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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
Q

surgical option for stress incontinence?

A

TVT/colposuspension 90% cure at 10 years

26
Q

women may choose to do? (non pharmacological)

A
  • pelvic floor exercises
  • vaginal cones
  • biofeedback
  • kegal exercisers
  • Pelvic floor stimulators
27
Q

urinary retention is more common in

A

men

28
Q

urinary retention in men means what - characteristic features

A

urethra too narrow - urine can’t go through

  • Poor urine flow (prostatism), double voiding,
    hesitancy, post micturition dribbling
29
Q

Urinary retention with overflow incontinence common IN?

A

Benign prostatic hypertrophy (BPH)

- older men

30
Q

how do we treat Urinary retention with overflow incontinence? WHY???

A

alpha blocker (relaxes sphincter, e.g. tamsulosin)

or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)

31
Q

When may you see Urinary retention with overflow incontinence in women

A

those who have had TVT

- PMH of cervical cancer (radiotherapy causes fibrosis0

32
Q

urge incontinence- what does this mean

A

Detrusor contracts at low volumes

33
Q

feature of urge incontinence-

A

sudden urge to pass urine immediately

34
Q

classic sign of urge incontinence

A

Patients often know every public toilet

35
Q

why is urge incontinence often caused?

A

bladder stones or stroke (MS)

36
Q

how can we treat urge incontinence? give a few examples of drugs

A

with anti-muscarinics (relax detrusor)

e.g. oxybutinin, tolterodine, solifenacin

37
Q

anti cholinergic drug side effects?

A
  • blurred vision
  • confusion
  • dry mouth - blocks salivary glands
  • trip more
  • drink more
  • stop gastric peristalsis
38
Q

main features of bladder overflow

A

urethral blockage

- bladder unable to empty properly

39
Q

main features of bladder stress

A

relaxed pelvic floor

- incased abdo pressure

40
Q

main features of bladder urge

A

bladderover sensitivity

- neurologic disorders

41
Q

Antimuscarinics (relax detrusor) (4) drug examples

A

oxybutinin, tolterodine, solifenacin, trospium

42
Q

Beta-3 adrenoceptor agonists (relax detrusor) - give the new drug

A

mirabegron

43
Q

Alpha-blockers (relax sphincter, bladder neck)

- drug examples

A

tamsulosin, terazosin, indoramin

  • helpful for outflow obstruction
44
Q

Anti-androgen drugs (shrink prostate) drug examples

A

finasteride, dutasteride

45
Q

Neuropathic Bladder- underachieve bladder can be secondary to?

A
  • multiple sclerosis or stroke

ALSO SECONDARY TO PROLONGED CATHETARISATION

46
Q

what might help for Neuropathic Bladder?

-why are they not really used?

A

parasympathomimetics

a pro cholinergic drug (Acetyl choline)
- VERY TOXIC

  • more for younger patients in ITU
47
Q

scheme for assessing incontinence? (lots so just give a few examples)

A

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
Q

what examinations for incontinence and why do you carry them out? (4)

A
  • 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
Q

bladder scanners look for?? when should they be done?

A

after the patient has passed water

  • os there residual volume
  • about 250 mls suggestive or retention and incomplete bladder emptying
50
Q

indications for referral to specialists (incontinence) (7)

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

Indications for referral to specialists - Faecal incontinence - failure after management

A

Referral after failure of initial management:

Constipation or diarrhoea with normal sphincter

52
Q

Indications for referral to specialists - Faecal incontinence - onset

A

Suspected sphincter damage

Neurological disease

53
Q

What canyon do if treatment fails (5)

A
  • Incontinence pads
  • Urosheaths
  • Intermittent -catheterisation
  • Long term urinary catheter
  • Suprapubic catheter
54
Q

Indications for referral to specialists- Urinary incontinence
- when should you refer and why?

A

failure of 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication

55
Q

Possible strategies for treatment

A
  • 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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