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Geriatrics
Disorders sphinctériens incontinence
Courses of Geriatrics
 


 

Urinary incontinence:

A - PHYSIOLOGY:

The continence is ensured by sphincters.

Some are under the control of the will: sphincter striated.

Others are under involuntary control: sphincter smooth.

Phenomena of pressures also intervene.

The affections of the prostate are at the man a factor of retention.

With the age, the vesical wall becomes less elastic:

• Collagenous

• Formation of fibrous fabric.

Sphincters:

• Reduction in tonicity sphinctérien

• Reduction in the force of contraction of the muscles of the pelvic floor

• Post-menopausic Atrophy Urethra:

• It becomes rigid

Prostate:

• Facteur of retention at the man Controls:

• Hyperactivity of the détrusor

B - EPIDEMIOLOGY:

Women:

• 23% permanent incontinence

• 48% of occasional incontinences

Men:

• 16% permanent

• 30% occasional 40% in institution.

C - TO ELIMINATE FALSE INCONTINENCES:

Micturition by overflow on acute retention of urine.

It is an urgency. Risk:

• Acute and organic renal Insufficiency

• Ascending Pyelonephritis and/or septicaemia

• Breakdown of bladder

D - FUNCTIONAL INCONTINENCE:

True incontinence.

Normal apparatus vésico-sphinctérien.

1) ETIOLOGY:

• Locomotor Handicap

• Disorders of vigilance

• Confinement

• Polyurie

• Behavioral Incontinence

2) PHYSIOPATHOLOGY:

• Deterioration of the mechanism of vesical fence

• Deterioration of the system of transmission of the pressures

• Reduction in the reflex of distension-evacuation: unstable bladder +++

• Hypo-activity of the Often mixed détrusor.

3) PRIVATE CLINIC:

a) Interrogation:

• Methods of installation: slow, brutal…

• Standard: night, of effort…

• Other urinary symptoms

• Previous: neurological, diabetes…

• Medicamentous Treatments: diuretic, psychotropic, myorelaxants, beat-blockings, parasympathomimetic

Often made difficult by the deterioration of the higher functions.

To put at contribution the family.

He to ask to establish a catalogue mictionnel

b) Clinical examination:

In two times:

• Full Bladder

• Post-mictionnel ECBU.

At the man:

• OGE

• Périnée

• Examination rectal +++ At the woman:

• Gynaecological Examination

• Systematic Smear

4) EXAMINATIONS PARACLINIQUES:

a) ECBU:

b) Assessment:

• Ionic

• Créatininémie

• Uraemia

• Glycemia

• Uricémie

c) possible pelvic Echography:

At the end of this assessment:

• 50% of given mechanisms

• 50% of mixed unspecified mechanisms

d) Assessment urodynamic:

When it is possible.

• Débimétrie

• Search for a residue post-mictionnel

• Installation of a urinary probe

• Cystomanométrie

• 1st need towards 150 DC

• 3rd need towards 350 DC

• Profilometry: good transmission enters the pressures

Is not possible that on lucid, co-operating and motivated patients.

Possibility of remaining one hour in décubitus.

To eliminate a functional incontinence.

Require:

• A sterile or sterilized ECBU.

• The result of echography

• A diary mictionnel

Affected most frequent:

• Urinary Incontinence of effort

• Vesical Instability

• Micturitions reflexes After urodynamic exploration:

• Sphinctériennes Insufficiency: 70%

• Vesical Instability: 65%

• Defect of transmission of the pressures: 50%

• Hypo-activity of the détrusor less frequent

5) CURABLE CAUSAL PATHOLOGIES:

a) Proctologic pathologies:

• Fécalome

• Hémorroïdes and anal crack

b) Urologic pathologies:

• Cystitides

• Lithiasis

• Tumour

• Adenoma

• Cancer of prostate

• Sténose urethral

c) gynaecological Pathologies:

d) Neurological pathologies:

• Parkinson

• HPN

• Tumour

• Myélopathie cervico-arthrosic

• Neuropathy diabetic

• Syndrome of the tail of horse

6) TREATMENT:

The strategy will depend on two factors:

• Request and motivation of the patient

• Degree of co-operation and comprehension

a) Curative treatment:

Surgical treatment of a curable pathology: exceptional.

Rehabilitation: aim at restoring a good contraction of the striated sphincter.

Cause a good relieving of the détrusor.

• Mictionnelle Programming

• Manual Rehabilitation

• Électrostimulation functional calculus

• Biofeedback

b) The practical Councils:

• To facilitate the access to the toilets

• Installation of a device on the basin

• Clothing easy to remove

• Installation of draw sheets

• Reduction in drinks the evening while fighting against the hydrous diet

Dédramatiser incontinence, its rehabilitation and the port of protections.

To fight against the hydrous diet.

c) palliative Treatment:

It is always indicated.

It is sometimes the only possible one:

• Patient not cooperating

• Failure of rehabilitation or the medical treatment

Material:

• Material absorbing

• Cases péniens

• Urinary Probe with residence

Urinary retention:

Residue post-mictionnel > 100 ml.

A - EPIDEMIOLOGY:

Prevalence of the chronic retention at the old people presenting of the disorders vésico-sphinctériens.

13 to 34% according to authors'.

B - PHYSIOPATHOLOGY:

Obstacle with the vesical evacuation:

a) Organics:

• Prostatic

• Urethral (sténose)

b) Functional calculus:

• Dyssynergie vésico-sphinctérienne

• Médicaments (anticholinergic which decreases the activity of the muscle, calcic inhibitors which slackens the détrusor) Hypo-activity of the détrusor. Hyposensibility of the détrusor.

