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Year 3 Elderly Medicine > 8 - Incontinence and Constipation > Flashcards

8 - Incontinence and Constipation Flashcards

1
Q

What is the epidemiology of urinary incontinence?

A

F > M

2 in 5 F over 60 have UIc

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2
Q
A
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3
Q

What maintains continence?

A

Bladder
Urethra
Pelvic floor muscles
Nervous system

Continence is maintained as long as uretheral pressure > bladder pressure

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4
Q

How does voiding of the bladder occur?

A

Voluntary relaxation of the striated muscle around the urethra

AND

Increase in bladder pressure - due to contraction of detrusor muscle via PSS

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5
Q

What is the most important thing regarding elderly patients and bowel opening?

A

Whether they can pass motions easily - not frequency of defecation.

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6
Q

What things can cause constipation in elderly Ps?

A

Faulty habits (poor diet, low fluid intake, lack of exercise, holding on)
Poor appetitie
Immobility
Drugs
Metabolic disease (DM, hypothyroid, hypercalcaemia, hypokalaemia, hypomagnesaemia)
Psychiatric causes - depression, dementia
IBS
Pain (piles, fissures)
Neurological issues (Parkinsons, spinal cord injury, MS and cerebrovascular disease)

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7
Q

How do you manage constipation in the elderly?

A

Identify nature and duration
Look for any cause
DRE
If impaction - enema
If not impacted - think stimulant (Senna) or osmotic laxative (mag sulphate)

ST - ensure adequate fluids & mobilise

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8
Q

What can you prescribe for small hard stools in association with opioids?

A

One of:

Co-danthrusate / Co-danthramer
Macrogols
Liquid paraffin
Magnesium hydroxide emlulsion

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9
Q

How can you treat severe constipation in bed bound Ps?

A

Manual evacuation

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10
Q

What can you prescribe for long-term treatment?

A

Macrogol or ispaghula husk

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11
Q

When is lactulose used? (Expensive!)

A

Hepatic encephalopathy

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12
Q

What are the potential complications of constipation in the elderly?

A

Faecal impaction
Overflow diarrhoea
Obstruction
Perforation
Megacolon -> sigmoid volvulus or rectal prolapse
Urinary retention –> Delirium

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13
Q

Which group of elderly Ps have the highest incidence of faecal incontinence? Patients who are in:
- Community-dwelling
- Residential homes
- Nursing homes

A

Nursing home residents

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14
Q

What do you need to ask a P with faecal incontinence?

A

Examine their fluid and food intake
Hx of GI or neurological disease?
Medications
PSHx - especially obstetric or rectal

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15
Q

How can you treat faecal incontinence in Ps with disinhibition or dementia?

A

Bulking preparations and regular toileting

Treat underlying cause if possible

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16
Q

What medical Tx can be given for faecal incontinence in frail older Ps?

A

Codeine phosphate (to cause constipation) with enemas at regular intervalsYou

Anal plugs to block rectum for short periods

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17
Q

What obstetric issues can cause faecal incontinence?

A

Third degree tear
Instrumental delivery
Damage to pudendal nerve

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18
Q

What colorectal diseases can cause weakness of the internal anal sphincter

A

Rectal prolapse
Haemorrhoids
IBD
Tumour

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19
Q

What neurological issues can cause faecal incontinence?

A

Parkinsons
Stroke
Spinal cord injury
Diabetic autonomic neuropathy

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20
Q

What percentage of prostates have hyperplasia by the age of
- 60
- 85

A

60 = 50%

85 = 90%

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21
Q

What causes cellular proliferation in the prostate?

A

5 α reductase - converts testosterone to dihydrotestosterone (DHT) - which causes cellular proliferation in the prostate

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22
Q

Which symptoms count as LUTS?

A

Frequency
Urgency
Dysuria
Nocturia
Poor stream
Hesitancy
Dribbling
Incomplete Voiding
Overflow incontinence

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23
Q

Which type drugs can be used in men to treat urinary obstruction caused by BPH?

Why is this class used?

A

α-adrenoreceptor antagonists

Muscle in the bladder which prevents micturition is controlled by α adrenoreceptors. Using a blocker of these receptors allows the muscle to relax to allow micturition.

