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geriatrics > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

can incontinence be normal

A

incontinence is abnormal at any age

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2
Q

how to stop bladder voiding

A

higher centres (thalamus and cerebral cortex) can inhibit urination unless the bladder volume is very high

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3
Q

on-off switch for voiding

A

pontine micturition centre (PMC)

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4
Q

bladder emptying occurs when

A

parasympathetic outflow increases sharply and somatic/sympathetic tone decrease
bladder contracts, sphincters open and the urethra widens

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5
Q

normal amount of voids

A

5-7 per day (3-4 hourly)
0-2 per night

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6
Q

normal bladder volume

A

400-600mL

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7
Q

urge to void usually occurs when

A

bladder volume is 150-300mL

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8
Q

minimum fluid intake should be

A

> 1500mL/day unless restricted

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9
Q

changes with ageing

A
  • bladder capacity declines
  • post-void bladder volume increases
  • involuntary bladder contractions increase
  • lose the ability to concentrate urine at nigh (ADH secretion decreases) with nocturia 1-2 times per night
  • prostate size increases
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10
Q

medical complications of urinary incontinence

A

UTI and urosepsis, falls, fractures, pressure injuries, skin and perineal rashes (including cellulitis, dermatitis)

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11
Q

psychosocial complications of urinary incontinence

A

social isolation, stigmatisation, embarrassment, depression, sleed deprivation, sexual dysfunction, caregiver stress, institutionalisation risk

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12
Q

urinary tract infection

A

infection in any part of he urinary tract (kidney, ureters, bladder, urethra). typically lower tract

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13
Q

stress incontinence

A

involuntary leakage of urine on stress or exertion. usually die to weakness of the pelvic floor muscle and fascial support, or weakness/damage to the urethral sphincter

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14
Q

urgency

A

abrupt, strong often overwhelming need to urinate. occurs when the pressure in the bladder increases suddenly, whether or not the bladder is full. can lead to urge incontinence

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15
Q

transient incontinence

A

typically occurs in association with acute illness

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16
Q

causes of transient incontinence

A

DIAPPERS:

Delirium
Infection (UTI)
Atrophic vaginitis/urethritis
Pharmaceuticals
Psychological
Excessive urine output
Restricted mobility
Stool impaction

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17
Q

anticholinergics cause

A

urinary retention

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18
Q

cholinesterase inhibitors cause

A

incontinence

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19
Q

calcium channel blockers cause

A

constipation, fluid

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20
Q

ACE-inhibitors cause

A

cough

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21
Q

Diuretics cause

A

fluid retention/diuresis

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22
Q

alpha blockers cause

A

urethral relaxation

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23
Q

beta-agonists cause

A

retention

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24
Q

narcotics cause

A

constipation, sedation

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25
Q

sedatives including alcohol cause

A

reductions in cognition/sedation

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26
Q

pathophysiological causes of incontinence

A

detrusor overactivity
detrusor underactivity
outlet obstruction
outlet incompetence

27
Q

detrusor overactivity is caused by

A

cystitis, cancer, stones, urethral obstruction, MS, stroke, alzeimer’s, Parkinson’s

28
Q

detrusor under activity is caused by

A

idiopathic, chronic outlet obstruction, autonomic neuropathy, surgical damage, disc compression, plexopathy

29
Q

outlet obstruction is caused by

A

prostate (benign prostatic hypertrophy or cancer), urethhral stricture, spinal cord lesion with detrusor-sphincter dyssynergia

30
Q

outlet incompetence is caused by

A

prostate surgery, urethral hyper mobility, sphincter incompetence, radical prostatectomy with nerve damage

31
Q

types of incontinence

A

stress, urge, mixed, overflow, functional

32
Q

stress incontinecen

A

involuntary leakage of a small volume of urine during periods of raised intra-abdominal pressure such as exertion, sneezing or coughing. most commonly occurs with women, post party or post menopausal

33
Q

urge incontinence

A

involuntary loss of urine shortly after the awareness of the need to empty the bladder but before the person can get to the toilet

34
Q

mixed incontinence

A

combined stress and urge, the commonest type of incontinence in women aged above 60 years

35
Q

overflow incontinence

A

involuntary leakage of small amounts of urine as a result of mechanical forces on an over-distended bladder

36
Q

functional incontince

A

physical, cognitive and environmental factors may contribute

factors outside the bladder

37
Q

causes of stress incontinence

A

in women, causes include oestrogen deficiency, obesity, previous vaginal deliveries, previous surgery

in men, causes include radiotherapy and prostatectomy

38
Q

urge incontinence pathophysiology

A

involuntary loss of urine accompanied by or immediately preceded by urgency.
detrusor has sudden, random contractions.
unable to delay voiding after sensation go bladder fullness felt.
more common with ageing

39
Q

DHIC - detrusor hyperreflexia with impaired contractility

A

a subset of patients with detrusor over activity.
emptying less than 1/3 of bladder volume, predisposed to urinary retention.

