1.
Continence Problems:
Assessment and
management
Shuli Levy
Consultant Geriatrician, Hammersmith hospital,
ICHNHST

2.
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

3.
Overview
• How continence normally functions
• Common continence failures
• Red flags
• Assessment and management
• Who to ask

4.
Normal continence (complex!)
• Neurological function
• Bladder function
• Sphincter function
• Cognition
• Mobility
• Dexterity
• Environment

5.
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)

6.
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

7.
Common problems with continence
• Urinary retention
• Urinary incontinence
• Asymptomatic bacteriuria and UTI
• Medications

8.
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

9.
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

10.
Don’t forget overflow

11.
If you like acronyms

12.
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

13.
Medications affecting continence

14.
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

15.
Cord compression
Urinary retention / incontinence / overflow
Faecal incontinence
Saddle anaesthesia
Lower limb weakness and sensory impairment
Loss of anal sphincter on PR
Upgoing plantars

16.
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

17.
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

18.
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

19.
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

20.
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

21.
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

22.
Thank you
Shuli.levy@nhs.net