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24
Q

Name a drug which is an α adrenoreceptor antagonist?

A

Tamsulosin
Doxazosin
Terazosin

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25
Q

What is the difference between tamsulosin AND doxazosin/terazosin?

A

Tamsulosin = more alpha1 specificity - thus causes less orthostatic hypotension

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26
Q

Which treatment is the mainstay treatment for symptomatic BPH?

A

TURP = transurethral prostatectomy

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27
Q

What complications can arise from a TURP procedure?

A

Perioperative haemorrhage
Absorption of irrigative fluids - can cause electrolyte imbalances
Urethral strictures
Incontinence

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28
Q

What is stress incontinence?

A

When urine leaks from the bladder due to higher pressures than the pelvic muscles are able to contain - e.g. on coughing, laughing etc

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29
Q

What is urge incontinence?

What are the symptoms?

A

When the P feels the need to urgently empty the bladder when it is not actually full. P is unable to prevent involuntary bladder contractions.

Symptoms = frequency, urgency and nocturia (always rule out UTI)

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30
Q

How is urge incontinence managed?

A

Conservative measures - avoiding irritants including dehydration, and bladder training.

Can use antimuscarinics.

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31
Q

What are the side effects of antimuscarinics?

A

Dry mouth, dry eyes, constipation, confusion.

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32
Q

Β-3 agonists (mirabegron) can be used as second line therapy for urge incontinence. What is the potential adverse effect of these?

A

Accelerated hypertension

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33
Q

What are the symptoms of overflow incontinence?

A

Difficulty initiating micturition
Poor stream
Terminal dribbling

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34
Q

What are the potential complications of overflow incontinence?

A

Renal failure due to obstructive uropathy

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35
Q

What is functional incontinence?

A

P is unable to reach the toilet in time, rather than there being a primary urogenital problem.

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36
Q
A
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37
Q

Which nervous systems control micturition?

A

Somatic and autonomic nervous systems

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38
Q

Which park of the brain provides voluntary control of micturition?

A

Frontal cortex

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39
Q

What coordinates detrusor contraction with urethral relaxation? Where is this found?

A

Pontine micturition centre
Found in the midbrain

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40
Q

Which nervous system mediates bladder contraction?

Where do these nerves originate from?

A

PSS

Originate from sacral plexus (S2-S4)

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41
Q

Which nervous system mediates bladder filling?

Where do these nerves arise from?

A

SS

Nerves arise from T11 - L2 - innervate smooth muscle of bladder neck and proximal urethra = contraction

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42
Q

Excitation of which nerve causes contractions of the external urethral sphincter (= voluntary control)

A

Pudendal nerve

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43
Q

What are the causes of urge incontinence?

A

Idiopathic (most common)
Neurogenic
Infective
Bladder outlet obstruction

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44
Q

Which neurological conditions can cause urge incontinence?

A

MS
Parkinsons
Stroke
Spinal cord injury

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45
Q

What are the RF for stress incontinence?

A

F
Age
Childbirth
Previous pelvic surgery
Neurological disease
UTI
Post-menopausal
Post-hysterectomy
Bladder outlet obstruction

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46
Q

What is mixed incontinence?

A

A combination of urge and stress

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47
Q

What is outflow obstruction?

A

Obstruction of the ureter preventing voiding of the bladder. Can have residual urine in the bladder after voiding.

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48
Q

What are the causes of outflow obstruction?

A

Phimosis
BPH
Stricture
Trauma
Blood clot
Calculi
Cancer
STIs

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49
Q

How do the following drugs put you at risk of urinary continence issues?

Diuretics
Anticholinergics
Sedatives
Alpha blockers
Alpha agonists
ACEi
Cholinesterase inhibitors
Ca channel blockers
Oestrogen deficiency

A

Diuretics – increase volume of urine
Anticholinergics – may precipitate poor bladder emptying or retention
Sedatives – may reduce awareness of need to pass urine and increase confusion
Alpha blockers – relax bladder outlet, may worsen SI
Alpha agonists – urinary retention, may lead to overflow
ACEi – chronic cough (bradykinin) may worsen SI
Cholinesterase inhibitors – increase bladder contraction
Ca channel blockers – decrease smooth muscle contractility

Oestrogen deficiency – very common in elderly women, causes urinary urgency

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50
Q

How can you treat vaginal atrophy?

