LUTS in Older People Flashcards
What is urinary incontinence?
Involuntary loss of urine, which is objectively demonstrable and is a social/hygienic problem
Why may some patients with urinary incontinence not present to their GP?
Embarrassment, think it is normal part of ageing, often come to doctor with another “more important” problem
What are some challenges associated with urinary incontinence?
May be low on priority list of clinician if patient has more than one problem
Lack of confidence in interventions
Cost about 2% of NHS budget
What are some of the challenges associated with treating urinary incontinence?
Main pharmacological treatments have side effects particularly troublesome in elderly
Non-pharmacological management takes time
Is urinary incontinence a normal part of ageing?
No = should always be investigated and treated if it causing the patient distress
What part of the brain is responsible for cortical awareness of bladder fullness?
Located in the postcentral gyrus
What parts of the brain are responsible for micturition?
Initiation of micturition occurs in the precentral gyrus
Voluntary control of micturition is located in the frontal cortex
What is activated when the bladder is distended?
Sympathetic outflow (T11-L2) is activated = maintains detrusor muscle relaxation and continence
What causes voiding of the bladder in response to bladder filling?
Parasympathetic activation (S2-4) produces contraction of detrusor muscle and relaxation of internal sphincter
What are some additional elements required for continence?
Mobility, manual dexterity and cognitive ability to react to bladder filling
What changes occur in the bladder as a natural part of ageing?
Decrease in bladder capacity and urethral closure pressure
Increase in post void residual and detrusor overactivity
What are some transient causes of incontinence?
Delirium and psychological (especially depression)
Infection = urinary (symptomatic)
Atrophic vaginitis/urethritis and endocrine
Pharmaceutical/prostate and stool impaction
Restricted mobility
What are the types of incontinence?
Stress, urge, mixed, overflow and functional
What is stress incontinence?
Involuntary urinary leakage on effort or exertion, sneezing or coughing
What is urge incontinence?
Involuntary leakage accompanied by or immediately preceded by urgency
What is mixed incontinence?
Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing
What is overflow incontinence?
Leakage owing to bladder outflow obstruction resulting in large post void residual volume
What is functional incontinence?
Incontinence resulting from an inability to reach or use the toilet in time (e.g poor mobility, cognitive impairment)
What areas should be covered when taking a history?
Urinary symptoms, bowels, mobility, containment (e.g pads), red flags, drugs, fluid intake, precipitants, previous pelvic surgery
What are some urinary symptoms that may be present?
Storage = frequency, nocturia, urgency
Voiding = hesitancy, poor urinary stream, dribbling
History of haematuria or recurrent UTIs
What are some bowel symptoms that patients may complain of?
Straining, constipation, incontinence
What additional areas should be covered when taking a history from a female patient?
Pregnancies, mode of delivery, birth weights
What are some drugs that may be associated with incontinence?
Sedatives and hypnotics, antimuscarinics, diuretics, alcohol
What should be covered in the examination?
General appearance, mobility and cognitive exam
Abdominal and pelvic examination ( especially women)
Urinalysis = only if result will change management
PR examination
What investigations can be done for urinary incontinence?
Bladder scan = for post-void residual and retention
Bladder diaries and blood test (PSA, U&Es, glucose)
Urodynamic studies = only before surgery or failure of conservative management
What are some lifestyle changes that can be made?
Reduce caffeine intake, encourage patient to lose weight
What physical interventions can be done for stress incontinence?
Pelvic floor exercises = trial for at least 3 months
In what patients is bladder training used for?
Those with urgency or mixed incontinence = increase voiding intervals
What are some physical/behavioural interventions for urinary incontinence?
Pelvic floor exercises and bladder training
Exercise = beneficial all round for elderly people
Prompted and timed voiding programmes
What happens in prompted and timed voiding programmes?
Taken to toilet at timed intervals throughout day
When can pharmacological interventions be considered?
Only after 3 months of non-pharmacological management
What is the first line medication for urinary incontinence?
Tolterodine 2mg twice daily = need to consider anti-cholinergic side effects
What is the second line medication for urinary incontinence?
Solifenacin 5mg daily = increase to 10mg daily if no/little response after 6 weeks
What is the third line medication for urinary incontinence?
Mirabegron MR 50mg daily = 25mg if moderate hepatic/renal impairment
Monitor BP before starting, after 1 month and annually
How often should new medication be reviewed?
Always review 4-6 weeks after starting
How is nocturia treated?
Late afternoon diuretic = furosemide
Desmopressin = check Na+ after 3 days and stop if below normal
In which patients is desmopressin contraindicated in?
Age >65 with hypertension or heart disease
How can atrophic vaginitis be managed?
Intravaginal oestrogens
How is significant post void residual treated?
Treat constipation
Men = alpha blockers, 5-alpha reductase inhibitors
What are the indications for specialist referral?
Symptomatic prolapse at/below intriotus = needs gynaecological surgery
Microscopic haematuria age >50 or frank haematuria
Recurrent/persisting UTI or chronic retention
Suspected malignant mass or men with stress UI
Failure of conservative treatment
What is the risk associated with catheters?
They are foreign body so increase infection risk
What are some acute indications for short term catheters?
Retention, acutely unwell patient, sepsis, part of surgical procedure
What are some indications for long term catheters?
Can’t cope with intermittent self catheterisation
Medical management failed and surgery not option
Skin wounds or ulcers being contaminated with urine
Patient distressed by changes in bedding/clothing
Are pads an important part of management?
Yes = referral for assessment and provision of pads is key
When would catheters be used to treat post void residual?
If volume 200-500ml
What are some red flags in a patient with faecal incontinence?
Blood in stool, changes in bowel habit
What are some important things to remember when dealing with a patient with faecal incontinence?
Must quantify what is normal for patient
Treat constipation first if present = may be causing overflow faecal incontinence
What are some causes of faecal incontinence?
Functional problems, anal sphincter or pelvic floor weakness, cognitive problems, rectal stool impaction, constipation, loose stools
What are some lifestyle changes for patients with faecal incontinence?
Diet, caffeine avoidance, fluids, exercise, regular toilet habits, abdominal massage, pads, odour control
How is functional faecal incontinence managed?
Avoid bed pans in hospital, multidisciplinary home visit
How is faecal incontinence caused by cognitive problems treated?
1st line = prompted toileting
2nd line = scheduled voiding
3rd line = loperamide and enema combo for bowel control
How is faecal incontinence caused by weak anal sphincter/pelvic floor treated?
Anal sphincter/pelvic muscle strengthening = taught be digital rectal examination or biofeedback
Holding on exercises = bowel retraining
Loperamide = monitor for constipation
How is rectal stool impaction treated?
Enemas for complete clearance
Prevention of recurrence
How is recurrence of rectal stool impaction prevented?
1st line = regular glycerine suppositories
2nd line = bisacodyl suppositories
3rd line = periodic enemas
How is constipation treated?
Polyethylene glycol for rapid disimpaction
Daily laxative regime to ensure regular comfortable defaecation
How is faecal incontinence due to loose stools managed?
Investigate for cause
