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Stage 2: Ageing > Incontinence > Flashcards

Incontinence Flashcards

1
Q

What do we need to be continent?

A

1) Functional anatomy
2) Neurological integrity
3) Physical function
4) Environmental access
5) Psychological factors

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2
Q

What other group of people other than the elderly have continence problems?

A

1) Women who have had children

2) People with neurological problems

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3
Q

Describe the nervous system of the bladder

A
  • The parasympathetic system controls the internal sphincter (involuntary) - at 200-300ml the stretch receptors in the bladder send signals to the brain and back to the internal sphincter
  • Somatic nervous system controls the external sphincter (voluntary control)
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4
Q

What skin condition can sitting in urine/faeces lead to?

A

Dermatitis

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5
Q

How can peripheral oedema lead to incontinence?

A

When you lie down, the fluid goes back into the circulation and then can wake up needing the toilet

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6
Q

How does fluid/food intake affect continence?

A
  • Drinking caffeine/fluid right before bed may lead to night incontinence
  • People may dehydrate themselves to avoid needing the toilet during the day
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7
Q

What conditions can be linked to incontinence?

A
  • Stroke
  • MS
  • Heart failure
  • PD
  • Dementia
  • Abdominal operations
  • Hernia
  • Obesity
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8
Q

How does obstetric/gynae history link to incontinence?

A
  • If delivered multiple children vaginally the chances that their pelvic floor muscles are intact by the time they are 60 is low
  • Increased risk if forceps delivery
  • Episiotomy (faecal incontinence?)
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9
Q

What types of medications can be linked to incontinence?

A

Medications that promote passing urine or cause constipation

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10
Q

What mnemonic is used to screen for incontinence?

A

URINE

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11
Q

How do you screen for incontinence with URINE?

A

1) Urgency
2) Regular trips
3) Incontinence, UTIs, indwelling catheter
4) Nocturia
5) Exercise, sneeze, cough leakage

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12
Q

What mnemonic is used to assess incontinence?

A

DRIPS

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13
Q

How do you assess incontinence with DRIPS?

A

1) Drugs/dementia
2) Rectal exam
3) Image bladder (post void residual volume)
4) PV - vaginal examination
5) Send urine sample if symptoms of UTI

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14
Q

What would you want to check for in a rectal exam in incontinence?

A
  • Constipation

- Anal tone if faecally incontinent

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15
Q

Describe post void residual volume (PVRV) imaging

A
  • Residual volume in bladder
  • If the bladder doesn’t fully empty due to e.g. prostate, constipation, neurological problems
  • e.g. RV of 500ml so when add any amount on top it leaks
  • Imaging using US or bladder scanner
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16
Q

What are you looking for in a vaginal exam in incontinence?

A
  • Vaginal atrophy

- Uterine prolapse

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17
Q

Why are urine dips pointless in old people when testing for a UTI?

A
  • > 50% of 80 year olds would have a positive urine dip regardless of whether they have an infection esp. bacteriuria
  • 80% of time don’t have UTI and something has been missed
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18
Q

When are urine dips useful in old people?

A
  • Proteinuria - kidney disease

- Haematuria - endocarditis

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19
Q

What is stress urinary incontinence?

A
  • Involuntary passive loss of urine through stress exerted on the bladder due to pelvic floor muscle weakness
  • Leaking of urine worse on coughing and standing up
  • No urgency symptoms
20
Q

Why do coughing, sneezing and exercise cause leaking in stress incontinence?

A
  • Abdominal muscles are what holds everything in place
  • So if suddenly cough and abdominal muscles aren’t strong, abdominal pressure will exceed bladder pressure so will squeeze and some urine will come out
  • Pelvic floor muscles don’t have a tight seal sot he urine comes out
21
Q

What are the causes/risk factors for stress incontinence?

A

1) Childbirth esp. traumatic or surgery
2) Prostate surgery - removal of prostate affects muscles
3) Obesity
4) Chronic cough e.g. COPD (eventually abdominal pressure increases)
5) Previous pelvic surgery
6) Post-menopause - vaginal atrophy and weakness
7) Uterine prolapse
8) Diuretics - cause more urine to be produced all the time

22
Q

How do you manage stress incontinence?

A

1) Pelvic floor exercises (v effective)
2) Fluid management, treat fluid balance
3) Treat causes e.g. menopause, COPD and lifestyle factors e.g. diet and fluid advice
4) Bladder training (increasing time between going to toilet)
5) Weight loss
6) Review diuretics e.g. take them earlier or remove them
7) Leg elevation during the day so not sudden rush of fluid into circulation at night
8) Review funding for incontinence products

23
Q

What is the effect of topical oestrogen?

A
  • Improves vaginal atrophy
  • Prevents UTIs
  • Improves dryness
  • Prevents muscle breakdown
24
Q

What medication can cause a cough?

A

Ramipril (ACEi)

25
Q

What is urge urinary incontinence?

A

A sudden and strong desire to urinate which causes incontinence

  • Overactive bladder, detrusor instability
  • Sudden urge to go many times a day and can’t always make it to the toilet in time
26
Q

What are the causes/risk factors for urge urinary incontinence?

A

1) Alcohol/food e.g. caffeine
2) Infection
3) Constipation - reduces bladder expansion capability
4) Age - urge symptoms worse with age
5) Structural problems e.g. bladder stones/cancer
6) Neurological disorders

27
Q

How do you manage urge urinary incontinence?