A

Topical oestrogens

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51
Q

What are red flag symptoms for LUTS?

A

Haematuria
Persistent UTI
Constitutional symptoms
Poor renal function
Abnormal neurology including saddle anaesthesia
Recent back trauma or pelvic surgery

52
Q

What type of urinary symptoms are these?

Hesitancy
Poor stream
Intermittent flow
Incomplete emptying (with associated frequency)(
Postvoid dribbling
Overflow incontinence

A

Obstructive / Voiding symptoms

53
Q

What type of urinary symptoms are these?

Frequency
Nocturia
Urgency
Urgency incontinence

A

Storage symptoms

54
Q

How is pelvic floor muscle strength assessed during a DRE?

A

Oxford classification of strength and function scale of 0 - 5
0 – no contraction
1 – flicker
2 – weak
3 – moderate
4 – good
5 – strong contraction

55
Q

How can you test the following nerves to make sure that they aren’t affecting micturition?

S3
L1-2
S1

A

S3 = dorsiflexion of foot and sensation of posterior thigh

L1-2 = perianal sensation

S1 = sensation of sole of the foot

56
Q

What do we need to rule out with imaging in Ps struggling with incontinence?

A

Chronic retention
Causes of renal failure / recurrent UTI
Masses, renal stones

57
Q

How much of your urine is produced at night?

A

1/3

58
Q

What is the definition of polyuria?

A

> 2500 pls per day

59
Q

What things do we look for with urinalysis?

A

Glucose (diabetes)
Protein (primary kidney pathology)
Blood(stones or malignancy)
Leucocytes/nitrites (infection, although this is less sensitive in the elderly)

60
Q

With continence problems - what do we look for in the bloods?

A

Bloods:
FBC – leucocytosis (infection)
U&Es – assess renal function
Glucose/HbA1c – assess for diabetes
Calcium – hypercalcaemia can cause constipation and confusion; both transient causes of incontinence

61
Q

What is a USS abdomen used for with urinary problems?

A

To evaluate kidney size (?renal failure) and look for signs of obstructive uropathy

62
Q

What is a CT urography / IV urogram used for?

A

Identifying the presence of renal stones

63
Q

What is a CT abdomen used for?

A

Excluding abdominal or pelvic masses if there is a clinical suspicion.

64
Q

What is uroflowmetry?

A

Used for measuring urinary flow rate - measured total voided volume against flow time.

Can be used to diagnose bladder outlet obstruction

65
Q

What does cystometry do?

A

Measures bladder pressure, sensation, capacity and compliance during filling and voiding.

  • Detrusor contractions at low volumes = urge incontinence

Voiding on increase in abdominal pressure = stress incontinence

66
Q

What are the 4 types of management for urinary issues?

A

Lifestyle advice / education
MDT - non-pharmalogical
Pharmacological
Surgical

67
Q

How can stress incontinence be managed?

A

Lifestyle:
Smoking cessation
Weight reduction
Managing constipation
Reduce alcohol and caffeine intake

Surgical:
Mid-urethral sling insertion
Colposuspension

MDT
Continence advisor referral
Pelvic floor exercises
Vaginal cone

Medical:
Duloxetine (can be offered as second line if preferred to, or patient not suitable for surgical treatment)

68
Q

How can urge incontinence be managed?

A

Lifestyle:
Reduced fluid intake (especially in evening)
Reduce caffeine and alcohol
Weight reduction
Manage constipation

Medical:
Anticholinergics (antimuscarinics)
Intravaginal oestrogens

MDT:
Community continence advisor
Bladder retraining
Pelvic floor exercises

Surgical:
Sacral nerve stimulation
Botulinum toxin (injected into detrusor muscle to decrease contractility)

69
Q

How do anti-muscarinic drugs affect the bladder?

