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Medicine for the Elderly > LUTS in Older People > Flashcards

LUTS in Older People Flashcards

1
Q

What is urinary incontinence?

A

Involuntary loss of urine, which is objectively demonstrable and is a social/hygienic problem

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2
Q

Why may some patients with urinary incontinence not present to their GP?

A

Embarrassment, think it is normal part of ageing, often come to doctor with another “more important” problem

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3
Q

What are some challenges associated with urinary incontinence?

A

May be low on priority list of clinician if patient has more than one problem
Lack of confidence in interventions
Cost about 2% of NHS budget

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4
Q

What are some of the challenges associated with treating urinary incontinence?

A

Main pharmacological treatments have side effects particularly troublesome in elderly
Non-pharmacological management takes time

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5
Q

Is urinary incontinence a normal part of ageing?

A

No = should always be investigated and treated if it causing the patient distress

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6
Q

What part of the brain is responsible for cortical awareness of bladder fullness?

A

Located in the postcentral gyrus

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7
Q

What parts of the brain are responsible for micturition?

A

Initiation of micturition occurs in the precentral gyrus

Voluntary control of micturition is located in the frontal cortex

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8
Q

What is activated when the bladder is distended?

A

Sympathetic outflow (T11-L2) is activated = maintains detrusor muscle relaxation and continence

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9
Q

What causes voiding of the bladder in response to bladder filling?

A

Parasympathetic activation (S2-4) produces contraction of detrusor muscle and relaxation of internal sphincter

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10
Q

What are some additional elements required for continence?

A

Mobility, manual dexterity and cognitive ability to react to bladder filling

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11
Q

What changes occur in the bladder as a natural part of ageing?

A

Decrease in bladder capacity and urethral closure pressure

Increase in post void residual and detrusor overactivity

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12
Q

What are some transient causes of incontinence?

A

Delirium and psychological (especially depression)
Infection = urinary (symptomatic)
Atrophic vaginitis/urethritis and endocrine
Pharmaceutical/prostate and stool impaction
Restricted mobility

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13
Q

What are the types of incontinence?

A

Stress, urge, mixed, overflow and functional

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14
Q

What is stress incontinence?

A

Involuntary urinary leakage on effort or exertion, sneezing or coughing

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15
Q

What is urge incontinence?

A

Involuntary leakage accompanied by or immediately preceded by urgency

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16
Q

What is mixed incontinence?

A

Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

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17
Q

What is overflow incontinence?

A

Leakage owing to bladder outflow obstruction resulting in large post void residual volume

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18
Q

What is functional incontinence?

A

Incontinence resulting from an inability to reach or use the toilet in time (e.g poor mobility, cognitive impairment)

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19
Q

What areas should be covered when taking a history?

A

Urinary symptoms, bowels, mobility, containment (e.g pads), red flags, drugs, fluid intake, precipitants, previous pelvic surgery

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20
Q

What are some urinary symptoms that may be present?

A

Storage = frequency, nocturia, urgency
Voiding = hesitancy, poor urinary stream, dribbling
History of haematuria or recurrent UTIs

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21
Q

What are some bowel symptoms that patients may complain of?

A

Straining, constipation, incontinence

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22
Q

What additional areas should be covered when taking a history from a female patient?

A

Pregnancies, mode of delivery, birth weights

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23
Q

What are some drugs that may be associated with incontinence?

A

Sedatives and hypnotics, antimuscarinics, diuretics, alcohol

24
Q

What should be covered in the examination?

A

General appearance, mobility and cognitive exam
Abdominal and pelvic examination ( especially women)
Urinalysis = only if result will change management
PR examination

25
Q

What investigations can be done for urinary incontinence?

A

Bladder scan = for post-void residual and retention
Bladder diaries and blood test (PSA, U&Es, glucose)
Urodynamic studies = only before surgery or failure of conservative management

26
Q

What are some lifestyle changes that can be made?

A

Reduce caffeine intake, encourage patient to lose weight

27
Q

What physical interventions can be done for stress incontinence?

A

Pelvic floor exercises = trial for at least 3 months

28
Q

In what patients is bladder training used for?

