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URINARY INCONTINENCE
July 2003
Deb Mostek
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Objectives Discuss screening for urinary incontinence
in the geriatric patient. Identify transient UI and review
management. Describe the types of established UI,
evaluation and management.
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Definition UI is the involuntary loss of
urine that is objectively demonstrable and a social or hygienic problem.
International Continence Society
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Prevalence of UI 15-30% of community dwelling
persons 65 years and older.
F>M until age 80 years, then M=F
Up to 50% in LTC
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Consequences of UI Cellulitis, Pressure ulcers, UTI Falls with fractures Sleep deprivation Social withdrawal, depression Embarrassment (50%), interference with
activities Caregiver burden, contributes to
institutionalization Costs > $16 billion
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Physiology and Anatomy:1. Filling (150-200 cc)--
sympathetic reflex--body relaxes, sphincter tightens, detrusor inhibited.
2. Further filling(350-500 cc)--somatic (voluntary) tone increases (external sphincter)
3. Voiding--detrusor contraction with coordinated reflex— somatic and sympathetic tone, parasympathetic action.
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GU Age-Related Changes Detrusor overactivity (20% of healthy continent) BPH PVR , nocturia, UO later in day Atrophic vagintis & urethritis ability to postpone voiding, total bladder
capacity, detrusor contractility urine concentrating ability, flow DuBeau CE.Urinary Incontinence.Geriatric Review Syllabus Fifth Ed.2002-2004.139-148
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Risk Factors for UI Impaired mobility Depression Stroke Diabetes Parkinson’s Disease Dementia (moderate to severe) 1/3 have multiple conditions FI, Obesity, CHF, Constipation, TIAs, COPD,
Chronic cough, Impaired mobility & ADLs
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Types of Urinary Incontinence Transient UI Established UI
Urge UI Stress UI Mixed UI Overflow UI “Functional” UI
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Transient Incontinence Lower urinary tract pathology Precipitated by reversible factor 1/3 Community dwelling 1/2 Hospitalized incontinent aged patients Causes: Delirium, UTI, Meds, Psychiatric
disorders, UO, Stool impaction Restricted mobility
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Causes of Reversible Incontinence D Delirium I Infection A Atrophic Vulvovaginitis P Psychological P Pharmacologic agents E Endocrine, excessive UO R Restricted Mobility S Stool impaction Source: Resnick NM. Urinary incontinence in the elderly. Med Grand Rounds. 1984;3:281-290.
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Pharmacologic Causes Opioids Calcium channel
blockers Anti-Parkinsons
drugs Anti-cholinergics Prostaglandin
inhibitors
Depress detrusor activity & produce urinary retention and overflow incontinence
Culligan PJ Urinary Incontinence in women Evaluation and Management AFP 12-1-01
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Pharmacologic Causes sedatives
loop diuretics
alcohol
caffeine
cholinergics (donepezil)
awareness, detrusor activity Func & O UI
Diuresis overwhelms bladder capacity Urge & O UI
Polyuria, awareness Urge & Functional UI
Polyuria, detrusor activity Urge
detrusor activity Urge
Culligan PJ Urinary Incontinence in women Evaluation and Management AFP 12-1-01
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Pharmacologic Causes, Continued
alpha-agonists urethral sphincter
tone retention and Overflow
alpha-antagonists urethral sphincter
tone Stress
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Screening Ask sensitively worded questions
Detailed History Duration, previous evaluation/treatment? Volume, how often, what situations? Urgency, dysuria, straining?
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EVALUATION:THE APPROACHFocused H & P for: 1) Reversible conditions2) Conditions that require Urologic or
Gynecologic consult or Urodynamics early on.
3) Function focused approach to the remaining cases
4) Contributing factors
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Evaluation, continued
UA, C&S Creatinine, BUN, Glucose, Calcium, ?
PSA,?Vitamin B12 level Clinical urinary stress test Post-void residual Voiding record
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Post-Void Residual (PVR) Measure volume of urine left in bladder after
voiding by catheter or bladder scan
< 50-100 Normal
100—400 Monitor until consistently less than 200cc.
> 400cc—Insert Foley catheter
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Clinical Stress Test Bladder should be full. Ask patient to strain
(Valsalva maneuver). If no leakage, have her perform a half sit-up and cough—look for leakage. If no leakage in supine position, repeat testing in standing position. Patient should relax perineum and cough once—if immediate leakage=stress UI; if leakage is delayed several seconds=detrusor overactivity
20 Common Problems in Urology; JM Teichman, Ed. 2001 2003 GAYFP; DB Reuben et al
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Evaluation, continued Voiding record (48 hours, timing of
incontinence episodes and normal voids, voided volume, frequency, day & nocturnal urinary output, associated activities, or Q 2-hour continence status in those with cognitive impairment)
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2) CONDITIONS To CONSIDER:EARLY UROLOGIC, or GYN,or
URODYNAMIC EVALUATIONPROBLEMRecurrent. symptomatic uti’s
with U.I. Pelvic Prolapse (marked)
Suspected prostate ca.
Hematuria (sterile)
Urinary retention (that does not respond to acute management).
