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Incontinence

Incontinence. Dr. Gary Sinoff Department of Gerontology University of Haifa. Incontinence. Definition. 2 - P C - M E. Definition. INCONTINENCE: Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem.

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Incontinence

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  1. Incontinence Dr. Gary Sinoff Department of Gerontology University of Haifa

  2. Incontinence

  3. Definition 2 - P C - M E

  4. Definition INCONTINENCE: Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem. A heterogeneous condition that ranges in severity from dribbling to continuous incontinence. If individuals lose only one or two drops of urine when they don’t want to, that’s considered incontinence!

  5. Myths: People who are incontinent are: • Very old • Feeble • Senile • Totally dependent • No longer in control

  6. Brussels

  7. How Common is Urinary Incontinence? • Prevalence increases with age • 25-30% of community dwelling older women • 10-15% of community dwelling older men • 50% of nursing home residents

  8. Rate of Seeking Help * ** * NIH Consensus Statement on Urinary Incontinence,1988 ** Holts et al, 1988

  9. Under-Diagnoses and Under-Treated • Only 32% of primary care physicians routinely ask about incontinence • 50-75% of patients never describe symptoms to physicians • 80% of urinary incontinence can be cured or improved

  10. Why is Incontinence Important? • Social stigmata - leads to restricted activities and depression • Medical complications - skin breakdown, increased urinary tract infections • Institutionalization - UI is the second leading cause of nursing home placement

  11. Anatomy of Micturition • Detrusor muscle • External and Internal sphincter • CNS control • Pons - facilitates • Cerebral cortex – inhibits • Hormonal effects - estrogen

  12. Peripheral Nerves in Micturition

  13. Peripheral Nerves in Micturition • Parasympathetic (cholinergic) - Bladder contraction • Sympathetic - Bladder Relaxation • Sympathetic - Bladder Relaxation (β adrenergic) • Sympathetic - Bladder neck and urethral contraction (α adrenergic) • Somatic (Pudendal nerve) - contraction pelvic floor musculature

  14. Bladder Pressure-Volume Relationship

  15. Potentially Reversible Causes D - Delirium I - Infection A - Atrophic vaginitis or urethritis P - Pharmaceuticals P - Psychological disorders E - Endocrine disorders R - Restricted mobility S - Stool impaction

  16. Degree of Bother YES : 53.7%

  17. Medications That May Cause Incontinence • Diuretics • Anticholinergics - antihistamines, antipsychotics, antidepressants • Sedatives/hypnotics • Alcohol • Narcotics • Calcium channel blockers

  18. Other factors for urinary incontinence • Sociocultural • Psychological • Muscle tone damage • Fluid intake • Diseases • Surgery

  19. Categories of Incontinence • Urge incontinence • Stress incontinence • Overflow incontinence • Functional incontinence

  20. Incontinence • In women 49% stress incontinence 22% urge incontinence 29% mixed stress & urge • In men 73% urge incontinence

  21. Urge Incontinence Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder • Most common cause of UI >75 years of age • Abrupt desire to void cannot be suppressed • Usually idiopathic • Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

  22. Stress Incontinence • Most common type in women < 75 years old • Occurs with increase in abdominal pressure; cough, sneeze, laughing, etc. • Hypermotility of bladder neck and urethra; associated with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases) • Intrinsic sphincter problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

  23. Overflow Incontinence • Over distention of bladder • Bladder outlet obstruction; stricture, BPH, cystocele, fecal impaction • Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury, medications

  24. Functional Incontinence • Does not involve lower urinary tract • Result of psychological, cognitive or physical impairment

  25. Diagnostic Tests • Stress test (diagnostic for stress incontinence; specificity >90%) • Post-void residual • Blood Tests (calcium, glucose, BUN, Cr) • Urine Culture • Simple (bedside) Cystometrics

  26. Urodynamics - Lower urinary tract • Uroflowmetry • Cystometrography • External sphincter electromyography • Pressure flow study • Videourodynamic study • Urethral pressure profilometry

  27. In-Hospital Use of Continence Aids and New-Onset Urinary Incontinence in Adults Aged 70 and OlderZisberg, A, Sinoff, G, Gur-Yaish, N, Admi, E,Shadmi, E OBJECTIVES: To describe the types of continence aids that older adults hospitalized in acute medical units use and to test the association between use of continence aids and development of new urinary incontinence (UI) at discharge. DESIGN: Prospective cohort study. SETTING: A 900-bed teaching hospital in Israel. PARTICIPANTS: Three hundred fifty-two acute medical patients aged 70 and older who were continent before admission. MEASUREMENTS: In-hospital use of continence aids was assessed according to participant self-report on use of urinary catheters (UCs) or adult diapers o of self-toileting. The development of new UI was defined as participant report of inability to control voiding at discharge. Multivariate analyses mode led the association between use of continence aids (vs self-toileting) and the development of new UI, controlling for baseline functional and cognitive status, disease severity, age, and length of stay.

