URINARY INCONTINENCE IN THE AGING PATIENT

September 2007Deb Mostek

Definition

UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem.

International Continence Society

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

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

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

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

Types of Urinary Incontinence

Transient UI (Acute) Established UI (Chronic)

Urge UI Stress UI Mixed UI Overflow UI “Functional” UI

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

Causes of Transient (Acute) 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.

Pharmacologic Causes Opioids Calcium channel

blockers Anti-Parkinsons

drugs Anti-cholinergics Prostaglandin

inhibitors

Depress detrusor activity & produce urinary retention and overflow incontinence

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

Pharmacologic Causes, Continued

alpha-agonists urethral

sphincter tone retention and Overflow

alpha-antagonists urethral

sphincter tone Stress

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.

Mrs. R SH: lives with daughter and grandson.

Dependent on family for assistance with ADL’s.

Physical Exam: BP 138/80 P78 R18 T98 Gen: Alert, cooperative, vague historian; Chest: Clear; CV: RRR; Abdomen: Benign; GU: Atrophic changes; Ext: Trace edema

Screening

Ask sensitively worded questions

Detailed History Duration, previous

evaluation/treatment? Volume, how often, what situations? Urgency, dysuria, straining?

EVALUATION:THE APPROACH

Focused 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

Evaluation, continued

UA, C&S Creatinine, BUN, Glucose, Calcium,

?PSA Post-void residual Clinical urinary stress test Voiding record

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

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

Established Incontinence

URGE STRESS Mixed type (both urge and stress) OVERFLOW (increased PVR) “Functional” incontinence

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

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, electrical stimulation, -adrenergic agonists, pessary, surgical interventions.

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.

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

Overflow UI

Management: Obstruction—Treat cause; -antagonists. Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.

“Functional” Incontinence

Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers

No underlying GU dysfunction Diagnosis of exclusion

3)FUNCTION FOCUSED APPROACH TO REMAINING CAUSES

Symptoms: URGE (REFLEXor 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 . ClinicalGeriatrics Vol. 10 Number 1 Jan 2002

Mrs. J Pleasant, thin 86 y/o with c/o urgency,

frequency, with variable UI for past 2-3 years. PMH: Osteoporosis with old thoracic vertebral

compression fractures, hypertension SH: Widowed, lives alone Meds: Calcium w Vit. D tid; alendronate 70

mg weekly; amlodipine 5 mg daily; MVI daily ROS: Mild fatigue, sleep disturbance, admits

to depressed ideation. Otherwise negative.

Mrs. J PE: BP 126/70 sitting; 118/68

standing. Wt. 44kg Gen: Thin, alert, excellent historian. CV, Pulm, Abd, Neuro: all neg GU: Ext genitalia/BSU/Vag– Atrophic;

no pelvic relaxation; Bimanual exam: consistent with previous hysterecomy, no masses. RV:Confirmatory

Mrs. J

PVR: 250 ml Clinical stress test: Some urine loss

after several seconds delay after cough

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.

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 last.

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

Bladder Retraining

Urge control exercises Scheduled toileting Prompted toileting

Pelvic Muscle Rehabilitation

Detailed instruction of pelvic muscle exercises

Biofeedback techniques Electrical stimulation

Anticholinergic Drugs Oxybutynin Tolterodine Trospium Darifenacin Variety of preparations: Immediate

Release; Extended Release; Transdermal Outcomes same; Try different agent if

one doesn’t work***** ALL these drugs suppress the detrusor contractility and MAY

CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!

Overflow UI

Obstruction—Treat cause; -antagonists; finasteride

Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.

Further Urological Evaluation

PVR > 400 cc Poor response to treatment Cystometry, cystoscopy,

urodynamic studies Evidence of GU tract pathology

UI Summary Look for reversible causes and Rx Check PVR (>100 cc investigate

further) Start with behavioral interventions

before meds Referral and urodynamic studies if

no response to usual measures Early referral if underlying GU tract

pathology present

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

Acknowledgments

Wendy Adams, MD MPH who also contributed slides

DuBeau CE. Urinary Incontinence. Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148