OP: Continence and constipation Flashcards
Is faecal incontinence ever normal?
No, always abnormal
How does a patients rectum change as they age?
the rectum can become more vacuous and the anal
sphincter can gape due to a number of factors including haemorrhoids and chronic constipation.
Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.
Why is diminished anal tone sensation important not to miss?
Could indicated spinal cord pathology-needs urgent management
What is the most common cause of faecal incontinence in OP?
1)Faecal impaction with overflow diarrhoea
2nd- neurogenic
What type of stool you be suspicious of overflow with impaction?
smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation
What are the risks of chronic constipation?
stercoral perforation and ischaemic bowel
What is the management of chronic constipation?
utilising enemas for rectal loading and stool softeners and stimulants.
Stimulants don’t work on hard stool.
Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.
Management of diarrhoea in OP?
underlying causes must be excluded by bowel imaging and stool culture
potentially causative medications removed then care
can focus on firming the stool.
Faecal impaction must be excluded
Pharmacological management of diarrhoea in OP?
Low dose loperamide
What to ask about when taking a continence hx from a patient?
Ask about:
how void
how frequent
What other symptoms -e.g burning?
oral intake
types of drinks consumed
bowel habit (stool type/frequemcy)
Drug Hx
Collateral Hx if needed
What are simple non drug management advice for continence
non caffeinated drinks
good bowel habit (water/fibre)
improve oral intake
regualr toileting
pelvic floor exercises
bladder retraining
Define urge incontinence
Frequent uncontrollable leaking / emptying after urge. cant hold urine - nocturnal incontinence is common.
see with detrusor overactivity can also get with obstruction
Define overflow incontinence
Urinary retention - e.g. obstructive symptoms in man with enlarged prostate
What would you do when to examine a patient for continence - examination and investigations
Examination:
Abdominal examination
PR - prostate men
external genitalia - atrophic vaginitis in women
Investigations:
Urine dip stick and MSU
Post micturition bladder scan
Other:
review patients bladder / bowel diary
Examining an older woman with stress incontinence - what look for ?
Pelvic floor weakness
Prolapse- e.g uterine
Pelvic masses
Urethrocele
What would you do when to examine a patient for continence - examination and investigations
Examination:
Abdominal examination
PR - prostate / faecal impaction
external genitalia - atrophic vaginitis in women
Investigations:
Urine dip stick and MSU
Post micturition bladder scan
Other:
review patients bladder / bowel diary
What co-morbidities need to rule out when dealing with a patient with incontinence?
Neurological cause - brain damage can be cause
Parkinsons
MS
Stroke
Dementia
spinal cord lesion // trauma
What co-morbidities need to rule out when dealing with a patient with incontinence?
Neurological cause - brain damage can be cause of urge incontinence/detrusor overactivity
Parkinsons
MS
Stroke
Dementia
spinal cord lesion / trauma
Why are drugs for incontinence problematic in older people?
Antimuscarinics are used - increase anticholingeric burden and cognitive impairment
Why are drugs for incontinence e.g. oxybutinin problematic in older people?
Increases the anticholingeric burden - older patients are likely to be taking ++ anitmuscarinic drugs.
This can cause cognitive impairment
Can cause hypotension - risk of falls
What are some side effects of antimuscarinic drugs for continence e.g. oxybutynin /
Dry mouth / eyes / skin
Drowsiness
Urinary retention
Constipation
Tacchy
Transient hypotension
glaucoma precipitation
What medications can impair cognition and look like dementia
Anticholinergics
sedatives - benzodiazepams
opioids
corticosteroids
A frail elderly pt has urge incontinence (overactive bladder). The drug treatment for this is antimuscarinics.
e.g. oxybutynin.
However, we know these are bad in frail, older pts. What drug can we give her instead?
mirabegron !
(a beta-3 agonist) if concern about anticholinergic side-effects in frail elderly patients