A

They act on M3 receptors in the detrusor muscle to reduce contraction

70
Q

How can anticholinergic drugs (antimuscarinic) affect the elderly?

A

They can precipitate falls and increase confusion

71
Q

What re the side effects of antimuscarinics?

A

Brain – cognitive impairment, hallucinations
Eyes – blurred vision
Salivary glands – dry mouth
Heart – tachycardia
GI tract – nausea, constipation
Urinary system – urinary retention

72
Q

What type of medications are these:
oxybutynin, tolterodine, solifenacin, trospium

A

Antimuscarinics

73
Q

What are the two types of medical treatment for BPH?

A

Α blockers (doxazosin, tamsulosin) reduces smooth muscle tone in the prostate

5-α reductase inhibitors - finasteride (reduces prostate volume by preventing conversion of testosterone to DHT)

74
Q

Name two types of surgical procedures for BPH

A

TURP - transurethral resection of the prostate

HoLEP - transurethral laser enucleation

75
Q

How long must symptoms be present for to qualify as chronic constipation?

A

3 months

76
Q

Which medications can cause constipation?

A

Antacids (that contain Al and Ca)
Anticholinergics
Antispasmodics
Anticonvulsants
Ca Channel Blocerks
Diuretics
Iron Supplements
PD meds
Opioids

77
Q

What is the definition of constipation?

A

BO < 3x per week +/- associated with excessive straining, abdominal pain / discomfort / distension / bloating

78
Q

What can be signs of constipation in elderly Ps?

A

confusion, delirium
functional decline
nausea / anorexia
overflow diarrhoea
urinary retention

79
Q

What are red flags for constipation?

A

Sudden change in bowel habit
Rectal bleeding / blood in stools
Weight loss
Abdo pain
Iron deficiency anaemia

80
Q

When examining a patient with constipation - what do you look for in a DRE?

A

Fissures
Haemorrhoids
Skin tags
Prolapse
Rectocele
Skin erythema / excoriation

Leakage of stool
Tone of anus

81
Q

What blood tests do you need to look at with constipation?

A

Bloods for anaemia, hypothyroidism, hypercalcaemia, coeliac disease

82
Q

What investigations can you order for constipation?

A

Stool sample
Colonoscopy / flexible sigmoidoscopy
CT AP

83
Q

How can you manage constipation?

A

Inc fluids and fibre
Inc mobilisation
Sort out impaction if present

84
Q

Name a drug for the following:
- Bulk forming laxative
- Osmotic laxative
- Stimulant laxative
- Stool softener

A

Bulk forming - Ispaghula hulk
Osmotic - Macrogol, Lactulose
Stimulant - Senna
Softener - Sodium docusate

85
Q

What type of laxative should you consider for opioid-induced constipation?

What should you NOT give?

A

Give osmotic and stimulant laxatives

Do not give bulk-forming!

86
Q

What can you consider giving if at least 2 laxatives from different classes have been tried at highest recommended dose for at least 6m, but have failed to relieve the constipation?

A

Prucalopride

87
Q

What is special about the trigone area?

A

Is from a different embryological origin to the rest of the bladder - contains nerves that are sensitive to stretch - gives the urge of the need to wee.

88
Q

Histologically - why can some Ps be more prone to UTIs?

A

Their transition cell epithelium lining of the bladder may have a glycosaminoglycan (GAG) deficiency

89
Q

Which nerves control micturition?

A

PSS via S2-4 = pudendal nerve
Somatic supply - S2-4 as well - controls urethral sphincter

90
Q

Which nerve receptors are found in the bladder?

A

M3 receptors - for PSS and somatic supply - when stimulated they cause contraction of the bladder.

Β-3 receptors (NOR) - for SS - cause relaxation of the bladder. Found in the body of the bladder.

α receptors - found in neck of bladder and urethra - when stimulated they cause contraction.

91
Q

Which anticholinergics can be used for the bladder?

A

Oxybutynin
Solifenacin

92
Q

Name a drug that is a β 3 agonist for the bladder?

A

Mirabegron

93
Q

Which drug is a nicotinic agonist for the external urethral sphincter that is used for leakage?

A

Duloxetine

94
Q

Why do infections cause diarrhoea?

