine

Voiding

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8
Q

What muscle is in the bladder wall? What kind of muscle is it?

A

Detrusor

Smooth

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9
Q

What is the internal urethral sphincter made from?

A

Smooth muscle

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10
Q

What is the external urethral sphincter composed of?

A

Striated muscle

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11
Q

What does urine storage involve?

A

Detrusor relaxation

With filling <10cm pressure to normal volume 400-600ml combined with sphincter contraction

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12
Q

What does voluntary voiding involve?

A

Voluntary relaxation of external urethral sphincter
Involuntary relaxation of internal urethral sphincter
Contraction of bladder

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13
Q

What is the parasympathetic supply to the bladder and what does it’s stimulation result in?

A

S2-4

Increases frequency and strength of contractions of detrusor

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14
Q

What is the sympathetic supply to the detrusor and what does it’s stimulation result in?

A

T10-12
B-adrenoreceptor
Causes detrusor to relax

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15
Q

What is the sympathetic supply to the neck of the bladder and what does it’s stimulation cause?

A

T10-S2
A-adrenoreceptor
Causes contraction of neck of bladder and internal urethral sphincter

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16
Q

What is the somatic nervous supply to the bladder?

What does it’s stimulation cause?

A

S2-4

Contraction of pelvic floor muscles (urogenital diaphragm) and external urethral sphincter

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17
Q

How do centres in the CNS contribute to continence?

A

By inhibiting parasympathetic tone and promoting bladder relaxation leading to storage of urine

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18
Q

What is bladder sphincter closure mediated by?

A

Reflex increase in a-adrengeric and somatic reflexes

19
Q

What is the function of the pontine micturition centre?

A

Exerts a storage programme of neural connections until a voluntary switch to voiding programme occurs

20
Q

What other parts of the CNS are involved in micturition?

A

Frontal cortex

Caudal part of spinal cord

21
Q

What are the intrinsic factors for urinary incontinence?

A

Bladder or outlet is too weak or too strong

22
Q

If the bladder outlet is too weak what kind of incontinence results?

A

Stress incontinence

23
Q

What are the characteristic features of stress incontinence?

A

Urine movement on laughing, coughing, squatting, movement etc.
Weak pelvic floor muscles
Common in those who’ve had children, esp after menopause

24
Q

What are the treatment options for stress incontinence?

A

Physiotherapy
Oestrogen cream
Duloxetine

25
Q

What are the surgical treatment options for stress incontinence?

A

TVT/colposuspension

26
Q

What may be involved in physiotherapy for stress urinary incontinence?

A 
Pelvic floor muscle training
Vaginal cones
Biofeedback
Kegel exercisers
Pelvic floor simulation
27
Q

What kind of incontinence occurs if the bladder outlet is too strong?

A

Urinary retention with overflow incontinence

28
Q

What are the characteristic features of urinary retention with overflow incontinence?

A

Poor urine flow, double voiding, hesitancy, post-micturition dribbling

29
Q

What causes urinary retention with overflow incontinence? In which group is it most common?

A

Urethral blockage

Older men with BPH

30
Q

How do you treat urinary retention with overflow incontinence?

A

Alpha blocker (relaxes sphincter, eg tamsulosin) or anti-androgen (shrinks prostate, eg finasteride) or surgery, eg TURP

May need catheterisation, often suprapubic

31
Q

What kind of incontinence results from the bladder muscle being too strong?

A

Urge incontinence

32
Q

What are the characteristic features of urge incontinence?

A

Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Patients often know every public toilet

33
Q

What can cause urge incontinence?

A

Bladder stones

Stroke

34
Q

How do you treat urge incontinence?

A

Anti-muscarinics (relaxes detrusor), eg oxybutinin, tolterodine, solifenacin
Bladder retraining

35
Q

Apart from anti-muscarinics, what other drugs can be used to relax the detrusor?

A

Beta-3 adrenoreceptor agonists (eg mirabegron)

36
Q

What do alpha blockers do?

A

Relax bladder neck and sphincter

Egs - tamsulosin, terazosin, indoramin

37
Q

Name two anti-androgen drugs

A

Finasteride

Dutasteride

38
Q

What is neuropathic bladder?

A

Underactive bladder
Rare
Usually secondary to neurological disease, typically MS/stroke
Also secondary to prolonged catheterisation
No awareness of bladder filling leading to overflow incontinence

39
Q

How to treat neuropathic bladder?

A

Medical treatments unsatisfactory but parasympathiometics may help
Catheterisation is only effective option

40
Q

What should be your scheme for assessing incontinence?

A

Hx (ensure to rule out extrinsic factors)
Intake chart and urine output diaries
General Ex and rectal/vaginal
Urinalysis and MSSU
Bladder scan for residual volume
Refer to incontinence clinic for further Ix
Suggest behaviour/lifestyle changes and maybe stopping drugs
Consider physio, medical or surgical Rx

41
Q

When should you refer urinary incontinence to a specialist?

A

After failure of initial management (max 3 months of pelvic floor exercise, cone therapy, habit retraining, and/or appropriate medications)

42
Q

When should you refer on a first visit with someone with urinary incontinence?

A

Vesico-vaginal fistula
Palpable bladder after voiding or confirmed large residual urine volume after voiding
Disease of CNS
Certain gynae conditions, eg fibroids, procedentia, rectocele, cystocele)
Severe BPH or prostatic carcinoma
Patients who’ve had previous surgery for incontinence
Other in whom a diagnosis has not been made

43
Q

When should you refer to a specialist for faecal incontinence?

A

Failure of initial management

Referral at onset if suspected sphincter damage or neurological dx

44
Q

What are last resort treatment options?

A 
Incontinence pads
Urosheaths
CISC
Long term urinary catheter 
Suprapubic catheter

Geriatrics (13 decks)

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