This week reflection is about a topic not very sexy but when explained clearly, it can be so interesting!
Bladder incontinence never crossed my mind that it could actually be an emergency medicine subject. It is!! I LOVE that! Open your minds to new subject, learn about it, and make it relevant for your learners/department!
I had a great talk about it.There is a link for further great informations about this: urinary incontinence in the frail elderly.
The more important part of it, is that it affects about 30% of our elderly (more women than men obviously), and is a common problem in 70% of people living in long term care. This might seems very common therefore banal, but in fact could be linked to shame and then social isolation, decrease of outdoor activities, exercise and then can contribute to the unfortunate appearance of frailty.
Convinced? Me too.
To understand everything about bladder incontinence, here is a summary:
- Frontal lobe: conscious control
- Thoracic and lumbar spine: sympathic control with alpha and beta They help to store urine (bladder distention, internal sphincter constriction)
- Sacral spine: parasympathic control via acetylcholine. It helps to pee (bladder constriction, sphincter opening + somatic control of the external sphincter (sacral and frontal lobes)
- Detrusor: the muscle of the bladder, calcium influences its function.
- Colon and prostate: external pressure/obstruction if enlarged.
Knowing that, everything that influences those can contribute to urinary incontinence. What is the definition of urinary incontinence? (Here I thought it would be something very specific and quantitative…) It is not. The definition is: uncontrolled loss of urine. (I am shocked!!)
Ok there are 5 types of incontinence:
- Stress: Lost of sphincter tone, weakened pelvic floor muscle, increased abdominal pressure, more mobility of the bladder.
- Loss of urine when sneezing, exercise, laughing, etc.
- Urgency: detrusor over-reactive
- Sensation of immediate needs to go to the bathroom and unable to get there in time.
- Mixed: stress + urgency (the most frequent cause in elderly)
- Overflow: flaccid detrusor, prostate hypertrophy, sphincter does not open properly
- Consistent leakage of urine despite the activity, sensation of incomplete voiding
- Functional: linked to dementia and/or physical limitations
There are some reversible causes to think about (This is the part that I like, what can “I” do for them in the emerg!). Here is a nice “mnemo-technic” (on my big piles of these…):
A trophic vagina/uretha
P harmacology, Psychiatry (dementia, depression), Prostate
E xcess urine output (caffeine, alcohol, diabetes, hypercalcemia)
R estricted mobility
The investigation will be linked to the review of these etiologies but basically, good physical exam, digital rectal exam, bladder scan post voiding, urinanalysis, creatinine, glucose, lytes, calcium.
The treatment again will be linked to specific causes. If no causes found, when do we start a pill? Well, not very often. Not in the emergency department anyway. But here is a quick review of what it can be offered to the patient by family physician (It is actually useful to know what is going on outside of the emergency department because you can adjust the patient expectations when you discharge them, and you look smart when you are right!)
First, try 3 months of non-pharmacologic treatment:
- Decrease fluid intake
- Decrease caffeine and alcohol
- Loss of excess weigh
- Kegel exercise (if stress incontinence)
- Timed toileting (every 1-2 hours)
- Bladder diary (to help monitor the evolution for the family physician)
The “pill” is only for urge incontinence. What do you think would be the mechanism? (review the summary!).
- Anticholinergic (eg: oxybutinine), 30% will have some benefits, a lot less will have complete incontinence.
Anti-cholinergic is usually avoided in older people because it can causes confusion, tachycardia, dry mouth (that will trigger drinking!), falls and constipation (that will increase the incontinence). It can not be used with donepezil (cholinergic pill for Alzheimer) or with narrow angle glaucoma.
There is another pill, mirabegron (beta-agonist), that is equally effective and has less adverse effects (hypertension).
For stress incontinence, surgery can be possible. Ask your urologist or gynaecologist for assistance.
See? It wasn’t that bad wasn’t it! Next time, constipation!