Urinary Incontinence in the Geriatric Population

1. Urinary Incontinence in the Geriatric Population S. Estella Horwath, MD 2018

2. Learning Objectives • To identify common types of urinary incontinence in the elderly • To identify people at risk for urinary incontinence and factors that may contribute • To discuss evaluation and treatment of common types of urinary incontinence

3. Urinary Incontinence • Involuntary leakage of any amount of urine • 15-30% of community dwelling adults >65 • 60-70% of LTC residents

4. UI Impact • Impairs QOL • Morbidity • Increased Caregiver Burden • LTC placement • $$$

5. Risk Factors • Age • Female sex • Cognitive impairment • Medications • Functional impairment • Environmental barriers to toilet access • Obesity • Smoking • Caffeine • ETOH intake

6. Age Related Physiologic Changes • Decreased bladder contractility • Bladder capacity decreases • More prevalent uninhibited bladder contractions • Diurnal urine output occurs later in the day • PVR increases • Vaginal mucosal atrophy • BPH increases

7. Types of UI • Stress • Urge • Mixed • Overflow • Functional • Neurogenic

8. Stress • Incontinence occurs with increases in intraabdominal pressure • cough, sneeze, standing, exercise • Impaired urethral sphincter support • Vaginal mucosa atrophy

9. Urge • “Overactive Bladder” • Detrusoroveractivity • Most common type in older men • Can be a few drops or complete bladder emptying. • Most common in elderly women Mixed

10. Overflow • impaired bladder emptying/obstruction • Elevated PVR • Most common in men with BPH • Women with urethral scarring or large cystocele/ pelvic organ prolapse • Intermittent small volume leakage

11. Neurogenic • Neuropathy • Spinal stenosis/disc herniation • Neurologic disease: MS, ALS • Mobility limitation • Cognitive impairment Functional

12. UI Evaluation • Screen • Do you have any problems with your bladder? • Do you have problems making it to the bathroom on time? • Do you ever leak urine?

13. The 3 incontinence Questions

14. UI Evaluation: History • Onset • Frequency • Volume • Timing • Identify red flag symptoms • Other LUT symptoms • Fecal incontinence, Painful intercourse • AUA Urinary symptom Assessment for men • Past treatments • Protective garment use • Depression screening • Medication review • Functional assessment

15. Red Flag Symptoms • Sudden onset UI • Pelvic pain • Hematuria • Evaluate for UTI • Refer to urology

16. Factors that can worsen UI • Constipation • CHF • DM • Myelopathy • Neuropathy • Cognitive impairment • Chronic cough • Psychiatric syndromes • Pelvic Organ Prolapse, Vaginal Atrophy • Medications

17. Medications that can worsen UI • Anticholinergics • Alpha blockers • Alpha agonists • ACE Inhibitors • Antipsychotics • TCAs • Ca Ch blockers • Loop diuretics • Cholinesterase inhibitors • Oral Estrogen • GABA agents • NSAIDs • Narcotics • Sedatives • TZDs • ETOH

18. UI Evaluation: Physical Exam • Functional and cognitive assessment • Neurologic exam • Male: prostate exam, genital exam • Female: Pelvic exam • Atrophic vaginitis • Pelvic support/Pelvic organ prolapse • Cough test • Spinal cord reflexes

19. Pelvic Organ Prolapse

21. UI Evaluation: Testing • Urinalysis • Only test recommended for all patients with UI • Bladder diary • Record time, volume of voids, activities, sleep • Post Void Residual • Hx of retention, DM, recurrent UTIs, GU abnormality • No standardized volume cut off (>200ml generally considered positive)

22. Urodynamic studies • Not routine

23. AGS Choosing Wisely • Do not perform cystoscopy, urodynamics or renal and bladder US in workup of uncomplicated urge UI (new from 2016) • Do not order upper tract imaging (renal) if there are only lower urinary tract symptoms.

24. UI Treatments: overview • Addressing comorbidities • Medication review • Lifestyle modification • Supportive care • Behavioral therapies • Medications • Minimally Invasive Procedures • Surgery

25. Treatment: Lifestyle modification • Weight loss • Avoid extremes of fluid intake (<32oz or >64 oz), caffeine, ETOH • Correct contributory factors • Vaginal Estrogen • Constipation • Smoking cessation • Optimize medical conditions • Minimize medications • Environment • Adapt environment, improve mobility • Supportive Care • Pads, protective garments.