C - ASSESSMENT:

a) Clinical assessment:

• Interrogation +++

• Vesical Earth: examination rectal +++

• Survey post-mictionnel

b) Assessment paraclinic:

• ECBU

• Pelvic Echography ± urorectale

• Even assessment urodynamic

D - ETIOLOGY:

a) Neurological attacks:

• Hémiplégie

• Paraplegia

• Parkinson

• Peripheral Neuropathies: diabetes

• Neuropsychological Disorders

b) Uro-gynaecological attacks:

• Hypertrophy prostate sufferer: adenoma or cancer

• Shorthand writings urethral

• Urinary Infection

• Gynaecological Tumour

c) Fécalome:

d) Post-surgical:

Hip.

E - TREATMENT:

1) CURATIVE TREATMENT:

The objective is that the bladder contains nothing any more but its capacity of tank.

400 to 450 ml.

a) Treatment etiologic:

Treatment of the cause.

b) Rehabilitation:

Iterative survey for:

• Breakdown of bladder

• Hypocontractilité

c) medical Treatment:

Urécholine:

• After failure of rehabilitation

• Hypo-activity of the détrusor Inhibiting calcic:

• sténose functional urethral.

d) Palliative treatment:

Survey with residence.

Fecal incontinence:

A - PHYSIOLOGY OF THE DEFECATION:

1) PHYSIOLOGY:

System sphinctérien:

• Smooth Sphincter

• Striated Sphincter

The pressure sphinctérienne must be higher than the pressure intrarectale.

The recto-anal angulation plays a part.

The rectal bulb is empty between two défécations.

When there is propulsion of a saddle:

• Rectal Distension

• Relaxation of the smooth sphincter

• Voluntary Contraction of the sphincter striated Then return to the normal after adaptation with the rectal bulb.

Minimal threshold of feeling: 5 to 20 ml.

Maximum capacity: 250 to 350 ml.

2) NORMAL DEFECATION:

a) Physiological Défécation:

Rectal propelling contraction.

Synergy with the contraction sigmoïdienne and relaxation of the sphincters.

b) Sociological Défécation:

Differed at the selected time.

Voluntary abdominal push.

Complete relaxation of the smooth sphincter: automatic.

Voluntary relaxation of the striated sphincter and the pelvic floor.

Opening of the angle.

Expulsion of the saddle by the anal channel.

3) AGEING OF FUNCTIONS ANO-RECTALES:

The power of the sphincters decrease little.

The anal pressure of rest is the same one until around 70 years.

The voluntary pressure of contraction is equal until:

• 70 years at the woman

• 80 years at the man

Rectal sensitivity.

Reduction in rectal compliance.

Worse quality of the opening of the ano-rectal angle.

4) INCONTINENCE SPHINCTERIENNE:

a) Voluntary insufficiency of contraction:

• Central neurological Lesion: paraplegia, syndrome of the tail of horse

• Peripheral Neuropathy

b) Destruction partial or total of the sphincter:

Traumatism by:

• Proctologic Intervention

• Tear obstétricale

c) Syndrome of périnée the descendant:

Had with the efforts of pushed in the final constipés old men.

Stretching and destruction of nervous fibres.

5) GOING BEYOND OF THE CAPACITIVE SYSTEM:

a) Reduction of the tank:

• Partial Amputation

• Rectite radic: following radiotherapy

• Inflammatory Pathology

b) Increased rectal plenitude:

B - ASSESSMENT:

1) INTERROGATION:

Dédramatisation +++.

• Previous proctologic and gynaecological

• Frequency and consistency of the saddles

• Recent Constipation

• Natural of incontinence

2) CLINICAL EXAMINATION:

Examination proctologic in génu-pectoral position.

Gynaecological examination.

Examination rectal +++

Neurological examination:

• Périnée

• General.

3) EXAMINATIONS PARACLINIQUES:

Seek of a tumour:

• Anuscopie

• Rectosigmoidoscopy ASP.

Calendar of the saddles.

Recto-manometric exploration ±.

C - TREATMENT:

a) Regularization of the transit +++

b) Rehabilitation:

• Biofeedback for rectal dyschesy

• With feeling of rectal plenitude for the dilated recta

• By electrostimulation for insufficient the sphinctériens

• Of the behavior défécatoire in the demented people

c) Surgical:

• Mucous Prolapsus

• Syndrome of périnée the descendant

• Major Deterioration of statics périnéale

The fecalome:

Major complication of the constipation.

Very important incidence.

A - EPIDEMIOLOGY:

42% of the patients admitted in psychiatry.

B - PHYSIOPATHOLOGY:

See incontinences.

C - PRIVATE CLINIC:

• Acute abdominal Pains

• Pseudo-occlusive Syndrome: vomiting, stop of the transit

• Confusion

• Fecal and urinary Incontinence

• Urinary Retention

• Distorts diarrhoea

To eliminate the fécalome before any treatment against the constipation.

Examination rectal +++

D - PARACLINIQUE:

ASP.

E - ETIOLOGY:

a) Polymédicamentation:

• Benzodiazepines

• Antihypertenseurs

• Antiacid

• Iron

• Morphine

b) Dehydration:

c) Loss of mobility:

F - TREATMENT:

a) Prevention +++

b) Rectal injection:

• Water

• Paraffin

• Hydrogen peroxide in the event of resistance but with prudence

c) manual Evacuation:

d) Purge colic:

After the evacuation of a fécalome after an evacuation of fécalome.

If not, risk of repetition.

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