Geriatric Didactic Session Urinary Incontinence

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Geriatric Didactic Session Urinary Incontinence
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Urinary Incontinence (UI) - Prevalence

• Increases with age
• Not a normal part of aging
• Present in 25 30 of community dwelling women
  over 60 years
• In 10 15 of community dwelling men
• Common cause of admission to long term care
  facility

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Prevalence

• Under diagnosed and Underreported
• Only 32 of primary care physicians routinely ask
  their patients about UI
• 50 75 of incontinent community dwelling
  patients never describe their symptoms to
  physicians

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Risk Factors Associated with UI

• Impaired functional and mobility status
• Medications
• Morbid Obesity
• Diabetes
• Stroke
• Estrogen depletion
• Number of pregnancies/vaginal delivery/episiotomy
• Hysterectomy
• Delirium/Dementia

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Pathophysiology of Micturition

• Normal micturition requires mobility, manual
  dexterity, cognitive ability to recognize and
  react to bladder filling and the motivation to
  stay dry
• Parasympathetic nerves (S2 S4)
• - contracts bladder detrusor muscle
• - relaxes proximal urethral smooth muscle
• Sympathetic nerves (T11 L2)
• - contracts proximal urethral sphincter smooth
  muscle
• - relaxes bladder detrusor muscle
• Micturition coordinated by the CNS - parietal
  lobes and thalamus receive and coordinate
  detrusor afferent stimuli - frontal lobes and
  basal ganglia provide signals to inhibit voiding
  
• - pontine micturition center integrates all
  input into socially appropriate voiding with
  coordinated urethral relaxation and detrusor
  contraction until the bladder is empty

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Pathophysiology of Micturition

• Summary
• Urine storage - under sympathetic control
  (inhibiting detrusor contraction and increasing
  sphincter tone)
• Voiding - parasympathetic (detrusor contractor
  and relaxation of sphincter tone

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Age-Related Changes

• Detrusor overactivity (in 20 of healthy,
  continent older adults) - urgency
• Benign prostatic hyperplasia
• More urine output later in the day - nocturia
• Atrophic vaginitis and urethritis
• Increased postvoid residual
• Decreased ability to postpone voiding
• Decreased total bladder capacity
• Decreased detrusor contractility
• Decrease in strength of pelvic support muscles

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Potentially Reversible Causes of Incontinence
(Transient Incontinence)

• Delirium
• Infection, urinary (symptomatic)
• Atrophic urethritis/vaginitis
• Pharmaceuticals
• Psychological disorders
• Endocrine disorders causing excessive urine
  production
• Restricted mobility
• Stool impaction

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Medications that may affect Continence

• Sedative/hypnotics
• Alcohol
• Anticholinergics i.e. antipsychotics,
  antidepressants, antihistamines
• Narcotic analgesics
• Alpha- adrenergic antagonists
• Calcium channel blockers
• Potent diuretics
• ACE-inhibitors

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Urinary Incontinence - types

• Stress
• Urge
• Overflow
• Functional

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Urge Incontinence

• Most common cause of UI in patients over 75
  years
• Symptoms urgency, frequency, nocturia
• Usually idiopathic
• Other causes bacterial cystitis, bladder tumor,
  bladder stones, atrophic vaginitis/urethritis,
  stroke, Parkinsons disease, dementia

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Urge Incontinence

• Detrusor hyperactivity with impaired bladder
  contractility (DHIC) Detrusor overactivity
  coexisting with impaired contractility
• Usually found in frail, older patients (e.g. NH)
• Involuntary bladder contractions, yet must strain
  to empty
• Elevated PVR
• Can be misdiagnosed as stress incontinence in
  women if weak bladder contractions are not
  detected
• Can also be misdiagnosed as outlet obstruction in
  men because if similarity of symptoms (urgency,
  frequency, weak flow rate, elevated residual
  urine)

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Stress Incontinence

• Second most common in older women
• Results from failure of the sphincter mechanism
  to preserve outlet closure during bladder filling
• Leakage due to impaired pelvic supports or
  intrinsic sphincter deficiency
• Hypermobility of bladder neck and urethra (85
  cases) aging, hormonal changes, multiple
  childbirth, hysterectomy, pelvic surgery
• Intrinsic sphincter deficiency (15 cases)
  previous pelvic/anti-incontinence surgery, pelvic
  radiation, trauma, neurogenic disorders
• Alpha- adrenergic blockers cause relaxation of
  urethral sphincter

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Overflow Incontinence

• Results from detrusor underactivity /- bladder
  outlet obstruction
• Leakage is small in volume but continual
• PVR increased
• Causes of bladder outlet obstruction stricture,
  obstruction, cystocele, BPH, fecal impaction
• Causes of Detrusor underactivity DM, MS, lumbar
  spinal stenosis, spinal cord injury, medications
  (anticholinergics)

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Functional Incontinence

• Does not involve lower urinary tract
• Results from physical (e.g. arthritis, stroke)
  and/or cognitive impairment

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Physical Examination

• Assess mental status
• Assess mobility
• Abdominal exam not sensitive for bladder
  distension
• Neurologic evaluation of lumbosacral nerves,
  focal findings, peripheral neuropathy
• Pelvic exam atrophic vaginitis, cystocele,
  uterine prolapse, rectocele, paravaginal muscle
  tone, mass
• Rectal sphincter tone (active/resting) to
  assess integrity of sacral plexus (S2 S4),
  fecal impaction
• Cough stress test perform with a full bladder,
  better with patient standing
• Instantaneous Leak with cough- specificity gt 90
  for stress UI
• Leakage delayed or persists after cough suspect
  urge UI

