This document discusses continence medicine, including types of urinary and fecal incontinence. It covers the anatomy of the lower urinary tract and discusses stress, urge, and mixed urinary incontinence. For fecal incontinence it discusses causes, types, and the anatomy involved. Assessment, investigations, red flags, and management are described for both conditions, including lifestyle changes, pelvic floor exercises, bladder retraining, and medications.

1. Continence Medicine
Anoja Rajapakse
Consultant Geriatrician
March 2021

2.  Geriatric giants –Bernard Issacs 1965
 Continence is one of the subspecialities
 Very common problem. Affects all ages.
 Affects about 38% of people at 65 years and
increase with age
 Affects women more than men
 Does not increase mortality
 Increase morbidity

3. Types of incontinence
 Urinary incontinence in women
 Urinary incontinence in males
 Faecal incontinence

4. Urinary Incontinence
 A complaint of any involuntary leakage of urine
(ICS)

5. Anatomy of lower urinary tract
 BLADDER is the main organ involved
 Shapeless smooth muscular(Detrusor) sac.
 Lined with impermeable urothelium
 Urine enter via Ureters at bladder trigone
 Unidirectional urine flow
 Bladder store and expulse urine

6. Anatomy of LUT….
 Urethra begins at the lower apex of bladder
 Internal urethral sphincter made of involuntary
smooth muscles
 External urethral sphincter made of voluntary
skeletal muscle
 Has central and peripheral nerve innervation.

7. LUT nerve innervation
 Pelvic nerves (S2-4 Parasympathetic)
 Hypogastric nerve (L1/2 Sympathetic)
 Pudendal nerve  (Somatic)
 Spinal micturition centre (S2-4)
 Pontine micturition centre
 Periaqueductal grey matter
 Cortical micturition centre

8. LUT during storage…

9. LUT during micturition

10. Female Urinary incontinence
 Commoner in women
 Short urethra (3.5-5cm) little support
 Weaker perineum
 Weakened by childbirth

12. Types of urinary incontinence
 Stress Incontinence
 Urge Incontinence or Over Active Bladder (OAB)
syndrome
 Mixed Incontinence
 Other types – bladder outlet obstruction and atonic
bladder, Functional

13. Stress incontinence
 Situational
 Small volumes
 Daytime

14. Urge incontinence
 Larger volumes of
urine lost
 Unpredictable
 Day and night both

15. Patient - 1
 60 year female complaining of urine incontinence
for several years.
 Gradually worsening
 Past history Parkinson’s disease, hypertension
 Had 3 normal vaginal deliveries.

16. What additional information?
 When/what worsen?
 Associated symptoms
 How many episodes in day/Night?
 How long the warning to pass urine
 Incontinence – always/occasional
 Volume passed
 Any precipitating factors
 Bowel/sexual dysfunction
 Types and volume of Fluid taken

17. Additional information…
 Past medical/surgical/obstetric history
◦ How many children, method of delivery, birth weight
 Medication and allergy
 Social history
◦ Alcohol intake
◦ Details about the living –bathroom
◦ How does she get about (mobility)
 What containment products?

18. Examination
 General –vision, hearing, pedal oedema, AMT,
GDS
 Neurological examination – PD control, weakness,
dexterity function, gait (TUG).
 Abdominal examination – bladder/abdominal mass
 Pelvic examination (always have a chaperon)
- uterine prolapse
- muscle strength
- Bladder stress test
 Rectal examination

19. Diagnosis ?
 Stress incontinence ?
 Urge incontinence ?
 Mixed incontinence ?
 Other - Atonic/overflow/functional?

20. Investigations
 Basic blood investigations
 Random blood sugar
 Urine analysis
 Blood or protein look for renal tract pathology
 Glucose look for diabetes Mellitus
 Nitrates +/- leucocytes look for infection
 Bladder/Void diary
 Post-void bladder scan

21. Voiding diary for 3 days
Record to understand bladder function
 Day + night frequency
 Precipitating symptoms - coughing, laughing
 Was there leaking of urine?
 Urine volume lost involuntarily
 How long can they hold ?
 Were the pads damped or soaked in urine
 How many pads were used during day and during
night?