A

Basically - there is a loss of absorptive area - can be due to cell death (toxins, ion channel disruption), inflammatory response, inc permeability of epithelium –> fluid and electrolyte loss

95
Q

When do you do stool microscopy on a P with diarrhoea?

A

If the Ps is very unwell, there is blood/pus in the stool, recent ABs, foreign travel or IC P.

96
Q

What is lost in diarrhoea?

A

H20, Na, HCO3 and K

Can cause dehydration, hypokalaemia and acidosis.

97
Q

What causes acidosis with diarrhoea?

A

AKI - less perfusion of kidney = HC03 loss

98
Q

Which drugs can cause diarrhoea?

A

Metformin
ACEIs
Omeprazole
Laxatives

99
Q

If the pancreas fails - how does this affect stools?

A

Can cause steatorrhea due to lack of absorption of fats from lack of bile salts

100
Q

What are the causes of urinary incontinence?

A

Mixed (urge & stress)
Outflow obstruction
Abnormal communication of urinary tract
Overflow
Functional - inability to reach the toilet

101
Q

Which medical conditions can cause urinary incontinence?

A

UTIs
Oestrogen deficiency
DM
Neurological - MS, stroke, cauda equina, previous pregnancy w/difficult delivery

102
Q

Which medications can cause urinary incontinence?

A
103
Q

What are transient causes of incontinence?

A
104
Q

What are red flag Sx for incontinence?

A

Haematuria
Persistent UTI
Constitutional Sx
Poor renal function
Abnormal neurology - inc saddle anaesthesia
Recent back trauma or pelvic surgery

105
Q

Which nerves allow bladder filling?

A

T11 - L2 (also responsible for perianal sensation)

106
Q

Which nerves innervate detrusor muscle contraction?

A

S2-S4

107
Q

How is stress incontinence managed?

A
108
Q

Which medication can be given for stress incontinence?

A

Duloxetine

109
Q

How is urge incontinence managed?

A
110
Q

Which drug is used for urge incontinence?

A

Anti-cholinergics

E.g. Solifenacin

111
Q

What are the SEs of solifenacin?

A

Cognitive impairment
Blurred vision
Dry mouth
Tachycardia
Nausea, constipation
Urinary retention

112
Q

Which drugs are given for bladder outlet obstruction caused by BPH?

A

Doxazosin
Tamsulosin (both α blockers)
Finasteride (5-α reductase)

113
Q

How do α blockers work for bladder obstruction?

A

Relax smooth muscle tone in the prostate

114
Q

How does finasteride work for bladder obstruction?

A

5-α reductase inhibitor
Blocks conversion of testosterone to dihydrotestosterone - limiting growth of prostate.

115
Q

What surgical procedures can be performed for BPH?

A

TURP
HoLEP

116
Q

How long do Sx have to be present for chronic constipation?

A

3m

117
Q

What conditions are associated with constipation?

A

Coeliac diease
Parkinsons
Spinal cord / brain injury
DM
Hypothyroid
Inflammation - diverticular disease
Intestinal obstruction

118
Q

Which medications can cause constipation?

A

Antacids
Anticholinergics
Antispasmodics
Anticonvulsants
Ca Channel blockers
Diuretics
Iron supplements
PD meds
Opioids

119
Q

What are the Sx of constipation?

A
120
Q

What are the red flags for constipation?

A

SCIBH
Rectal bleeding / bloody stools
Weight loss
Abdo pain
IDA

121
Q

What investigations can you do for constipation?

A
122
Q

How is constipation managed?

A
123
Q

What is first line laxative for constipation?

A

Ispaghula husk - BUT require adequate fluid intake which can be challenging in elderly Ps

124
Q

In elderly Ps - what is often given first line for constipation?

A

Osmotic laxatives - Macrogol, Lactulose

125
Q

If P finds stool difficult to pass, hard or incomplete emptying - what should be prescribed?

A

Senna (stimulant)
Sodium docusate (stool softener)

126
Q

What should you give for opioid induced constipation?

A

Osmotic + Stimulant
NEVER bulk forming

Year 3 Elderly Medicine (20 decks)

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