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URINARY INCONTINENCE IN THE AGING PATIENT

Learn about different types of urinary incontinence, risk factors, consequences, and evaluation methods in elderly patients. Explore pharmacologic causes, impact on caregivers, and treatment options.

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URINARY INCONTINENCE IN THE AGING PATIENT

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  1. URINARY INCONTINENCE IN THE AGING PATIENT September 2007 Deb Mostek

  2. Definition • UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. International Continence Society

  3. 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

  4. 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

  5. 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

  6. 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

  7. Types of Urinary Incontinence • Transient UI (Acute) • Established UI (Chronic) • Urge UI • Stress UI • Mixed UI • Overflow UI • “Functional” UI

  8. 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

  9. 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.

  10. Opioids Calcium channel blockers Anti-Parkinsons drugs Anti-cholinergics Prostaglandin inhibitors Depress detrusor activity & produce urinary retention and overflow incontinence Pharmacologic Causes

  11. 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

  12. Pharmacologic Causes, Continued • alpha-agonists •  urethral sphincter tone  retention and Overflow • alpha-antagonists •  urethral sphincter tone  Stress

  13. 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.

  14. 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

  15. Screening • Ask sensitively worded questions Detailed History • Duration, previous evaluation/treatment? • Volume, how often, what situations? • Urgency, dysuria, straining?

  16. EVALUATION:THE APPROACH Focused H & P for: 1)Reversible conditions 2) Conditions that require Urologic or Gynecologic consult or Urodynamics early on. 3) Function focused approach to the remaining cases 4) Contributing factors

  17. Evaluation, continued • UA, C&S • Creatinine, BUN, Glucose, Calcium, ?PSA • Post-void residual • Clinical urinary stress test • Voiding record

  18. 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

  19. 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

  20. Established Incontinence • URGE • STRESS • Mixed type (both urge and stress) • OVERFLOW (increased PVR) • “Functional” incontinence

  21. 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

  22. 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.

  23. 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.

  24. 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

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

  26. “Functional” Incontinence • Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers • No underlying GU dysfunction • Diagnosis of exclusion

  27. 3)FUNCTION FOCUSEDAPPROACH TO REMAINING CAUSES

  28. 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.

  29. 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

  30. Mrs. J • PVR: 250 ml • Clinical stress test: Some urine loss after several seconds delay after cough

  31. 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.

  32. 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.

  33. 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

  34. Bladder Retraining • Urge control exercises • Scheduled toileting • Prompted toileting

  35. Pelvic Muscle Rehabilitation • Detailed instruction of pelvic muscle exercises • Biofeedback techniques • Electrical stimulation

  36. 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!!!

  37. Overflow UI • Obstruction—Treat cause; -antagonists; finasteride • Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.

  38. Further Urological Evaluation • PVR > 400 cc • Poor response to treatment • Cystometry, cystoscopy, urodynamic studies • Evidence of GU tract pathology

  39. 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

  40. 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

  41. Acknowledgments • Wendy Adams, MD MPH who also contributed slides • DuBeau CE. Urinary Incontinence. Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148

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