40
Q

urinary retention may be caused by either

A

outflow obstruction
or
non-contractile detrusor

41
Q

does a normal sized prostate on rectal exam and normal PVR (post residual void scan) exclude obstruction?

A

negatory

42
Q

what can confirm/exclude obstruction

A

urodynamic studies

43
Q

crucial points on history

A

effect on QOL
need for assistance
use of acids
previous UTIs
surgical and obstetric history
bowel and fluid intake
mobility
alcohol, caffeine and smoking

44
Q

crucial points on examnation

A

urine stained or malodorous clothing
mobility
cognition
abdo exam - palpable bladder
neuro exam - LL neurological signs
cardiovascular exam - fluid status
PR - anal tone, constipation (faeces), prostate (size, nodules)

45
Q

urinary stress test

A

cough and observe for urine leakage

46
Q

urodynamic studies are used when

A

used for complex patients not responding to treatment
or patients with previous pelvic surgery or radiation
used for younger patients if diagnosis is uncertain
or used when surgery s being considered

47
Q

contained incontinence

A

uses pads or appliances
may be the best goal for some patients

48
Q

treatment considerations

A

patient commitment to therapy
tolerance and risk of adverse effects
financial considerations

49
Q

general management measures

A

avoid constipation
avoid dehydration
avoid excessive coffee
avoid alcohol
stop smoking
use continence aids such as pads or bed protection
use toileting regimes (timed toileting intervals usually 2-3 hourly)
consider environmental factors (urinary bottle, toilet rials and aids, call bell)
weight loss in overweight or obese women reduces episodes

50
Q

behavioural/physcial interventions

A

bladder training, pelvic floor muscle exercises

51
Q

bladder training

A

deferred voiding = delayed voiding for progressively longer periods of time so as to train the bladder to hold increasingly larger volumes of urine. recommended for symptomatic overactive bladder

52
Q

pelvic floor muscle exercises

A

recommended for men and women with symptoms of overactive bladder, and for stress and mixed incontinence in women.
can assess muscle contraction with ultrasound, or supplement with electrical stimulation.

53
Q

fluid management

A

frequent intake of small amounts of fluid (120-150mL per hour) up to 2L per day
avoid large episodic fluid boluses
consider comorbidities eg. heart failure

54
Q

how do anticholinergics help

A

significant adverse effects
oxybutinin tablets and patches
acts via mascurinic receptors - antispasmodic effects on bladder

55
Q

how do beta-3 agonists help

A

mirabegron (betmega). non PBS
stimulation of the beta-3 pathway promotes smooth muscle relaxation of the bladder to increase urine storage
efficacy similar to anticholinergics
causes HTN as adverse effect

56
Q

oestrogens

A

low dose vaginal oestrogens (creams, tablets or rings) are approved for the treatment of vaginal atrophy.
modest improvement in urinary incontinence in post-menopausal women compared to placebo

57
Q

anticholinergic side effects

A

dry mouth, blurred vision, urinary retention, constipation, confusion (esp. in older patients) warn patients/carers

58
Q

surgical management of stress incontinence

A

highly effective
mid urethral sling is the most commonly performed surgery
also retro pubic Burch colposuspension

59
Q

surgical management of urge incontinence

A

prostate surgery (if this is the cause of the urge incontinence)
percutaneous tibial nerve stimulation (acupuncture needle) - messages to sacral plexus
botox A into the bladder
sacral neuromodulation

60
Q

overflow incontinence may be caused by

A
  1. anatomical obstruction: prostate, stricture, cystocoele)
  2. acontractile bladder: associated with diabetes or spinal cord injury (functional obstruction)
  3. medication related
61
Q

overflow incontinence is

A

leakage of small amounts of urine due to mechanical forces on an over distended bladder

62
Q

management of overflow incontinence

A

catheter if significant infection then refer to urology.
can try ‘double voiding’ if no catheter
prostate enlargement due to BPH can be treated with drugs

63
Q

prostate enlargement due to BPH can be treated with

A

prazosin, tamsulosin, duodart
or surgery

64
Q

duodarrt

A

combination of 5-alpha reductase inhibitor (dutasteride) plus alpha-blocker (tamsulosin)

geriatrics (8 decks)

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