REFERAL for/to: GU Imaging & cystoscopy
Gyn surgical eval. or pessary
Urologic evaluation
GU Imaging & Urology (cystoscopy )
Urologic evaluation. and treatment
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Urge Incontinence Most common Detrusor overactivity with uninhibited bladder
contractions Unpredictable, abrupt urgency, frequency,
variable volumes lost, PVR usually normal (“Post-void residual”—the volume of urine left in bladder after spontaneous voiding)
Management: bladder retraining, scheduled toileting, pelvic muscle exercises (PME), pharmacologic agents
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Stress UI 2nd most common cause in aging females Impaired urethral closure due to insufficient
pelvic support, sphincter opens during bladder filling
Leakage occurs with intra-abdominal pressure Management: pelvic muscle exercises,
biofeedback, vaginal cones, electrical stimulation, -adrenergic agonists, pessary, surgical interventions.
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Ahronheim JC. Aging. In Epps RP, Stewart SC eds. Women’s Complete Healthbook, 1995.The Philip Lief Group, Inc. and the American Medical Women’s Association, Inc.1996. Stress Urinary Incontinence figure 11.2, p156.
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Mixed Incontinence Features of both urge and stress
incontinence. Common in older women Management: bladder retraining, pelvic
muscle exercises, other pelvic muscle rehabilitative options outlined previously, pharmacologic agents.
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Overflow UI Detrusor underactivity and/or outlet obstruction Continuous small volume leakage Dribbling, weak stream, hesitancy, nocturia Outlet obstruction=2nd most common cause of UI in
Males Detrusor underactivity Urinary retention & overflow
Incontinence in 12%F; 29%M Management: Obstruction—Treat cause; -
antagonists. Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.
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“Functional” Incontinence
Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers
No underlying GU dysfunction Diagnosis of exclusion
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DHIC (Detrusor Hyperactivity with Impaired Contractility)
Most common cause of UI in frail and old:
Detrusor hyperactivity plus impaired bladder contractility (DHIC).
The clinical picture is:
a “story” of Urge incontinence with elevated or borderline PVR
ie PVR= 100-400 cc range.
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Rare Causes Bladder fistulas
Detrusor-sphincter dyssynergia
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Pelvic Muscle exercises Motivated patient, careful instruction 56-95% decrease in UI episodes—
dependent on intensity of program Focus on pelvic muscles (10 ctx 3-10
times/d)—avoid buttock, abdomen, thigh muscle contraction.
Biofeedback may help
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Mrs. R 85 y/o female brought to the emergency room
with new onset urinary incontinence. Daughter is worried about possible UTI and inability to care for patient at home if incontinence persists.
PMH: Dementia, hypertension, advanced osteoarthritis, gait disturbance.
Meds: ASA 81mg daily, hydrochlorothiazide 12.5 mg daily, calcium with vitamin D tid.
SH: lives with daughter and grandson. Dependent on family for assistance with ADL’s.
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Mrs. V 89 y/o with severe low back pain and difficulty
walking which started after a fall 6 weeks ago. Was hospitalized for 1 ½ weeks for pain control and mobilization. Currently residing at a nursing home for OT/PT rehabilitation. Initially was progressing with therapy until she fell again at NH. Now difficulty with ambulation, requiring assistance of 2 for transfers.
PMH: Degenerative disc disease of spine, Stress UI.
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Mrs. V Current meds: Oxycontin 20 mg q 12 hrs,
Oxycodone 5 mg q 4 hrs for breakthru pain. SH: Widowed. Was living independently 6
weeks ago, traveling, very active & social. Has concerned, involved daughter.
ROS: Notes worsening of her UI, now has continuous leakage. Depressed ideation. Otherwise negative.
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3)FUNCTION FOCUSED APPROACH TO REMAINING CAUSESSymptoms: URGE (REFLEX
or NEUROGENIC)STRESS OVERFLOW
leakage variable volumes small volume small volume pattern of urine loss unpredictable with intrabd. pressure
(cough, sneeze, laugh)almost continuous
delay voiding? unable able except with intrabd. pressure
able, (at times)
voiding volumes(normally)
variable normal small
N o c t u r n a lincontinence 1
Yes (pt. is unaware) Rare Yes (dribbling)
1.Rovner ES, Wein AJ, The treatment of Operative bladder in the geriatric patient . Clinical Geriatrics Vol. 10Number 1 Jan 20022.DuBeau C.E. Urinary Incontinence Geriatric Review Syllabus Fifth Ed. 2002-2004 pp139-148
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Management of UI Treat reversible cause (ie. Constipation) Review meds General measures: Behavioral
interventions before pharmacologic Rx,. Avoid caffeine & ETOH, minimize evening intake, pads, Surgery usually last.
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Further Urological Evaluation PVR > 400 cc Poor response to treatment Cystometry, cystoscopy, urodynamic
studies Evidence of GU tract pathology
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UI Summary Look for reversible causes and Rx Check PVR (>100 cc investigate further) Start with behavioral interventions before
pharmacologic agents Referral and urodynamic studies if no
response to usual measures Early referral if underlying GU tract
pathology present
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Acknowledgments Ahronheim JC. Aging. In Epps RP,
Stewart SC eds. Women’s Complete Healthbook, 1995. The Philip Lief Group, Inc. and the American Medical Women’s Association, Inc. Stress Urinary Incontinence figure 11.2, p156.
Edward Vandenberg, MD who contributed a number of the slides
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Acknowledgments Wendy Adams, MD MPH who also
contributed slides DuBeau CE. Urinary Incontinence.
Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148