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Post-void Residual

• Perform within 5 minutes of voiding
• Catherization or bladder ultrasound
• - PVR lt 50cc - adequate bladder emptying
• - PVR lt100cc adequate bladder emptying in
  patients older 65 years
• - PVR 100- 200cc inadequate emptying
• - PVR gt 200cc refer to urology

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Laboratory Evaluation for UI

• Calcium, glucose
• BUN/Cr especially if PVR gt 200cc
• Urinalysis and Culture
• Simple cystometry usually done in urology
• Can be an office based procedure 15 20 mins
• Determines bladder capacity and stability
• 79 91 positive predictive value for urge
  incontinence

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UTI and Incontinence

• Among chronically incontinent NH residents,
  elimination of bacteruria (with or without
  pyuria) has no effect on morbidity, mortality,
  severity or UI
• Treatment symptoms of infection (dysuria,
  hematuria, sudden decline in physical and/or
  mental function), recent onset UI, recently
  worsened UI

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Prevention of Recurrent UTI

• Topical estrogen/Estring can lower vaginal pH by
  increasing lactobacilli and prevent E.Coli from
  adhering to vaginal cells
• Cranberry juice- In a study showed decrease UTI
  in elderly women who drank 300cc/d for 6
  months(15 versus 28)

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Management of UI

• Behavioral therapies
• Pharmacological therapies
• Surgery
• Pessaries
• Periurethral bulking agents
• Occlusive devices
• Garments and pads
• Catheters

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Behavioral Interventions

• First line therapy
• Simple measures
• reduce amount and timing of fluid intake
• avoid bladder stimulants such as caffeine,
  alcohol
• avoid using diuretics just before bedtime
• make toilet easier to get to bedside commode
  if necessary

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Behavioral Interventions

• Patient Dependent Behavioral Interventions
• - Bladder retraining 20 dry rate, 75 of
  pts with 50 reduction in symptoms
• - Pelvic muscle (Kegel) exercises 56 95
  effective if done about 30 -80 times/day for
  minimum of 6 weeks
• - Biofeedback 54 87

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Behavioral Interventions

• Caregiver Dependent Behavioral Interventions
• - Scheduled toileting (fixed toilet schedule)
  29 85 effective
• - Habit training (toileting based on individual
  pattern) 86 effective
• - Prompted voiding (given regular opportunities
  to void) useful in the NH decreases
  incontinent episodes

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Drug therapy for urge incontinence

• Oxybutynin (Ditropan, Ditropan XL) cure rate
  up to 44, reduction rate 9 54, less dry
  mouth with XL
• Tolterodine (Detrol, Detrol LA) Cure rate 50
  with short acting, 71 with long acting, less dry
  mouth compared to oxybutynin
• Propantheline (Pro-Banthine) Reduction rate 0
  - 53, not well tolerated by older patients
• Hyoscyamine (Levsin) rapid, short acting, SL,
  not well studied
• Dicyclomine (Bentyl) reduction rate - up to
  62, unlabeled use, not well tolerated by older
  patients
• Imipramine (Tofranil) useful for nocturnal UI,
  mixed UI (urge/stress)

Caution when treating with pretreatment PVR gt75cc
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Transdermal Oxybutynin

• As effective as oral delivery
• Better anticholinergic side-effect profile

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Stress incontinence - treatment

• Medications
• Phenyl-propanolamine (ornade), pseudo-ephedrine
  (sudafed)
• Both increase urethral smooth muscle contraction
• Useful in stress incontinence with sphincter
  weakness
• Improvement 20 60
• Adverse Effects headache, tachycardia,
  elevation of BP

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Stress incontinence - treatment

• Estrogen increase periurethral blood flow,
  strengthen periurethral tissues
• Useful in stress and urge incontinence associated
  with atrophic vaginitis
• Should be given with progestin in women with
  uterus
• Adverse effect endometrial cancer, gallstones,
  elevation of BP, deep venous thrombosis

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Stress incontinence - treatment

• Surgery
• Sling procedure useful intrinsic sphincter
  deficiency 84 cure rate
• Needle neck suspension, Burch colosuspension
  useful for urethral hypermobility 79 84 cure
  rate
• Surgery cure rate decreases by about 50 after 10
  years

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Stress incontinence - treatment

• Pessary
• Useful in genital prolapse uterine or vaginal,
  cystocele
• Indicated in women who are at high risk for
  surgery, or who have had previous surgery for
  incontinence
• Elevates bladder neck and corrects the
  vesico-urethral angle
• Also increases outflow resistance by compressing
  the urethra against posteriosuperior aspect of
  the pubic symphsis

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Stress incontinence - treatment

• Occlusive devices occludes the urethral meatus
  by suction
• Some are intravaginal devices similar to pessary,
  require daily removal
• Example Fem-Assist, Introl, Reliance urinary
  control insert
• 80 -84 cure rate

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Stress incontinence - treatment

• Periurethral bulking agents involves injection
  of glutaraldehyde cross-linked bovine collagen or
  carbon-coated beads under cystoscopy into an
  incompetent periurethral area
• UTI and transient urethral irritation are most
  common side effects
• 40 cure rate, 67 improved
• Complications urgency, UI, urinary retention

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Overflow Incontinence

• Obstruction alpha blockers (terazosin,
• doxazosin, tamsulosin)
• - surgery
• Neurogenic bladder intermittent
• 
  catheterization

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Criteria for further evaluation

• Incontinence associated with recurrent
  symptomatic infection
• previous anti- incontinence surgery or pelvic
  radical surgery
• Symptomatic pelvic prolapse
• Abnormal PVR gt 200cc
• Hematuria in the absence of infection
• Failure to respond to an adequate therapeutic
  trial