Incontinence in the elderly Flashcards
What are some extrinsic factors (don’t originate from the urinary system itself) that cause Incontinence?
- 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 and social circumstances
Intrinsic factors that cause Incontinence?
Problems with the bladder or urinary outlet.
They can either be:
- Too weak
- Too strong
This leads to 4 clinical syndromes…
What does continence depend on?
Continence depends on the effective function of the bladder/urethra and the integrity of the neural connections which bring it under voluntary control (local innervation and CNS connections)
Why do people often empty their bladders as they lose consciousness or have epileptic fit?
- There are centres within the CNS that control the bladder and urethra. These centres inhibit parasympathetic tone (send inhibitory descending pathways) in the bladder and therefore tell it to relax.
- When the bladder gets stretched by urine, it automatically wants to contract and empty, however, this permanent inhibitory tone stops the bladder from doing this.
- if you lose consciousness etc then you lose this tone and the bladder empties
What syndrome of incontinence occurs if the bladder outlet is too weak?
Stress incontinence
Who classically gets stress incontinence? and why?
Tends to be post-menopausal women who have had children.
Why?
- Pelvic floor damage during pregnancy
- Loss of catabolic hormones like oestrogen that strengthen the pelvic floor muscles - leads to saggy muscles
Characteristic features of stress incontinence
- Urine leak on movement, coughing, laughing, squatting, etc.
- Weak pelvic floor muscles
Treatment for stress incontinence
1st line (non-pharmacological)
- Physiotherapy e.g Pelvic floor (kegel exercises), vaginal cones (hold them in your vagina), biofeedback
- Oestrogen cream - best given by pessary (gets closer to pelvic floor)
2nd line
- Duloxetine - SSRI (Selective Serotonin Reuptake Inhibitor) - unknown why anti-depressive drug is effective at treating incontinence
Ultimate treatment
- Surgical option – TVT/colposuspension - lift the bladder outlet and pelvic floor - 90% cure at 10 years
What devices can be used to strengthen your pelvic floor muscles?
- Vaginal cones (hold them in your vagina)
- Biofeedback - sensors that connect to computer that show when the patient is doing the right movement to strengthen their pelvic floor - teaches them what to do
- Kegal excersisers - looks like a dildo
- Pelvic floor stimulators - electrodes put into vagina or rectum
What incontinence syndrome occurs if the bladder outlet is too strong?
Urinary retention with overflow incontinence
Who classically gets Urinary retention with overflow incontinence?
More common in males with BPH- this is the only incontinence where this is the case
Symptoms of urinary retention + overflow incontinence
- Poor urine flow
- Double voiding
- Hesitancy
- Post micturition dribbling
Cause of urinary retention + overflow incontinence
- In men
- Benign prostatic hypertrophy - urethra is too narrow so urine can’t get through
- In women
- Urethral strictures e.g fibrosis etc
- Previous cervical cancer
How is urinary retention + overflow incontinence treated?
- Alpha-blocker (e.g tamsulosin)- relaxes and dilates sphincter (sympathetic N.S control internal sphincter so this blocks that)
- Anti-androgen - shrinks prostate
- Surgery (TURP - transurethral resection of the prostate)
- May need catheterisation
What syndrome of incontinence do you get if the bladder muscle is too strong?
Urge incontinence - detrusor muscle is contracting when there is a low volume of urine in the bladder
- It is very disabling - sudden urges to pass urine
- People often present with this earlier than other types of incontinence because of how disabling it is
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