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Geriatrics > Incontinence > Flashcards

Incontinence Flashcards

1
Q

how man times is it more common in women?

A

3 times

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2
Q

incontinence is a ?

A

symptom

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3
Q

causes - extrinsic

A

Environment, habit, physical fitness, etc.

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4
Q

causes - intrinsic

A

Problem with bladder or urinary outlet

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5
Q

Extrinsic Factors examples??

A
  • Physical state and co-morbidities
  • Reduced mobility
  • Confusion (delirium or dementia)
  • Drinking too much or at the wrong time
  • Medications, e.g. diuretics
  • Constipation
  • Home - circumstances
  • Social circumstances
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6
Q

Anatomy and Physiology - what do you need for continence?

A
  1. Bladder and Urethra
  2. Local Innervation
  3. CNS Connections
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7
Q

function of the bladder?

A
  • Urine storage

- Voluntary voiding.

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8
Q

features of the bladder

A
  • Detrusor is smooth muscle
  • Internal urethral sphincter is smooth muscle (autonomic NS)
  • External urethral sphincter is striated muscle (voluntary control)
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9
Q

what can the bladder normally hold ?

A

400-600ML

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10
Q

what muscle controls urine storage?

A

detrusor muscle relaxation ( with filling)

  • combined with sphincter contraction.
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11
Q

voluntary voiding involves?

A

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

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12
Q

local innervation of parasympathetic - what causes relaxation?

A

S2-S4

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13
Q

local innervation of sympathetic

- what causes relaxation and what is contracted? ?

A

T10-L2

  • ß - adrenoreceptor : causes detrusor to relax.
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14
Q

local innervation of sympathetic - what causes contraction and what is contracted? ?

A

T10-S2

  • adrenoreceptor : Causes contraction of neck of bladder, and internal urethral sphincter.
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15
Q

local innervation of somatic - what causes contraction and what is contracted?

A

S2-S4

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

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16
Q

CNS connections - tone?

A

permanent inhibitory tone

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17
Q

parasympathetic tone promotes ?

A

bladder relaxation and hence storage of urine

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18
Q

Sphincter closure is mediated by ?

A

reflex increase in a-adrenergic and somatic activity.

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19
Q

The pontine micturition centre normally exerts ??

A

a “storage program” of neural connections until a voluntary switch to a voiding program occurs.

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20
Q

other areas the are involved in incontinence?

A
  • Frontal cortex

- Caudal part of spinal cord

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21
Q

what happens when the bladder is too weak - what is this called?

A

stress incontinence

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22
Q

characteristic features of incontinence

A
  • Urine leak on movement, coughing, laughing, squatting, etc.
  • Weak pelvic floor muscles
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23
Q

why is stress incontinence more common in post menopausal women who have had children?

A
  • damage to pelvic floor

- love catabolic hormones eg oestrogen which would normally strengthen the muscles

24
Q

treatments of stress incontinence (3)

A

pads

- physiotherapy, oestrogen cream (pessary) and duloxetine (SSRI)

25
surgical option for stress incontinence?
TVT/colposuspension 90% cure at 10 years
26
women may choose to do? (non pharmacological)
- pelvic floor exercises - vaginal cones - biofeedback - kegal exercisers - Pelvic floor stimulators
27
urinary retention is more common in
men
28
urinary retention in men means what - characteristic features
urethra too narrow - urine can't go through - Poor urine flow (prostatism), double voiding, hesitancy, post micturition dribbling
29
Urinary retention with overflow incontinence common IN?
Benign prostatic hypertrophy (BPH) | - older men
30
how do we treat Urinary retention with overflow incontinence? WHY???
alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
31
When may you see Urinary retention with overflow incontinence in women
those who have had TVT | - PMH of cervical cancer (radiotherapy causes fibrosis0
32
urge incontinence- what does this mean
Detrusor contracts at low volumes
33
feature of urge incontinence-
sudden urge to pass urine immediately
34
classic sign of urge incontinence
Patients often know every public toilet
35
why is urge incontinence often caused?
bladder stones or stroke (MS)
36
how can we treat urge incontinence? give a few examples of drugs
with anti-muscarinics (relax detrusor) | e.g. oxybutinin, tolterodine, solifenacin
37
anti cholinergic drug side effects?
- blurred vision - confusion - dry mouth - blocks salivary glands - trip more - drink more - stop gastric peristalsis
38
main features of bladder overflow
urethral blockage | - bladder unable to empty properly
39
main features of bladder stress
relaxed pelvic floor | - incased abdo pressure
40
main features of bladder urge
bladderover sensitivity | - neurologic disorders
41
Antimuscarinics (relax detrusor) (4) drug examples
oxybutinin, tolterodine, solifenacin, trospium
42
Beta-3 adrenoceptor agonists (relax detrusor) - give the new drug
mirabegron
43
Alpha-blockers (relax sphincter, bladder neck) | - drug examples
tamsulosin, terazosin, indoramin - helpful for outflow obstruction
44
Anti-androgen drugs (shrink prostate) drug examples
finasteride, dutasteride
45
Neuropathic Bladder- underachieve bladder can be secondary to?
- multiple sclerosis or stroke | ALSO SECONDARY TO PROLONGED CATHETARISATION
46
what might help for Neuropathic Bladder? -why are they not really used?
parasympathomimetics a pro cholinergic drug (Acetyl choline) - VERY TOXIC - more for younger patients in ITU
47
scheme for assessing incontinence? (lots so just give a few examples)
Careful history – may need closed question - Good social history to assess impact of incontinence and identify ‘extrinsic’ factors - Intake chart and urine output diaries - General examination to include rectal and vaginal examination - Urinalysis and MSSU - Bladder scan for residual volume - Consider referral to incontinence clinic for further investigation in difficult cases - Suggest lifestyle/behavioural changes and stopping unnecessary drugs - Consider physio, medical treatment or surgical options
48
what examinations for incontinence and why do you carry them out? (4)
- rectal examination for low anal tone - perhaps neuropathic bladder - faeces in rectum - element of irritation of the bladder - vaginal examination looking for atrophy and low vaginal tone - abdominal examination - feeling for overfull bladder
49
bladder scanners look for?? when should they be done?
after the patient has passed water - os there residual volume - about 250 mls suggestive or retention and incomplete bladder emptying
50
indications for referral to specialists (incontinence) (7)
- 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
Indications for referral to specialists - Faecal incontinence - failure after management
Referral after failure of initial management: | Constipation or diarrhoea with normal sphincter
52
Indications for referral to specialists - Faecal incontinence - onset
Suspected sphincter damage | Neurological disease
53
What canyon do if treatment fails (5)
- Incontinence pads - Urosheaths - Intermittent -catheterisation - Long term urinary catheter - Suprapubic catheter
54
Indications for referral to specialists- Urinary incontinence - when should you refer and why?
failure of 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
55
Possible strategies for treatment
- 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) - Use containment strategies, etc, etc…

Geriatrics (10 decks)

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