Case 1 - Constipation and incontinence - WB and Case

Question 1

Common causes of constipation - general

Answer 1

• Lack exercise
• Lack fibre
• Dehydration
• Post-op pain
• IBS
• Old age
• Hospital environment - decreased privacy

Question 2

Exam for constipation?

Answer 2

• Abdominal exam
• DRE - fissures, haemorrhoids anal sphincter tone prolapse?

Question 3

Investigations for constipation

Answer 3

• FBC, ESR, U&E, Ca2+, TFT
• Colonoscopy if suspected malignancy
• Abdo X-ray - suspect obstruction?
• Threshold decreases with age for investigations

Question 4

Causes of constipation anorectal disease

Answer 4

• Fissues
• Haemorrhoids
• Rectal prolapse
• Anal/rectal cancer
• Pelvic muscle dysfunction/levator ani syndrome

Question 5

Causes of constipation obstruction

Answer 5

• Intestinal carcinoma
• Strictures eg Crohns
• Diverticulosis

Question 6

Metabolic causes constipation

Answer 6

• Hypercalcaemia
• Hypokalaemia
• Hypothryoidism
• Lead poisioning

Question 7

Drugs which can cause constipation

Answer 7

• Opiates
• Anticholinergics
• Iron supplements
• Antacids (eg with aliminium)
• Diuretics - furosemide
• CCBs

Question 8

Management of severe constipation

Answer 8

• Stimulant such as senna ± a bulking agent is more effective
• 1st line NICE CKS = bulking eg Isphagula husk
• Add or switch to osmotic (eg macrogol or lactulose) if hard stool
• Add stimulant eg Bisacodyl/senna if soft

Question 9

Factors contributing to incontinence

Answer 9

• Immobility
• Previous pregnancies/childbirth
• Overweight
• Post menopause
• Stroke/other neurological causes
• Constipation

Question 10

3 most common types of incontinence

Answer 10

1. Urge - urgency followed by leakage, can be complete or partial emptying of bladder
2. Stress - when intrabdominal pressure rises, urine leaks, inadequate sphincter
3. Functional - eg due to immobility or unfamiliar surroundings

Question 11

Urgency incontience precipitated by…

Answer 11

• arriving home (latchkey incontinence a conditioned reflex);
• cold
• the sound of running water;
• caffeine
• obesity.

Question 12

Medications that contribute to incontinence

Answer 12

• ACEi
• Diuretics
• Antidepressants
• HRT
• Sedatives

Question 13

Medications that cause urinary retention

Answer 13

• Anticholinergics
• Opioids
• Anaesthetics
• Alpha agonists
• CCBs
• NSAIDs
• Benzodiazepines

Question 14

Non pharmacological interventions for urinary incontinence

Answer 14

• Modify fluid intake
• Reduce caffeine intake
• Weight loss
• Stop smoking
• Avoid constipation
• Pelvic floor exercises - stress I
• Bladder training - urge

Question 15

Common drugs used for urge incontinence and their class

Answer 15

• Oxybutynin, Solifenacin - Antimuscarinics
• Mirabegron - B3 agonist
• Intravaginal oestrogen
• Desmopressin - off label

Question 16

Common drugs used to treat stress incontinence and class

Answer 16

• Duloxetine - SNRI

Question 17

What is the type of incontinence that occurs with retention?

Answer 17

Overflow incontinence

Question 18

Exams required for incontinence presentation

Answer 18

• Bladder and bowel diary review
• Abdo exam
• Urine dip and MSU
• PR exam - inc prostate assessment in males
• External genitalia review esp looking for atrophic vaginitis
• Post micturition bladder scan

Question 19

What pharmacological drug is not good in older patients for incontinence

Answer 19

Antimuscarinics - Oxybutynin

Question 20

Side effect of many drugs used to treat incontinence

Answer 20

Postural hypotension = increased falls risk

Question 21

What kind of stool can cause impaction?

Answer 21

Hard and soft

Question 22

Where can impaction occur?

Answer 22

Most often rectum but can be above
If clinical signs fit and rectum empty - be suspicious

Question 23

What to do if patient is found to have full bladder on scan ie retention?

Answer 23

PR exam - assess for impacted rectum +/- large prostate

Question 24

Examination of constipation

Answer 24

Abdo exam - faeces can sometimes be palpated

Question 25

Risk of constipation

Answer 25

• Stercoral perforation
• Ischaemic bowel

Question 26

Management constipation overall

Answer 26

• Enemas for rectal loading
• Stool softners
• Stimulants
• If stool hard - use softner

Some enemas do fall out if stool is hard

Question 27

When is manual evacuation performed?

Answer 27

• Difficult cases and risk of perforation is outweighed by positive impact on patient sympotms and wellbeing

Question 28

What should happen with all drugs that can cause constipation in elderly patinets?

Answer 28

Co-prescribe laxative!!

Question 29

Why does faecal impaction occur more commonly in elderly?

Answer 29

• Anal sphincter can gape because of haemorrhoids and chronic constipation
• Cannot exert same intrabdominal pressure

Question 30

When is it normal to have faeces in rectum?

Answer 30

Never - unless passing stool

Question 31

Red flags for faecal incontinence

Answer 31

• Loss anal tone and sensation
• Suggests cord compression

Question 32

Most common cause faecal incontinence

Answer 32

• Faecal impaction wiht overflow diarrhoea
• 2nd cause is neurogenic dysfunction

Question 33

Exam for faecal incontinence

Answer 33

PR exam - rectum, prostate, anal tone and sensation
Visual inspection around anus too
Assess stool type if in rectum

Question 34

Investigations chronic diarrhoea

Answer 34

• Bowel imaging
• Stool culture
• Rule out faecal impaction

Question 35

Management chronic diarrhoea

Answer 35

Low dose loperamide (paeds doses) can be trialled
Then constipating and enema regimes can be used