  28. New Onset Incontinence RESULTS: Of the 352 participants, 58 (16.5%) used adult diapers, and 27 (7.7%) had a UC during most of the hospital stay. Sixty (17.1%) participants developed new UI at discharge. The odds of developing new UI were 4.26 (95% confidence interval (CI)51.53–11.83) times higher for UC users and 2.62 (95% CI51.17–5.87) times higher for adult diaper users than for the self-toileting group, controlling for the above risk factors. CONCLUSION: The use of adult diapers and UCs during acute hospitalization is associated with the development of new UI at discharge. The management of continence in hospitalized older adults requires more diligence, and further investigation is needed to devise continence promotion methods in hospital settings. J Am Geriatr Soc 2011

  29. Treatment Options 1

  30. Lifestyle choices • Reduce or eliminate caffeine • Reduce or eliminate alcohol • Drink 6 to 8 glasses of water daily • Quit smoking • Weight control • Follow a healthy diet high in fiber • Reduce physical barriers to toilet (use bedside commode)

  31. Timed Voiding • Regular scheduled pattern of voiding where the intervals between voiding are gradually increased. • It reduces irritability of the bladder • Reverses bad habits • No longer needing to camp out by the bathroom promotes freedom and independence once again.

  32. Treatment Options • Bladder training • Patient education • Scheduled voiding • Positive reinforcement • Pelvic floor exercises (Kegel Exercises) • Biofeedback • Caregiver interventions • Scheduled toileting • Habit training • Prompted voiding 2

  33. Treatment for Detrusor Overactivity

  34. Pharmacological Interventions • Urge Incontinence • Oxybutynin (Novitropan) • Imipramine (Tofranil) • Stress Incontinence • Phenylpropanolamine (Alcinal) • Pseudo-Ephedrine (Histafed, etc.) • Estrogen (orally, transdermally or transvaginally)

  35. Surgical Interventions Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years. • Urethral Hypermotility • Marshall-Marchetti-Kantz procedure • Needle neck suspension • Intrinsic sphincter deficiency • Sling procedure

  36. Other Interventions • Pessaries • Periurethral bulking agents (periurethral injection of collagen, fat or silicone) • Diapers or pads • Chronic catheterization • Periurethral or suprapubic • Indwelling or intermittant

  37. Leg Bags

  38. Designer Diapers

  39. Pessaries

  40. Indwelling Catheter

  41. Fecal Incontinence

  42. Fecal Incontinence • “The inability to control the passage of flatus, liquid or solid stool” • 2% prevalence community, increases in NH • Profoundly disabling, also on body image • Number of different etiologies • Variety of medical and surgical treatments available

  43. Normal continence mechanism • Internal sphincter (smooth muscle involuntary): maintains high resting tone • External sphincter (skeletal muscle voluntary): important in the voluntary inhibition of the defaecatory reflex

  44. Factors Affecting GIT Elimination • Physiological changes with age • Physical Activity • Diet • Psychological Factors • Surgical

  45. Classification of Incontinence • Pseudoincontinence • soiling, urgency, frequency • Overflow incontinence • Incontinence with abnormal pelvic floor

  46. Pseudo-incontinence • Perineal soiling • hemorrhoidal prolapse • fistula en ano • incomplete defecation • perianal dermatoses • Urgency • non compliant rectum (radiation) • IBD • absent rectal reservoir • Frequency • diarrheal states ie IBD, autonomic neuropathy, parasites, toxins

  47. Overflow Incontinence • Rectal fecal impaction • decreased rectal sensation • obtuse anorectal angle • chronic stimulation of rectoanal inhibitory reflex • Neoplasm

  48. Abnormal pelvic floor • Neurogenic/Infiltrative • pudendal neuropathy • generalized neuropathy or cord lesion • Diabetes Mellitus and Scleroderma • Sphincter disruption • Obstetric • Surgical • Trauma

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