22. 3-day Bladder Chart

24. Bladder Chart
 What is taken by person
◦ Caffeine containing drinks
◦ Carbonated drinks
◦ Medication
 How much is taken by person
 Too little fluids and too much fluids both can
cause bladder problems

25. Assessment of residual urine
 Post-void bladder scan
 With ageing post-void residual urine volume
increases
 In-out Catheterization
 Higher incidence of urinary tract infection

26. Patient -2
 65 year old man
 Urine incontinence for 6 months
 Had T2DM well controlled
 ADL and mobility - independent

27. What additional information?
 When/what started?
 Other associated symptoms- hesitancy, poor
stream, urgency
 How many episodes in day/Night?
 Always/occasional incontinence
 Volume passed
 Any precipitating factors
 Bowel/sexual dysfunction
 Types and volume of Fluid taken

28. Additional information
 Past medical/surgical history
◦ TURP
◦ Catheterisation
 Medication and allergy
 Social history
◦ Details about the living –bathroom
◦ How does he get about (mobility)
◦ Alcohol intake and smoking
 What containment products?

29. Examination
 General –vision, hearing, pedal oedema, AMT
 Neurological examination – weakness, dexterity
function, gait (TUG).
 Diabetic sensory neuropathy signs
 Abdominal examination – bladder/abdominal mass
 Rectal examination

30. Investigations
 Basic blood investigations
 Random blood sugar, PSA
 Urine analysis
 Blood or protein look for renal tract pathology
 Glucose look for diabetes Mellitus
 Nitrates +/- leucocytes look for infection
 Bladder/Void diary
 Post-void bladder scan

32. Diagnosis ?
 Stress incontinence ?
 Urge incontinence ?
 Mixed incontinence ?
 Other - Atonic/overflow/functional?

33. Management

34. Red flags
 Persisting bladder or urethral pain
 Pelvic masses
 Associated faecal incontinence
 Suspected neurological disease
 Suspected urogenital fistulae
 Previous pelvic surgery
 Previous pelvic radiation

35. Treatable causes -DIAPPERS
 Delirium/Depression
 Infection
 Atrophy of vulva
 Pharmacological - medication
 Pelvic pathology and Pregnancy
 Excess urine production
 Reduced mobility
 Stool impaction

36. Medication cause/worsen UI

37. Neurotransmitter

38. Stress incontinence
 Commoner in younger women, post-TURP
 Small volumes of urine leaked
 Precipitating factors – coughing, sneezing, bending
 Symptoms mainly during daytime

39. Lifestyle change
 Weight reduction
 Drink enough fluids
 Avoid bladder irritants
 Medication antipsychotics, alpha agonist
 Caffeine  decaffeinated
 Carbonated drinks
 Alcohol

40. Treatment for stress
incontinence
 Pelvic floor exercises at least for 3 months (level -1
evidence)
 Electrical stimulation and biofeedback for women
who cannot actively contract pelvic floor muscles

41. Pelvic floor exercised
 Contract the muscle for 5 sec
 Relax for 5 sec
 Do for 10 times
 3 times a day

42. Access response to intervention
 Review patient after 3 months
 Repeat bladder diary for 3 days before clinic

43. Follow up
 Reinforce life style modification
 Duloxetine (SNRI) improve symptoms by
increasing urethral sphincter tone
 Tropical oestrogen and ⍺ agonist

44. Urge incontinence
 Symptoms of urgency- when you want to go you
are gone
 Daytime and night time frequency is similar
 Larger volumes of urine is leaked
 BPH, neurological conditions(PD, stroke,
Alzheimer), medication

45. Treatment of Urge Incontinence
 Weight reduction
 Stop smoking
 Change offending medications
 Bladder re-training for 6 months (level -1 evidence)

46. Access response to treatment
 Access response to treatment with bladder diary
 Consider starting medication

47. Treatment for UI….
 Antimuscarinics
◦ Oxybutynin, oral and tropical
◦ Solifenacin
◦ Tolterodine
 β3 agonist
◦ mirabegron
 Side effects – confusion, dry mouth, urine retention

48. Mixed incontinence
 Treat pelvic floor exercise when stress
incontinence symptoms are predominant problem
 Bladder re-training when OAB symptoms are
predominant
 Treat the predominant symptom with medication
when above has failed

49. Nocturnal enuresis
 More than 1/3 the total urine passed at night
 Look for fluid overload - congestive cardiac failure
 Limiting oral fluid intake after 1800 hours
 Medication
◦ Diuretics around midday
◦ Desmopressin - sodium monitoring

50. Urine retention
 Atonic bladder
◦ Diabetic autonomic neuropathy
◦ Stroke
 Outflow obstruction
◦ BPH
◦ Pelvic tumours
◦ Faecal impaction

51. Treatment of overflow and atonic
bladder
 Urinary catheters
◦ Kidney damage
◦ Skin wounds, pressure ulcers contaminated by urine
◦ Distress or disruption caused by bed and clothing changes

52. Urinary catheters
 Intermittent urinary catheter
◦ Good dexterity function
◦ Younger people
 Indwelling urethral catheter
 Indwelling suprapubic catheter
◦ Lower risk of UTI