A

Those with urgency or mixed incontinence = increase voiding intervals

29
Q

What are some physical/behavioural interventions for urinary incontinence?

A

Pelvic floor exercises and bladder training
Exercise = beneficial all round for elderly people
Prompted and timed voiding programmes

30
Q

What happens in prompted and timed voiding programmes?

A

Taken to toilet at timed intervals throughout day

31
Q

When can pharmacological interventions be considered?

A

Only after 3 months of non-pharmacological management

32
Q

What is the first line medication for urinary incontinence?

A

Tolterodine 2mg twice daily = need to consider anti-cholinergic side effects

33
Q

What is the second line medication for urinary incontinence?

A

Solifenacin 5mg daily = increase to 10mg daily if no/little response after 6 weeks

34
Q

What is the third line medication for urinary incontinence?

A

Mirabegron MR 50mg daily = 25mg if moderate hepatic/renal impairment
Monitor BP before starting, after 1 month and annually

35
Q

How often should new medication be reviewed?

A

Always review 4-6 weeks after starting

36
Q

How is nocturia treated?

A

Late afternoon diuretic = furosemide

Desmopressin = check Na+ after 3 days and stop if below normal

37
Q

In which patients is desmopressin contraindicated in?

A

Age >65 with hypertension or heart disease

38
Q

How can atrophic vaginitis be managed?

A

Intravaginal oestrogens

39
Q

How is significant post void residual treated?

A

Treat constipation

Men = alpha blockers, 5-alpha reductase inhibitors

40
Q

What are the indications for specialist referral?

A

Symptomatic prolapse at/below intriotus = needs gynaecological surgery
Microscopic haematuria age >50 or frank haematuria
Recurrent/persisting UTI or chronic retention
Suspected malignant mass or men with stress UI
Failure of conservative treatment

41
Q

What is the risk associated with catheters?

A

They are foreign body so increase infection risk

42
Q

What are some acute indications for short term catheters?

A

Retention, acutely unwell patient, sepsis, part of surgical procedure

43
Q

What are some indications for long term catheters?

A

Can’t cope with intermittent self catheterisation
Medical management failed and surgery not option
Skin wounds or ulcers being contaminated with urine
Patient distressed by changes in bedding/clothing

44
Q

Are pads an important part of management?

A

Yes = referral for assessment and provision of pads is key

45
Q

When would catheters be used to treat post void residual?

A

If volume 200-500ml

46
Q

What are some red flags in a patient with faecal incontinence?

A

Blood in stool, changes in bowel habit

47
Q

What are some important things to remember when dealing with a patient with faecal incontinence?

A

Must quantify what is normal for patient

Treat constipation first if present = may be causing overflow faecal incontinence

48
Q

What are some causes of faecal incontinence?

A

Functional problems, anal sphincter or pelvic floor weakness, cognitive problems, rectal stool impaction, constipation, loose stools

49
Q

What are some lifestyle changes for patients with faecal incontinence?

A

Diet, caffeine avoidance, fluids, exercise, regular toilet habits, abdominal massage, pads, odour control

50
Q

How is functional faecal incontinence managed?

A

Avoid bed pans in hospital, multidisciplinary home visit

51
Q

How is faecal incontinence caused by cognitive problems treated?

A

1st line = prompted toileting
2nd line = scheduled voiding
3rd line = loperamide and enema combo for bowel control

52
Q

How is faecal incontinence caused by weak anal sphincter/pelvic floor treated?

A

Anal sphincter/pelvic muscle strengthening = taught be digital rectal examination or biofeedback
Holding on exercises = bowel retraining
Loperamide = monitor for constipation

53
Q

How is rectal stool impaction treated?

A

Enemas for complete clearance

Prevention of recurrence

54
Q

How is recurrence of rectal stool impaction prevented?

A

1st line = regular glycerine suppositories
2nd line = bisacodyl suppositories
3rd line = periodic enemas

55
Q

How is constipation treated?

A

Polyethylene glycol for rapid disimpaction

Daily laxative regime to ensure regular comfortable defaecation

56
Q

How is faecal incontinence due to loose stools managed?

A

Investigate for cause

Medicine for the Elderly (9 decks)

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