26. Treatment: Behavioral • For Urge, Stress, Mixed • Prompted Voiding • Only behavioral therapy with proven efficacy in cognitively impaired • Check and Change (frail) • Pelvic muscle exercises • “Kegel Exercises” • Isolated muscle contractions of pelvic floor • Bladder training • Frequent voiding with urge suppression • Gradual increase in timing

27. Behavioral Treatment: Biofeedback

28. Treatment: MedicationsAntimuscarinics Treatment of urge or mixed UI • Oxybutynin (Ditropan) • >10mg very anticholinergic • Tolterodine (Detrol)- R* • Trospium (Sanctura)- R* • Darifenacin (Enablex) • Solifenacin (Vesicare)- R* • Fesoterodine (Toviaz)- R* • CI: narrow-angle glaucoma, urinary retention, impaired gastric emptying • Do not combine with cholinesterase inhibitors • CYP-450 interactions (except trospium)

30. Treatment: Medications • Mirabegron (Myrbetriq) R* • B3-adrenergic agonist • detrusor relaxation and increased bladder capacity • Similar efficacy as anitmuscarinics • No CI to cholinesterase inhibitors or closed angle glaucoma • DI: digoxin, metoprolol, venlafaxine, deipramine, dextromethorphan. • Major SE: elevated BP, dizziness, retention

31. Treatment: BPH Associated • Alpha blockers • Relax smooth muscle and allow better emptying • Tamsulosin (Flomax) • Alfuzosin (Uroxatral) • Silodoson (Rapaflo) • Terazosin (Hytrin) • Doxazosin (Cardura) • Major SE: orthostatic hypotension, dizziness, floppy iris syndrome

32. Treatment: BPH Associated • 5 Alpha Reductase inhibitors • Finasteride (Proscar) • Dutasteride (Avodart) • Phosphodiesterase-5 inhibitors • TadalafilR*

33. Treatment: Minimally Invasive Procedures • Urethral Bulking Agents • Artificial Urinary Sphincter • Pessaries • 50% success rate when combined with Beh. Therapy • Risk of vaginal erosions, discharge

34. Minimally Invasive Procedures: Urge UI • Sacral nerve neuromodulation • For urinary retention and refractory Urge UI • Percutaneous implant of electrode at S3 root • Posterior Tibial Nerve Stimulation • Accupuncture needle placed medially behind ankle • E-Stim for 30 min/week for 12 weeks

35. Minimally Invasive Procedures • Intravesical Injection of botulinum toxin • For refractory Urge UI • Risk of retention • Indwelling Catheters • Significant morbidity

36. Surgical Intervention • Bladder Sling • Colposuspension: Prolapse repair • Most effective for Stress UI • TURP

37. Urologic referral • Red Flag symptoms • Neurologic symptoms associated with incontinence • Abnormal prostate exam • Significant retention • Pelvic organ prolapse past introitus • Previous pelvic surgery or radiation • Candidate for minimally invasive or surgical options • Uncertain diagnosis

38. Helpful Tools • Voiding Diary: niddk.nih.gov/health-information/health-topics/urologic-disease/daily-bladder-diary/pages/facts.aspx • AUA Urinary Symptom score: https://www.uptodate.com/contents/image?imageKey=PC%2F57680&topicKey=PC%2F6891&search=5%20alpha%20reductase%20inhibitors&rank=1~62&source=see_link • Pelvic Muscle Exercises: https://www.youtube.com/watch?v=Rcip2Mnfy8M • Incontinence Quiz (LGH) • LGH Incontinence Program • (717) 544-3270 • http://www.lancastergeneralhealth.org/LGH/Our-Services/Outpatient-Services/Urinary-Incontinence-Program.aspx

39. Resources • Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 9th Ed. 2016, 2018 • American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults:https://geriatricscareonline.org/access-free-content/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001 • American Medical Directors Association. Urinary Incontinenc in the Long Term Care Settting Clinical Practice Guideline. Columbia, MD: AMDA 2012. • Gotoh M, et al. Impact of urinary incontinence on the psychological burden of family caregivers. Neurourol Urodyn 2009; 28:492. • Morrison A, Levy R. Fraction of nursing home admissions attributable to urinary incontinence. Value Health 2006; 9:272. • Herderschee R, et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev 2011; :CD009252. • Effective Health Care Program. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Agency for Healthcare Research Quality 2012. Available at: http://effectivehealthcare.ahrq.gov/ehc/products/169/1021/CER36_Urinary-Incontinence_execsumm.pdf. (Accessed 11/5/2016) • Richter HE,et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010; 115:609. • Gupta,P. et al. Current Urol Rep (2015) 16: 4, doi:10.1007/s11934-014-0479-1 • Yeaw J, Benner J, Walt JG et al. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm. 2009:15(9):724-736 • Brown JS, Bradley CS, Subak LL, et al.; Diagnostic Aspects of Incontinence Study (DAISy) Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144(10):715–723 • Effective Health Care Program. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Agency for Healthcare Research Quality 2012. Available at: http://effectivehealthcare.ahrq.gov/ehc/products/169/1021/CER36_Urinary-Incontinence_execsumm.pdf • Brown JS, Bradley CS, Subak LL, et al.; Diagnostic Aspects of Incontinence Study (DAISy) Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144(10):716 • Diagnosis of urinary incontinence. Khandelwal et al. Am Fam Physician. 2013 Apr 15;87(8):543-550.