Overview of GU and GI Problems in Geriatric Patients

9/24/96 Peter B. J. Wu, M.D.

GU:

I. Neuroanatomy

II. Functional Classification

Failure to store
- Because of the bladder
- Because of the outlet
Failure to empty
- Because of the bladder
- Because of the outlet

III. Treatment of storage dysfunction

1) Hyperreflexia of detrusor:

--- propantheline bromide (Pro-Banthine) 7.5 - 15 mg tid - qid., Oxybutynin chloride (Ditropan) 5 mg tid - qid.

--- b-adrenergic stimulation: Isopreoterenol, progesterone, less effective with marked side effects.

2) Ineffective closure of the internal urethral sphincter:

--- a-sympathetic:phenylephrine, phenylpropanolamine, ephedrine, pseudoephedrine, imipramine (Tofranyl) 25 mg tid.

3) Ineffective closure of the voluntary external sphincter:

--- neuromuscular re-education and strengthening, surgery.

IV. Treatment of emptying dysfunction

1) Weak expulsive force of detrusor:

--- bethanechol (Urecholine) 25 - 50 mg tid or qid.30 minuets before voiding, Crede maneuver.

2) Hyperactive internal sphincter:

--- a-adrenergic blockers: phenoxybenzamine (Dibenzyline) 10 mg tid or qid, phentolamine (Regitine), prazosin HCl (Minipress), terazosin (Hytrin).

3) Hyperactive external sphincter:

--- baclofen, diazepam, dantrolene: not effective.

V. Surgical treatment

1) To promote drainage: TUR-S, Pudendal nerve block and neurectomy, Electrical stimulation.

2) To promote storage: Subarachnoid blocks, Sacral rhizotomy, Perivesical denervation, enterocystoplasty, Cystourethropexy, Bladder neck tubularization, Artificial urinary sphincter, Urinary diversion, Continent pouches and Reservoirs.

GI:

Neuroanatomy

Parasympathetic fibers: GI proximal to the the level of the midtransverse colon---vagus n, distally---S2-4.

Sympathetic fibers: T5-L2.

The enteric nervous system: The myenteric plexus (Auerbach's) and mucosal (Meissner's) plexus.

Causes of Constipation

Inadequately dietary fibre and fermentable carbohydrate

Immobility, disinclination to defaecate

Drug therapy

Opiates
Anticholinergic agents including antidepressants
Iron therapy

Functional constipation

Organic obstruction

Neoplasm
Diverticular disease
Crohn's disease

Metabolic disease

Hypothyroidism
Hypercalcemia

Extrinsic neurological disease
Spinal-cord and sacral-nerve disease
Pudendal-nerve damage
Parkinson's disease

Chronic intrinsic neuromuscular disease of the colon

Hirschprung's disease
Chronic pseudo-obstruction
Systemic sclerosis
Diabetic neuropathy

Treatment

Fiber

Laxatives Docusate sodium/calcium

Osmotic cathartics

MOM
Magnesium citrate
Lactulose
Lavage solutions

Stimulant Cathartics

Bisacodyl P.O. or P.R.
Castor oil
Extract of cascara and extract of senna

Causes of Acute Diarrhea

Viral Rotavirus, Norwalk agent, adenovirus

Bacterial Campylobacter, Aeromonas, Pleisomonas, Salmonella, Shigella, Vibrio cholerae, invasive Escherichia coli, Yersinia enterocolitica, Toxin-mediated: Staphylococcus aureus, Clostridium difficile, C. perfringens, C. botulinum, Bacillus cereus, Vibrio parahemolyticus

Parasitic Giardia lamblia, Entamoeba histolytica, Cryptosporidium, Isospora belli

Medications Magnesium based antacids, quinidine, laxatives, colchicine, digitalis, propranolol, theophylline, NSAIDs, antibiotics, chemotherapeutic agents, diuretics

Idiopathic Ulcerative colitis, Crohn's disease

Miscellaneous Postobstructive conditions (impaction, stricture, carcinoma), diveritculitis, radiation injury

Vascular Ischemic bowel disease, vasculitis

Treatment

Pseudomembranous colitis. Metronidazole 250 mg PO qid. Vancomycin 125mg PO qid for 7-10 days.

Nonspecific antidiarrheals

Absorbents: Kaopectate
Opiod agents
- Loperamide
- Paregoric
- Deodorized tincture of opium
- Codeine
- Lomotil
Bulk-forming agents

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