What is urinary incontinence a major culprit of in older people?
Types of incontinence.
Explain stress incontinence.
Small volumes of urine leak during any sort of stress exerted on the body, such as coughing or laughing.
This is more common in women.
Explain urge incontinence.
Frequent voiding, often cannot hold the urine.
Symptoms such as frequency, urgency and nocturia.
It is commonly seen in detrusor muscle overactivity but can occur in obstruction as well.
If urge incontinence is acute in onset, what should be considered?
History of urge incontinence.
Do you ever not make it to the toilet in time?
Able to hold it or do you need to go quickly?
What happens if you do not go to the bathroom?
Do you plan your day around going to the bathroom?
Do you use continence pads?
What is urgency and leaking precipitated by?
The sound of running water
Causes of urge incontinence.
Detrusor overactivity e.g. from central inhibitory pathway malfunction.
Bladder muscle problem
Causes of stress incontinence.
Pelvic floor weakness/prolapse/pelvic masses.
Look for cough leak on standing and with a full bladder.
Common in pregnancy and following birth.
Uterine prolapse or urethrocele.
Explain overflow incontinence.
Due to urinary retention.
Symptoms include difficulty initiating micturition, poor stream and terminal dribbling.
This can also lead to renal failure due to obstructive uropathy.
Causes of overflow incontinence.
This can be seen with obstructive symptoms in men with BPH or prostate cancer for example.
Also medication such as anticholinergics can cause this.
Explain functional incontinence.
There is no primary urogenital problem in this, the physiological factors are relatively unimportant.
Instead the patient is caught short and too slow in finding the toilet in time.
This can be due to cognitive impairment, immobility or behavioural problems.
It can also be due to unfamiliar surroundings.
Management of functional incontinence.
CGA to address any modfiable components such as pain control to allow improved mobilisation.
How people void, frequency, symptoms, oral intake
Types of drinks ocnsumed.
Bowel habit including stool type and frequency.
Full drug history and collateral if need be.
Examination of continence.
Review of bladder and bowel diary
Urine dip stick and MSU
PR examination including prostate assessment in a male
External genitalia review paricularly looking for atrophic vaginitis in females.
Post-micturition bladder scan
Incontinence in men.
Most commonly enlarged prostate leading to overflow incontinence.
Urge incontinence can also happen in enlarged prostate.
TURP and other pelvic surgery may weaken the bladder sphincter and cause incontinence as well.
Incontinence in women.
Stress incontinence is a big issue - post-menopausal, prolapse, weak pelvic floor and obesity are factors needed to be considered as well as pregnancy.
Functional incontinence also happens.
Urge incontinence and overactive bladder syndrome can also be seen.
Investigation of incontinence.
Drugs and pads are not first line management for urinary incontinence.
Pelvic floor strengthening
Review of fluid intake
Optimisation of resp disease
Pharmacological management of incontinence.
Anticholinergics - you need to be mindful with these drugs in the elderly however due to its side effects and interaction with cognitive impairment.
Oxybutynin can be used in young patients but should not be used in older people.
Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.
Management of stress incontinence.
Pelvic floor exercises is first line.
Intravaginal electrical stimulation can also be done but a lot of women do not like it and refuse.
A ring pessary to help uterine prolapse may be tried.
There are surgical options such as;
Stabilising mid-urethra by tension-free vaginal tape.
Medical options such as duloxetine.
Management of urge incontinence.
Patient/carer should complete an incontinence chart for 3 days to define the pattern of incontinence.
Examine for spinal cord and CNS signs as well as vaginitis.
Bladder training and weight loss are important. Bladder training involves not going to the bathroom when ever you feel like, but holding in the urine to a certain time and then going and then gradually increasing that time period.
Absorbent pads if this does not help.
In males you can consider a condom catheter.
Treatment of urge incontinence due to vaginitis.
Topical oestrogen therapy
Pharmacological treatment of the nocturia in urge incontinence.
Antimuscarinics to improve frequency and urgency.
Topical oestrogens for post-menopausal urgency, frequency and nocturia.
B3 agonists if antimuscarinics are CId.
Botox if anything else is ineffective.
Non-prostate related urinary incontinence.
PRimary bladder neck obstruction.