OP: Continence and constipation

Question 2

Is faecal incontinence ever normal?

Answer 2

No, always abnormal

Question 3

How does a patients rectum change as they age?

Answer 3

the rectum can become more vacuous and the anal
sphincter can gape due to a number of factors including haemorrhoids and chronic constipation.
Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.

Question 4

Why is diminished anal tone sensation important not to miss?

Answer 4

Could indicated spinal cord pathology-needs urgent management

Question 5

What is the most common cause of faecal incontinence in OP?

Answer 5

1)Faecal impaction with overflow diarrhoea
2nd- neurogenic

Question 6

What type of stool you be suspicious of overflow with impaction?

Answer 6

smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation

Question 7

What are the risks of chronic constipation?

Answer 7

stercoral perforation and ischaemic bowel

Question 8

What is the management of chronic constipation?

Answer 8

utilising enemas for rectal loading and stool softeners and stimulants.
Stimulants don’t work on hard stool.
Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.

Question 9

Management of diarrhoea in OP?

Answer 9

underlying causes must be excluded by bowel imaging and stool culture
potentially causative medications removed then care
can focus on firming the stool.
Faecal impaction must be excluded

Question 10

Pharmacological management of diarrhoea in OP?

Answer 10

Low dose loperamide

Question 11

What to ask about when taking a continence hx from a patient?

Answer 11

Ask about:
how void
how frequent
What other symptoms -e.g burning?
oral intake
types of drinks consumed
bowel habit (stool type/frequemcy)
Drug Hx
Collateral Hx if needed

Question 12

What are simple non drug management advice for continence

Answer 12

non caffeinated drinks
good bowel habit (water/fibre)
improve oral intake
regualr toileting
pelvic floor exercises
bladder retraining

Question 13

Define urge incontinence

Answer 13

Frequent uncontrollable leaking / emptying after urge. cant hold urine - nocturnal incontinence is common.

see with detrusor overactivity can also get with obstruction

Question 14

Define overflow incontinence

Answer 14

Urinary retention - e.g. obstructive symptoms in man with enlarged prostate

Question 15

What would you do when to examine a patient for continence - examination and investigations

Answer 15

Examination:
Abdominal examination
PR - prostate men
external genitalia - atrophic vaginitis in women

Investigations:
Urine dip stick and MSU
Post micturition bladder scan

Other:
review patients bladder / bowel diary

Question 16

Examining an older woman with stress incontinence - what look for ?

Answer 16

Pelvic floor weakness
Prolapse- e.g uterine
Pelvic masses
Urethrocele

Question 17

What would you do when to examine a patient for continence - examination and investigations

Answer 17

Examination:
Abdominal examination
PR - prostate / faecal impaction
external genitalia - atrophic vaginitis in women

Investigations:
Urine dip stick and MSU
Post micturition bladder scan

Other:
review patients bladder / bowel diary

Question 18

What co-morbidities need to rule out when dealing with a patient with incontinence?

Answer 18

Neurological cause - brain damage can be cause

Parkinsons
MS
Stroke
Dementia
spinal cord lesion // trauma

Question 19

What co-morbidities need to rule out when dealing with a patient with incontinence?

Answer 19

Neurological cause - brain damage can be cause of urge incontinence/detrusor overactivity

Parkinsons
MS
Stroke
Dementia
spinal cord lesion / trauma

Question 20

Why are drugs for incontinence problematic in older people?

Answer 20

Antimuscarinics are used - increase anticholingeric burden and cognitive impairment

Question 21

Why are drugs for incontinence e.g. oxybutinin problematic in older people?

Answer 21

Increases the anticholingeric burden - older patients are likely to be taking ++ anitmuscarinic drugs.

This can cause cognitive impairment
Can cause hypotension - risk of falls

Question 22

What are some side effects of antimuscarinic drugs for continence e.g. oxybutynin /

Answer 22

Dry mouth / eyes / skin
Drowsiness
Urinary retention
Constipation
Tacchy
Transient hypotension
glaucoma precipitation

Question 23

What medications can impair cognition and look like dementia

Answer 23

Anticholinergics
sedatives - benzodiazepams
opioids
corticosteroids

Question 24

A frail elderly pt has urge incontinence (overactive bladder). The drug treatment for this is antimuscarinics.
e.g. oxybutynin.

However, we know these are bad in frail, older pts. What drug can we give her instead?

Answer 24

mirabegron !

(a beta-3 agonist) if concern about anticholinergic side-effects in frail elderly patients