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
What is the only way you can prevent yourself from being incontinent straight away with urge incontinence?
By using external sphincter (under voluntary control)
It is a small muscle and it needs to fight against the detrusor muscle so you can normally only hold it for a very short period of time.
Common causes of urge incontinence?
- Neurological problems
- Stroke
- Multiple sclerosis (MS)
- Bladder stones
Treatment of urge incontinence
There are lots of cholinergic receptors around the detrusor muscle so these are blocked by anti-muscariniscs (anti-cholinergics) in order to relax the detrusor muscle
- Oxybutinin
- Tolterodine
- Solifenacin
Why are anti-muscarinics considered a ‘double edged sword’ when treating urge incontinence?
They have many side effects that can be dangerous for the patient, especially if they are incontinent:
- Blurred vision - affects balance - dangerous when trying to get to the toilet
- Dry mouth - blocks salivary glands - make you drink more = need the toilet more
- Stop gastric/colonic peristalsis - constipation
- Confusion - muscarinic receptors in the brain
- Vasodilation, postural instability, Orthostatic hypotension (when standing up) - muscarinic receptors in blood vessels
Always follow up to see how the medication is affecting them
Look
What is Neuropathic bladder?
An underactive bladder
Causes of neuropathic bladder
- Often secondary neurological disease i.e stroke or M.S
- But also secondary to prolonged catheterisation - as the detrusor muscle isn’t being used
What is the only effective treatment for a neuropathic bladder?
Catheterisation
Medical treatments that could work are exceptionally toxic so aren’t used
What should you cover when assessing incontinence in a patient?
- Careful history
- Good social history to assess impact of incontinence/QOL 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
When will someone be referred to a specialist service if there are no red flag symptoms?
After initial failure of management (usually after 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)
Reasons why someone will be immediately referred to specialist service? (7)
- Vesico-vaginal fistula
- Palpable bladder after micturition or confirmed large residual volume of urine after micturition (strongly suggests urinary retention)
- 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
Faecal incontinence referral
Referral after failure of initial management:
- Constipation or diarrhoea with normal sphincter
Referral necessary at onset:
- Suspected sphincter damage
- Neurological disease
Management of incontinence if all else fails
- Incontinence pads - underwear or ones that cover beds or chairs
- Urosheaths - not very reliable - used in patients that are very immobile (just out of surgery or stroke)
- Intermittent Catheterisation - safer than longterm catheter - self catheterise 4 times a day
- Long term urinary catheter
- Suprapubic catheter - reversible but usally left in indefinitely
