Elderly - Continence

Question 1

How common is incontinence in patients in hospital care?

Answer 1

50-70%

Question 2

How common is incontinence in patients in nursing home care?

Answer 2

40%

Question 3

How common is incontinence in patients in residential care?

Answer 3

25%

Question 4

Urinary incontinence is most common in which gender?

Answer 4

Women (3x as likely)

Question 5

What are the causes of Urinary incontinence?

Answer 5

Extrinsic (environment, habit)

Intrinsic (body)

Question 6

What are the extrinsic causes of Urinary incontinence?

Answer 6

Physical state
Co-morbidities
Reduced mobility 
Confusion
Drinking too much
Medications
Constipation
Home/social circumstances

Question 7

What are the muscles of the bladder and urethra, and what is their control?

Answer 7

Detrusor - smooth muscle
Internal urethral sphincter - smooth muscle
External urethral sphincter - striated muscle

Question 8

What is the local innervation of urinary continence?

Answer 8

S2-4 (Parasympthetic)
T10-L2 (Sympathetic)
T10-S2 (Sympathetic)
S2-S4 (Somatic)

Question 9

What is the role of parasympathetic innervation of the urinary system?

Answer 9

Increased strength and frequency of contractions

Question 10

What is the role of Sympathetic innervation of the urinary system?

Answer 10

Beta adrenoreceptor - detrusor relaxation

Alpha adrenoreceptor - Contraction of neck of bladder, internal urethral sphincter

Question 11

What is the role of somatic innervation of the urinary system?

Answer 11

Contraction of pelvic floor and external urethral sphincter

Question 12

What are the neurological controls of micturition?

Answer 12

Pontine micturition centre
Frontal cortex
Caudal spinal cord

Question 13

What are the causes of stress incontinence?

Answer 13

Bladder outlet too weak

Question 14

What are the features of stress incontinence?

Answer 14

Urine leak on movement/coughing/laughing
Weak pelvic floor
Common in women with children

Question 15

What are the treatments for stress incontinence?

Answer 15

Physio (kegel exercises)
Estrogen cream/pessaries
Duloxatine
Surgery (TVT/Colposuspension)
Biofeedback
Pelvic floor stabilisers

Question 16

What are the characteristic features of overflow incontinence?

Answer 16

Poor flow
Double voiding
Post-micturition dribbling
Blockage to urethra 
Older men - BPH

Question 17

How is overflow incontinence treated?

Answer 17

Alpha blockers
Anti-androgens
Surgery - TURP

Question 18

What are the characteristic features of urge incontinence?

Answer 18

Detrusor contracts at low volumes
Sudden urge to pass urine
Patients often know every public toilet
Associated with bladder stones or stroke

Question 19

How is urge incontinence treated?

Answer 19

Anti-muscarinics

Bladder re-training

Question 20

How to antimuscarinics work for incontinence?

Answer 20

Relax detrusor muscle

Question 21

How do Beta-3 adrenoceptor agonists work for incontinence?

Answer 21

Relax detrusor muscle

Question 22

How do alpha-blockers work for incontinence?

Answer 22

Relax sphincter and bladder neck

Question 23

What is a neuropathic bladder?

Answer 23

Bladder that cannot contract, leading to atrophy of the detrusor muscle

Question 24

What are the characteristic features of neuropathic bladder?

Answer 24

Secondary to neurological disease (MS, Stroke) or prolonged catheterisation
No awareness of full bladder

Question 25

How is neuropathic bladder treated?

Answer 25

Parasympathomimetics (extensive side-effects) | Catheterisation

Question 26

How should incontinence be assessed?

Answer 26

``` History with extensive social Hx Intake/Output chart General exam + rectal and vaginal Urinalysis and MSSU Residual bladder scan Incontinence clinic Consider Rx ```

Question 27

What are the indications for referral to urinary incontinence specialists?

Answer 27

``` After failure of initial management max 3 months Fistula Large residual volume CNS disease BPH Previous continence surgery ```

Question 28

When should faecal incontinence be referred?

Answer 28

Failure of initial diarrhoea/constipation management Suspected sphincter damage Neurological damage

Question 29

What are the last options in incontinent patients?

Answer 29

``` Pads Urosheaths Intermittent catheterisation Long-term catheter Suprapubic catheter ```