Incontinence in the elderly

Question 1

What is urinary incontinence?

Answer 1

Involuntary loss of urine, which is objectively demonstrable and is a social or hygienic problem

Question 2

What are the key points of incontinence in the elderly?

Answer 2

1. Urinary incontinence is not a normal part of ageing
2. The most frequent presenting complaint will include a combination of symptoms
3. Always remember the bowels
4. Only do urinalysis if the result will change your management
5. Remember polypharmacy when prescribing medication
6. Local oestrogens may make a significant difference

Question 3

Describe the normal physiology of continence?

Answer 3

• Cortical awareness of bladder fullness by the post-central gyrus
• Initiation of micturition in the pre-central gyrus
• Voluntary control of micturition in the frontal cortex
• Parasympathetic nerve activation (S2-4) produces contraction of the detrusor muscle and relaxation of the internal sphincter

Question 4

What is required for normal continence?

Answer 4

• Normal physiology
• Good mobility
• Manual dexterity
• Cognitive ability to react to bladder filling

Question 5

What are some changes in bladder function that occur with age?

Answer 5

• Decreased capacity
• Increased involuntary detrusor contractions
• Decreased contractility
• Increased residual urine

Question 6

What are the transient causes of incontinence? (DIAPPERS)

Answer 6

D - Delirium
I - Infection (Urinary)
A - Atrophic urethritis/vaginitis
P - Pharmaceutical or prostate
P - Psychological (E.g. depression)
E - Endocrine or Excess fluid intake
R - Restricted mobility
S - Stool impaction

Question 7

What are the main types of incontinence?

Answer 7

Stress
Urge
Mixed
Overflow
Functional

Question 8

What is meant by stress incontinence?

Answer 8

Involuntary leakage on effort or exertion, sneezing or coughing

Question 9

What is meant by urge incontinence?

Answer 9

Involuntary leakage accompanied by or immediately preceded by urgency

Question 10

What is meant by mixed incontinence?

Answer 10

Stress + Urge

Question 11

What is meant by overflow incontinence?

Answer 11

Leakage owing to bladder outflow obstruction of any cause resulting in large post-void residual volume

Question 12

What is meant by functional incontinence?

Answer 12

Incontinence resulting from an inability to reach or use the toilet in time (Poor cognition, Poor mobility)

Question 13

How is incontinence in the elderly managed?

Answer 13

MDT approach
Lifestyle changes
Pelvic floor exercises
Bladder training
Pharmacological
Surgical

Question 14

1st line drug for urge incontinence

Answer 14

Tolterodine 2mg BD (Anti-muscarinic)

Question 15

2nd and 3rd line drugs for urge incontinence

Answer 15

• 2nd line - Solifenacin 5mg OD
• 3rd line - Mirabegron MR 50mg (ß3-agonist)

Question 16

Drug therapy for nocturia

Answer 16

• Late afternoon diuretic
• Desmopressin (Monitor sodium)

Question 17

Drug therapy for significant post-void residual

Answer 17

• Treat constipation
• Men - a-blockers, 5-alpha reductase inhibitors

Question 18

What are some indications for specialist referral in elderly incontinence

Answer 18

• Symptomatic prolapse at or below introitus
• Microscopic haematuria aged > 50
• Frank haematuria
• Recurrent or persisting UTI
• Suspected malignant mass
• Chronic retention
• Men with stress UI
• Failure of conservative Rx

Question 19

Multifactorial assessment and management of foecal incontinence in older people

Answer 19