A

1) Pelvic floor exercises
2) Functional review - help with getting to toilet
3) Bladder training
4) Double voiding - wait longer on toilet if more urine will come out, bladder not completely emptying bc weak in chronic urinary retention and holding onto urine
5) Drugs e.g. anticholinergics, B3 agonists (not good in old people)
6) Botox/nerve stimulator to try and reduce detrusor overactivity
7) Surgery if specific cause
8) Exclude urine infection or anatomical cause
9) Treat constipation
10) Referral for urodynamic studies

28
Q

What medications can be used to treat urge incontinence (none work v well)?

A

1) Muscarinic receptor antagonists (stop detrusor muscle contractions and overactivity) e.g. solifenacin, darifenacin or tolterodine, fesoterodine
2) Oxybutynin - also anti-cholinergic to help with urge symptoms (does more harm than good)
3) B3 agonist e.g. mirabegron - increase smooth muscle relaxation in bladder but causes uncontrolled hypertension

29
Q

What is severe cognitive impairment in the context of incontinence?

A

Loss of voluntary control over micturition or defection
- Like going back to being a baby, more reflex mediate, lost voluntary control over reflexes and can’t decide when to go to the toilet anymore

30
Q

What are the causes of severe cognitive impairment causing incontinence?

A

1) Dementia, neurodegenerative conditions

2) Trauma, stroke, neurodisability

31
Q

How do you manage severe cognitive impairment causing incontinence (improve QoL, can’t really stop incontinence)?

A

1) Modify any reversible causes e.g. UTI, constipation, vaginal atrophy, retention, thrush
2) Toileting regime if possible - sit on toilet 4 times a day where she can get everything out so has less incontinence, in practice not enough staff
3) Continence products
4) Good skin and pressure area care

32
Q

Which Alzheimer’s drug could cause incontinence?

A

Donepezil - cholinesterase inhibitor (opposite effect to anti-cholinergic)

33
Q

How can you treat faecal incontinence?

A

1) Check for impaction with PR ± AXR - if impacted, will have overflow diarrhoea and will help if can sort that out
2) Use bulking agent (ispaghula), laxatives
3) Consider regular suppository or enema
4) Exclude other medical causes
5) Stop drugs that cause bad constipation
6) Barrier creams to protect skin and turned over regularly

34
Q

Which drugs cause bad constipation?

A
  • Amlodipine
  • Adcal D3
  • Ferrous sulphate
35
Q

What scan would you do if someone was badly constipated to check for impaction?

A

AXR (±CT)

36
Q

How can constipation lead to faecal incontinence?

A

Passive faecal incontinence of overflow watery diarrhoea

37
Q

What are 3 laxatives?

A

Macrogol, lactulose, senna

38
Q

How can Parkinson’s lead to constipation and faecal incontinence?

A
  • NMS of PD is constipation due to present of gut Lewy bodies
  • Unable to manually evacuate bc tremor and mobility is so bad
39
Q

How would you manage a PD patient with severe constipation?

A

1) Rule out urinary retention
2) Modify laxatives - not enough, needs regular enema or suppository 2x a week to stimulate things to move
3) Footstool to aid Valsalva (straightens out rectal canal) and strengthen rectum
4) Abdominal massage can stimulate colonic motility
5) Optimise PD medications for pelvic dystonia
6) Prucalopride?

40
Q

How can constipation lead to significant complications?

A
  • Delirium from constipation or infection which translocates through bowel
  • Falls
  • Faecal impaction
41
Q

Why does older age lead to constipation?

A

Reduced gut activity and poor mobility

42
Q

How would you manage constipation in frail older people?

A

1) Lifestyle and dietary factors
2) Laxatives
3) Suppositories or enemas if needed
4) Drugs e.g. prucalopride
5) Manual evacuation
6) For people with profound neurological problems, more advanced procedures can be done

43
Q

What are harmful consequences of catheters?

A

1) Urethral trauma - haematuria

2) Infections e.g. CAUTI, sepsis

44
Q

What are the indications for catheters in older people?

A

1) Severe illness where active urine output monitoring will change management and help e.g. severe sepsis, candidate for dialysis so need to know urine output - but if frail and old probably won’t escalate so won’t help
2) Painful urinary retention e.g. 1L in bladder and need to drain out urine, delirious or in pain
3) Urinary tract obstruction e.g. urinary tract blockage that needs to be passed by catheter
4) Severe skin damage/pressure sores with incontinence and immobility where incontinence would cause more damage (short term catheter)
5) Patient choice (rare) e.g. v immobile or pressure sores

45
Q

When might someone need a long term catheter?

A

1) BPH - severe prostatic disease, recurrent episodes of urinary retention, need catheter to drain urine if they can’t pass it and not suitable for prostate surgery
2) Severe neurological conditions e.g. stroke, PD, MS
3) Anatomical problems e.g. local cancer or significant surgery

46
Q

What should you do when putting in a long term catheter?

A
  • Plan around catheter care e.g. to stop infection/blockage
  • Planned changes of catheter every 8-12 weeks to reduce infection, how to stop catheter becoming infected
  • Plan around review of need
47
Q

Even if someone has sepsis and you need to monitor urine output why is not necessary to put in a catheter?

A

If they can still pass urine themselves, can wee into a bottle and measure urine output that way

Stage 2: Ageing (10 decks)

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