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Toronto Notes 2019 Differential Diagnoses of Common Presentations Geriatric Medicine GM7
Epidemiology
• theincidenceoffecalincontinencediffersbysetting:community(17-36%),hospital(16%)andnursing home (33-65%)
• riskfactors:constipation,age>80yr,femalesex,urinaryincontinence,impairedmobility,dementia, neurologic disease
Etiology
• physiologicalchangeswithage>80yr(e.g.decreasedexternalsphincterstrength,decreasedrestingtone of internal sphincter, weakened anal squeeze, increased rectal compliance, and impaired anal sensation)
• trauma(e.g.vaginaldelivery,pudendalnervedamage,caudaequina)
• iatrogenic
■ surgical (e.g. anorectal surgery, lateral internal sphincterotomy, hemorrhoidectomy, colorectal resection)
■ radiation (e.g. pelvic radiation)
• neurogenic(e.g.neuropathy,stroke,MS,diabeticneuropathy)
• anorectal/colorectaldiseases(e.g.rectalprolapse,hemorrhoids,IBD,rectocele,cancer)
• medication(e.g.laxative,anticholinergics,antidepressants,caffeine,musclerelaxants)
• cognitive(e.g.dementia,willfulsoilingwithpsychosis)
• constipation/fecalimpaction
Investigations (if cause not apparent from history and physical)
• differentiatetrueincontinencefromfrequencyandurgency(e.g.IBS,IBD) • stoolstudies
• endorectalultrasound
• colonoscopy, sigmoidoscopy, anoscopy
• anorectalmanometry/functionaltesting
Management
• physiologicalchangeswithage:medicationmanagement(anti-motilityagents(e.g.loperamide),diet/ bulking agents for loose stool) increase fluid intake , biofeedback, retraining of pelvic floor muscles, surgery
• trauma:directsurgicalrepairoraugmentationofthesphincters
• iatrogenic:surgicalrepair,artificialsphincters
• neurogenic:medicationmanagement,abdominalmassage,digitalstimulationfordysfunction,
biofeedback and behavioural training, prevent autonomic dysreflexia in spinal injury
• anorectal/colorectaldiseases:treatunderlyingcause(optimizeIBDmedications),surgical(e.g.mass
removal, prolapse repair, hemorrhoid removal, colostomy)
• medication-relatedcauses:stoplaxatives,lowerdoseordiscontinueanyotheroffendingagents
• cognitive:regulardefecationprograminpatientswithdementia,psychiatricconsult(optimize
medications and cognitive function)
• constipation/fecalimpaction:disimpaction,preventimpaction,enemaorrectalirrigation
URINARY INCONTINENCE
• seeUrology,U6
Definition
• complaintofanyinvoluntarylossofurine
• canbefurtherclassifiedaccordingtopatientsymptomsas:urgeUI,overflowUI
Epidemiology
• 15-30%prevalencedwellingincommunityandatleast50%ofinstitutionalizedseniors
• morbidity:cellulitis,pressureulcers,urinarytractinfections,fallswithfractures,sleepdeprivation,
social withdrawal, depression, sexual dysfunction
• notassociatedwithincreasedmortality
Pathophysiology
• notanormalpartofaging,urinaryincontinenceisalossofcontrolduetoacombinationof:
■ genitourinary pathology: increased post-void residual volume, increased involuntary bladder
contractions (urge incontinence), urinary retention
■ age-related changes: decreased bladder capacity
■ comorbid conditions and medications
■ functional impairment
■ in elderly women: decline in bladder outlet and urethral resistance pressure promoting stress
incontinence
■ in elderly men: prostatic enlargement can cause overflow and urge incontinence