54. Faecal incontinence
 Involuntary loss of solid or liquid faeces
 Anal incontinence includes flatus too
 Less commoner than UI
 Incidence increase with age
 M = F
 Doesn’t contribute to mortality
 Contribute to morbidity

55. Anatomy

56. Normal physiology
 When defecating the anorectal angle straightens
 Facilitated by squatting or sitting
 Abdominal pressure is increased by straining
 Increase pressure cause descend of pelvic floor,
contraction of the rectum, relaxation of the external
anal sphincter
 Evacuation of anal content

57. Anorectal inhibitory reflex
 transient involuntary relaxation of the IAS in
response to distention of the rectum.
 mesenteric plexus
 Pelvic, Splanchnic and Pudendal nerve
 Gut-brain pathway ??

58. Factors contributing for
continence
 Cognitive function
 Stool volume
 Stool consistency
 Colonic transit time
 Rectal distensibility
 Anal sphincter function
 Anorectal sensation

59. Types of faecal incontinence
 Urge incontinence
◦ External anal sphincter weak/damage
◦ Decrease rectal capacity
◦ Rectal hypersensitivity
 Passive incontinence – lacks awareness of need to
empty bowel
◦ Internal anal sphincter weakness

60. Causes of faecal incontinence
 Anal sphincter damage
◦ Obstetric injury, haemorrhoidectomy, anal
dilatation, radiation, IBD
 Rectum
◦ Rectal prolapse, neoplasms, excessive perineal
descent, hypo/hyper sensitivity of rectum
 Neurological causes
◦ Stroke, spinal cord injury, back surgery ,
dementia, diabetes autonomic neuropathy, MS,
Tabes dorsalis, cauda equina injury/tumours

61. Causes of Faecal
incontinence…
 Rectal irritants
◦ bile salt, malabsorption. laxatives
 Medications
◦ Laxative overuse
 Food intolerance, IBS
 Infections C. difficile infection
 Psychiatric illness, dementia
 Faecal impaction and overflow

62. Patient - 3
 60 year old female
 Faecal incontinence for 5 months
 Past history of T2DM
 3 children all normal vaginal deliveries
 Lacto-vegetarian

63. Additional information
 When symptoms started
 Frequency day/night
 How much warning does the patient get
 What is passed Solid/liquid stools?
 Amount passed –smear, small, moderate, full
motion
 Associated other symptoms
◦ lower back/perineal/abdominal pain
◦ Any blood/mucus/melaena
 Bladder involvement
 Diet and recognised associations to FI

64. Additional information…
 Past medical/surgical history
◦ Cholecystectomy/weight reduction Sx,
 Obstetric history
◦ Number of children/Type of delivery, birth weight
 Medication and Allergy
 Social history
◦ Type of toilet, access,-distance/steps, privacy,
floor safety

65. Examination
 General examination, vision, hearing, AMT, GDS,
gait (TUG)
 Abdominal examination
◦ Abdominal mass, pelvic mass, distended bladder
 Rectal examination
◦ See colour of stools/ blood/melaena
◦ Anal tone/perianal sensation
◦ Anal fissures/ prolapsed haemorrhoids
◦ Rectal masses/Rectal prolapse/uterine prolapse

66. Investigations
 Food diary
 Bowel chart
 Stools examination for o-c-p
 Sigmoidoscopy/barium enema

67. Medication that cause or
worsen loose stools/FI
 Antibiotics –penicillin, cephalosporin,
 Metformin
 Laxatives
 Calcium Channel Blockers
 β blockers
 SSRI
 Digoxin
 Orlistat
 Antidepressants
 Antipsychotics
 Benzodiazepine

68. Red Flag signs
 Loss of weight, Loss of appetite
 Suspected neurological disease
 Pelvic mass
 Suspected rectovesical fistula
 Previous pelvic surgery
 Previous pelvic radiation

69. Food diary

70. Management of FI
 Supportive management
◦ Avoiding food that cause or worsen FI
◦ Avoid caffeine, lactose, fructose
◦ Improving perineal skin hygiene
 Clean and dry
 Avoid excessive wiping
 Apply barrier cream (Zinc oxide)|

71. Lifestyle changes
 Dietary advice
 Bowel retraining
 Pelvic floor muscle exercise

72.  Reduce frequency and improve consistency of
stools.
 Exclude infection and use Loperamide/codeine
/cholestyramine
Medical management

73. Right consistency and right
timing

74. Bristol stools chart

76. Correct toileting position

77.  NICE has guidelines for management of urinary
continence in women (CG 171) – November, 2015
 NICE Guideline (NG123) April 2019
 Faecal incontinence NICE CG 49 June 2007
updated in February 2021