Shuli Levy Continence
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Assessment & management of continence problems
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Shuli Levy Continence
- 1. Continence Problems: Assessment and management Shuli Levy Consultant Geriatrician, Hammersmith hospital, ICHNHST
- 3. Why Continence? • Not part of normal ageing • Morbidity burden • Up to 55% of women • Up to 30% men • 30-50% adjusted increase in hospitalisation • Up to 70% in nursing home residents • 2-3 x increased institutionlisation rate • Strong association with functional decline • Higher mortality post stroke
- 4. Overview • How continence normally functions • Common continence failures • Red flags • Assessment and management • Who to ask
- 5. Normal continence (complex!) • Neurological function • Bladder function • Sphincter function • Cognition • Mobility • Dexterity • Environment
- 6. Normal continence Brain • Frontal cortex external sphincter • Pons – learned behaviour • Bladder motor cortex Spinal cord • Sympathetic chain (L2) • Parasympathetic (S2-S4) • Somatic supply to external sphincter (pudendal)
- 7. As we age … • Bladder functional capacity decreases, residual capacity increases • Reduced detrusor contractility • Reduced urine flow rate • Loss of vaginal oestrogen post menopausally • Dryness and irritation • Less hostile environment to bacteria (? Increased pH) • Pelvic floor muscle atrophy • Enlargement of prostate in men • Increased gut transit time and colonic diverticulae constipation • Loss of circadian ADH / reduced RAA activity – increased nocturnal urine production • Cerebral white matter changes • Drugs drugs drugs
- 8. Common problems with continence • Urinary retention • Urinary incontinence • Asymptomatic bacteriuria and UTI • Medications
- 9. Urinary retention 1. Constipation • BNO or overflow, faecal impaction on PR, dehydration, drugs 2. Infection • pain, frequency, offensive smell, systemic illness, delirium 3. BPH • prostatism history / medications, big prostate on PR, PSA 4. Medications / medication changes 5. Cord compression
- 10. Urinary incontinence Neurological Functional/ iatrogenic Urological Urological • Stress incontinence • OAB / urge • Mixed UI • Infection • Atrophic vaginitis Bladder outlet obstruction • Constipation • BPH Functional /iatrogenic • Mobility / dexterity • Delirium & dementia • Medications • Metabolic (DM, Ca++) Neurological • Stroke • Cerebrovascular disease • Autonomic neuropathy • Demyelination • Cord compression
- 12. If you like acronyms
- 13. Asymptomatic bacteriuria (ASB) • Bacteriuria without symptoms • Up to 10% men and 20% women over 75y • Up to 40% men and 50% women in care homes • Associated with dementia, incontinence and immobility • ALL catheters become colonised • Causes localised inflammation – 90% have white cells • Do NOT treat • No morbidity or mortality improvement • Increase in resistant organisms • No proven effect on symptoms in chronic incontinence • High re-infection rates
- 15. Red flags: cord compression • Vertebral collapse • traumatic, osteoporotic • Known or new cancer - myeloma, solid organ metastases (look at Ca++, ALP and FBC), • Disc prolapse - sudden or subacute back pain
- 16. Cord compression Urinary retention / incontinence / overflow Faecal incontinence Saddle anaesthesia Lower limb weakness and sensory impairment Loss of anal sphincter on PR Upgoing plantars
- 17. Red flags Haematuria • Send for cytology • Rule out infection / calculi • Feel the prostate • Imaging Acute kidney injury • Overflow with obstruction Recurrent symptomatic infection • Diabetes • Neoplasm
- 18. Assessment • Very history based diagnosis • Timing of symptoms – acute / subacute / chronic • Retention / urge / stress / neurogenic / BOO • Trauma • Other features • Parity • Drug history and medication changes • Functional history • Cognitive assessment
- 19. Examination • Well or unwell • Hydration • Mental state – delirium • Feel for bladder • Dip urine for glucose, blood • PR for faecal impaction, prostate size, anal tone, perianal anaesthesia • Spinal tenderness • Limited neurological examination – lower limb power, tone, sensation, reflexes
- 20. Tests • Renal profile • PSA • Calcium and ALP if worried about bony infiltration • Inflammatory markers if worried about infection • Spinal x-rays +/- CT if worried about fracture • MRI if ? Cord compression • Urine cytology • Bladder scan / renal tract US
- 21. Who and when to ask • Urogynaecology multidisciplinary assessment • For urge, stress or mixed UI in females • Stress symptoms - pelvic floor exercises, bladder training, surgery • Drugs for OAB (fesoterodine, mirabegron) • Topical agents / pessaries for atrophic vaginitis • Urologists • PSA elevated beyond BPH range • BPH not controlled by drugs (Tamsulosin, finasteride) • Persistent haematuria
- 22. Who and when to ask • Neurosurgeons / spinal surgeons • Cord compromise on imaging and symptoms • If appears malignant may require radiotherapy rather than surgery • If acute, likely to need decompression • Vertebral collapse sometimes treated by kypho / vertebroplasty • Neurologists • Neurogenic bladder may respond to botox injections e.g. MS, spinal cord injury • Autonomic syndromes – diabetes, Parkinson’s disease • Geriatrician – if in doubt, ask us