Systems: Specialities AB > Geriatrics: Continence > Flashcards

Geriatrics: Continence Flashcards

(39 cards)

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1
Q

Why is incontinence so important to learn about?

A
  • Common
  • Stigmatising
  • Disabling
  • Treatable
  • Most doctors not good at treating it
  • Often becomes permanent if untreated
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2
Q

What is the prevalence of incontinence?

A
  • Increases with age
  • Women 3x more likely
  • High rates in hospital, nursing homes and care homes
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3
Q

How should incontinence be viewed?

A

As a symptoms with many causes

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4
Q

What are the 2 classes of causes of incontinence?

A

Extrinsic to the urinary system
-Environment, habit, physical fitness

Intrinsic to the urinary system
-Problem with bladder or urinary outlet

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5
Q

Give examples of extrinsic factors that can lead to incontinence

A
  • Physical state and co-morbidities
  • Reduced mobility
  • Confusion (delirium or dementia)
  • Drinking too much or at the wrong time
  • Diuretics
  • Constipation
  • Home circumstances
  • Social circumstances
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6
Q

What does continence depend on?

A

Continence depends on the effective function of the bladder and the integrity of the neural connections which bring it under voluntary control

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7
Q

What are the 2 functions of the bladder?

A
  • Voluntary voiding

- Urine storage

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8
Q

Describe the muscle of the bladder and the sphincters.

A
  • Detrusor is smooth muscle
  • Internal urethral sphincter is smooth muscle
  • External urethral sphincter is striated muscle
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9
Q

How does urine storage occur in the bladder?

A

Involves detrusor muscle relaxation with filling (<10CM pressure) to normal volume 400-600ML combined with sphincter contraction.

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10
Q

How does voluntary voiding occur in the bladder?

A

Involves voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder

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11
Q

What local innervation is there at the bladder?

A
  • Parasympathetic
  • Sympathetic
  • Somatic
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12
Q

What is the parasympathetic action on the bladder?

A

S2-S4

-Increases strength and frequency of contractions

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13
Q

What is the sympathetic action on the bladder?

A

T10-L2
-B-adrenoreceptor: causes detrusor to relax

T10-S2
-A-adrenorecptor: causes contraction of the neck of the bladder and internal urethral sphincter

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14
Q

What is the somatic action on the bladder?

A

S2-S4

-Contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter

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15
Q

What CNS connections are there to the bladder?

A

Centres within the CNS inhibit parasympathetic tone, and promote bladder relaxation and hence storage of urine.

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16
Q

What is sphincter closure mediated by?

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A

Reflex increase in a-adrenergic and somatic activity.

17
Q

What role does the pontine micturition centre play?

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A

The pontine micturition centre normally exerts a “storage program” of neural connections until a voluntary switch to a voiding program occurs.

18
Q

Apart from the pontine micturition centre, what other parts of the CNS is involved in the storage of urine?

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A
  • Frontal cortex

- Caudal part of the spinal cord

19
Q

What are the 4 physiological problems that can result in incontinence?

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A
  • Bladder too weak
  • Bladder too strong
  • Outlet too weak
  • Outlet too strong
20
Q

What type of incontinence occurs when the bladder outlet is too weak?

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A

Stress incontinence

21
Q

What are the features of stress incontinence?

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A
  • Urine leak on movement, coughing, laughing, squatting etc.
  • Weak pelvic floor muscles
  • Common in women with children, especially after menopause
22
Q

What are the treatments for stress incontinence?

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A
  • Physiotherapy
  • Oestrogen cream
  • Duloxetine
  • TVT/colosuspension (90% cure at 10 years)
23
Q

What exercises can help strengthen the pelvic floor?

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A

Kegel exercises

24
Q

What type of incontinence occurs when the bladder outlet is too strong?

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A

Urinary retention with overflow incontinence

25
What are the features of overflow incontinence?
- Poor urine flow, double voiding, hesitancy, post micturition dribbling - Blockage to urethra - Common in older men with BPH
26
How is overflow incontinence treated?
- Alpha blockers - Anti-androgen - TURP surgery - May require catheterisation, often suprapubic
27
What type of incontinence occurs when the bladder muscle is too strong?
Urge incontinence
28
What are the features of urge incontinence?
- Detrusor contracts at low volumes - Sudden urge to pass urine immediately - Patients often know every public bathroom
29
What can cause urge incontinence?
- Bladder stones - Stroke - Infection
30
How is urge incontinence treated?
- Anti-muscarinic (relax detrusor) | - Bladder retraining
31
What are the main drugs used in incontinence?
Anti-muscarinic (relax detrusor) -Oxybutin, tolterodine, solifenacin, trospium Beta-3-adrenoreceptor agonists (relax detrusor) -Mirabegron ``` Alpha blockers (relax sphincter, bladder neck) -tamsulosin, terazosin, indoramin ``` Anti-androgen drugs (shrink prostate) -Finasteride, dutasteride
32
What problem is associated with a neuropathic bladder?
Underactive bladder
33
What happens in an underactive bladder?
- It is rare - Secondary to neurological disease or prolonged catheterisation - No awareness of bladder filling resulting in overflow incontinence
34
How is a neuropathic bladder treated?
- Medical treatments rarely work but parasympathomimetics may work - Catheterisation
35
How is incontinence assessed?
- History - Social history (impact) - Intake chart and urine output diaries - General exam - Urinalysis and MSSU - Bladder scan for residual volume - Referral to incontinence clinic - Suggest lifestyle changes and stop unnecessary drugs - Consider treatment options
36
When is it indicated that urinary incontinence be referred to specialists?
-Referral after failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication
37
When is a referral for urinary incontinence required at its onset?
- Vesico-vaginal fistula - Palpable bladder after micturition or confirmed large residual volume of urine - Disease of the CNS - Certain gynaecological conditions (fibroids, procidentia, rectocele, cystocele) - Severe BPH or prostatic carcinoma - Patients who have had previous surgery for continence concerns - Other in whom a diagnosis has not been made
38
When should faecal incontinence be referred?
Referral after failure of initial management -Constipation of diarrhoea with normal sphincter Referral necessary at onset: - Suspected sphincter damage - Neurological disease
39
What options are there for managing incontinence when all else fails?
- Incontinence pads - Urosheaths - Intermittent catheterisation - Long term urinary catheter - Suprapubic catheter
Systems: Specialities AB
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