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Elderly Medicine > Incontinence > Flashcards

Incontinence Flashcards

1
Q

Extrinsic causes of Incontinence

A

Environment, habit, physical fitness

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2
Q

Causes intrinsic to urinary system

A

Bladder or urinary outlet issue

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3
Q

Specific Extrinsic factors

A 
Physical state and comorbidities
Reduced mobility
Confusion; delirium or dementia
Drinking too much/at wrong time
Medications - diuretics
Constipation
Home circumstances
Social circumstances
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4
Q

Function of bladder

A

Urine storage and voluntary voiding

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5
Q

Detrusor- type of muscle?

A

Smooth

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6
Q

Internal urethral sphincter- type of muscle?

A

Smooth

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7
Q

External urethral sphincter- type of muscle?

A

Striated

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8
Q

Action of detrusor and sphincter on filling

A

Detrusor relaxes

Sphincter contracts

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9
Q

Actions on voluntary voiding

A

Internal sphincter relaxes involuntarily
External relaxes voluntarily
Bladder contracts

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10
Q

Parasympathetic Innervation?

A

S2-S4

Increases stength and frequency of contractions

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11
Q

Sympathetic

A

T10-L2
Beta adrenoreceptor - detrusor relaxes

T10-S2
Alpha receptor - contraction of neck of bladder and internal sphincter

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12
Q

Somatic innervation

A

S2-S4

Contraction of pelvic floor muscle (urogenital diaphragm|) and external sphincter

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13
Q

CNS connections

A

Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.

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14
Q

What mediates sphincter closure?

A

Reflex increase in alpha adrenergic and somatic activity

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15
Q

Which centre exerts the storage through neural connections until switch to voiding?

A

Pontine micturition centre

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16
Q

Which other areas are involved in control of continence?

A

Frontal cortex

Caudal part of spinal cord

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17
Q

Name a specific intrinsic factor of incontinence?

A

Stress incontinence

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18
Q

What causes stress incontinence?

A

Weakness of bladder outlet

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19
Q

Features of stress incontinence

A

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

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20
Q

Treatments of Stress incontinence

A

Physiotherapy
Oestrogen cream
Duloxetine
Surgery - TVT/colposuspension

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21
Q

Other treatments

A

Kegel exercises
Kegel exercisers
Vaginal cones
Biofeedback

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22
Q

If bladder outlet ‘too strong’?

A

Urinary retention with overflow incontinence

23
Q

Features of urinary retention & overflow incontinence

A

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

24
Q

Overflow incontinence is common in?

A

Older men with Benign Prostatic Hyperplasia

25
Q

Treatment of urinary retention

A

Alpha blocker
Antiandrogen
Surgery - TURP

26
Q

TURP?

A

Transurethral Resection of the Prostate

27
Q

Purpose of alpha blocker?

A

Relaxes sphincter

28
Q

Example of alpha blocker

A

tamsulosin

29
Q

Purpose of antiandrogen?

A

Shrinks prostate

30
Q

Example of antiandrogen

A

Finasteride

31
Q

Further procedure that may be needed in urinary retention

A

Catheterisation - suprapubic

32
Q

Condition when bladder muscle ‘too strong’

A

Urge incontinence

33
Q

Features of urge incontinence

A

Sudden urge to pass urine immediately

34
Q

What happens the detrusor at low volumes?

A

Contracts

35
Q

Causes of urge incontinence

A

Bladder stone or stroke

36
Q

Treatment of urge incontinence

A

Antimuscarinics

37
Q

Action of antimuscarinics

A

Relax detrusor

38
Q

Examples of antimuscarinics

A

Oxybutinin
Tolterodine
Solifenacin

39
Q

Other management of urge incontinence

A

Bladder training

40
Q

Underactive bladder known as a

A

Neuropathic bladder

41
Q

Features of a neuropathic/underactive bladder

A

No awareness to bladder filling leading to overflow incontinence

42
Q

Type of incontinence experienced with neuropathic bladder

A

Overflow

43
Q

Neuropathic bladder occurs secondary to

A

Neurological disease, stroke or multiple sclerosis

44
Q

Treatment

A

Catheterisation only effective treatment

45
Q

Medical treatment

A

Parasympathomimetics- not overly effective but may help

46
Q

How to assess incontinence

A 
History
Examination- general with rectal and vaginal
Intake chart and urine output diary
Urinalysis, MSSU
Bladder scan - residual volume
47
Q

How to check residual volume?

A

Bladder scan

48
Q

Further management

A 
Refer to incontinence clinic
Consider lifestyle changes
Consider drugs and medication review
Refer to physio
Medical treatment
Surgery
49
Q

When to refer to specialists

A

Failure of management - max 3 months pelvic floor exercises

50
Q

Referral at onset

A

Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume of urine after micturition
Disease of the CNS
Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
Severe benign prostatic hypertrophy or prostatic carcinoma
Patients who have had previous surgery for continence problems
Others in whom a diagnosis has not been made

51
Q

Referral of faecal incontinence

A

Failure of initial management

Constipation or diarrhoea with normal sphincter

52
Q

Referral for faecal incontinence at onset

A

Suspected sphincter damage

Neurological disease

53
Q

Options if management fails

A 
Incontinence pads
Urosheaths
Intermittent catheterisation
Long term urinary catheter
Surprapubic catheter
54
Q

Case
85 y/o lady, taken to bed, incontinent

PMHx: OA, CCF, Type II DM, COPD, anxiety

DHx: Dihydrocodeine 30mg qds
Furosemide 40mg od Combivent nebs qds Ranitidine 150mg bd Prednisolone 10mg od Temazepam 20mg nocte Citalopram 40mg od Metformin 500mg bd

A

Management

Improve pain relief
Increase COPD medications
Increase diuretics or other CCF medications
Stop furosemide
Improve diabetic control (up or down)
Minimise risk of syncope
Use cough suppressant
Stop constipating medications
Stop anticholinergic and sedative medications
Mobility aids
Make toilet more accessible e.g. stair-lift, commode
Lifestyle changes (e.g. restrict fluid)
Bladder exercises
Specific treatments (e.g. tolterodine)

Elderly Medicine (5 decks)

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