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Geriatric Incontinence and Nocturnal polyuria

Geriatric Incontinence and Nocturnal polyuria. Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital. Lower urinary tract symptoms in geriatric population. LUTS are common in elderly Nocturia is the third most bothersome LUTS

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Geriatric Incontinence and Nocturnal polyuria

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  1. Geriatric Incontinence and Nocturnal polyuria Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

  2. Lower urinary tract symptoms in geriatric population • LUTS are common in elderly • Nocturia is the third most bothersome LUTS • Prevalence of nocturia increases to 80% in patients aged over 80 years • Nocturia is one of the most common causes of disturbed sleep pattern

  3. Prevalence of Male Urinary Symptoms

  4. Prevalence of Female LUTS

  5. Bothersomeness of LUTS

  6. Voiding Diary • Assessment of frequency, urgency, and nocturia in patients with LUTS • Record voided urine volume and total daily urine volume • Calculate nocturnal urine volume • Investigate causes for frequency and polyuria

  7. 排 尿 記 錄 單 姓名：王進輝 病歷號碼：U100009234 日期（第一天）ˍ9ˍ月ˍ2ˍ日 日期（第二天）ˍ9ˍ月ˍ3ˍ日 日期（第三天）ˍ9ˍ月ˍ4ˍ日 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 7-8 150 500 7-8 200 500 7-8 250 500 8-9 100 8-9 8-9 9-10 150 9-10 150 9-10 200 10-11 90 10-11 250 10-11 200 11-12 11-12 200 11-12 12-1 100 200 12-1 200 12-1 150 200 1-2 1-2 200 1-2 2-3 100 200 2-3 2-3 150 3-4 3-4 3-4 250 4-5 120 250 4-5 150 250 4-5 5-6 5-6 5-6 150 6-7 150 250 6-7 250 6-7 250 7-8 7-8 150 7-8 8-9 120 200 8-9 8-9 9-10 9-10 9-10 200 250 10-11 90 10-11 100 10-11 11-12 11-12 11-12 150 睡 眠 cc/次 100/2次 睡 眠 cc/次  150/1次 睡 眠 cc/次 200/2次 Hypersensitive bladder with small functional capacity

  8. 排 尿 記 錄 單 姓名： 施冠慨 病歷號碼：U100016284 日期（第一天）ˍ8ˍ月ˍ29ˍ日 日期（第二天）ˍ8ˍ月ˍ30ˍ日 日期（第三天）ˍ8ˍ月ˍ31ˍ日 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 7-8 300 7-8 300 7-8 300 8-9 300 8-9 100 300 8-9 300 9-10 9-10 300 9-10 10-11 300 10-11 10-11 11-12 100 300 11-12 100 11-12 200 12-1 300 12-1 300 12-1 500 1-2 1-2 100 1-2 100 2-3 200 2-3 2-3 3-4 300 3-4 3-4 4-5 4-5 4-5 5-6 5-6 5-6 300 6-7 200 300 6-7 300 6-7 100 7-8 7-8 200 100 7-8 8-9 100 8-9 8-9 100 300 9-10 9-10 9-10 10-11 10-11 10-11 11-12 11-12 11-12 睡 眠 cc/次 700, 600 500 ,150  4次 睡 眠 cc/次  500,400  2次 睡 眠 cc/次 200,900 350  3次 Normal functional capacity and nocturnal polyuria

  9. 排 尿 記 錄 單 姓名：連信雄 病歷號碼：U100036348 日期（第一天）ˍ8ˍ月ˍ19ˍ日 日期（第二天）ˍ8ˍ月ˍ20ˍ日 日期（第三天）ˍ8ˍ月ˍ21ˍ日 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 7-8 1000 7-8 100 1200 7-8 900 8-9 200 8-9 8-9 220 9-10 200 9-10 200 9-10 200 150 10-11 100 10-11 100 150 10-11 11-12 100 11-12 150 11-12 200 12-1 100 200 12-1 150 300 12-1 200 1-2 150 1-2 1-2 2-3 150 2-3 200 2-3 200 200 3-4 3-4 120 3-4 4-5 100 150 4-5 4-5 120 5-6 100 5-6 120 5-6 6-7 100 150 6-7 300 6-7 100 300 7-8 7-8 7-8 150 8-9 300 8-9 230 8-9 200 9-10 200 100 9-10 200 9-10 100 150 10-11 10-11 10-11 100 11-12 210 200 11-12 11-12 睡 眠 cc/次 300, 300 400 350 睡 眠 cc/次  400,480 220  350 睡 眠 cc/次 400,400 440 Daytime frequency and Nocturnal polyuria

  10. 排 尿 記 錄 單 姓名：李特民 病歷號碼：B100338896 日期（第一天）ˍ9ˍ月ˍ14ˍ日 日期（第二天）ˍ9ˍ月ˍ15ˍ日 日期（第三天）ˍ9ˍ月ˍ16ˍ日 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 時間 尿量 喝水量 急尿感 漏尿 7-8  100,800 230  2 7-8   120,80,50 230 3 7-8  80,100,50 230  3 8-9 100,70,80 460 3 8-9  100,100,80 460 3 8-9 100,80,60 460  3 9-10 100,100 230 2 9-10 100,50 230  2 9-10 50,100 230  2 10-11  120,90 230  2 10-11 120,70 230  2 10-11  100,70 230 2 11-12   180,100 120 230  3 11-12 100,80 230 2 11-12 80,100 230  2 12-1 150,80,100 230 3 12-1   180,100, 80 230 3 12-1  80,100,120 230 3 1-2  100,110 230  2 1-2 180,100,80 230  2 1-2  80,100 230  2 2-3  100,120 230  2 2-3  100,150 230  2 2-3 100,120 230  2 3-4 80,100,80 230  3 3-4   100,80,50 230  3 3-4 80,100,60 230  3 4-5 100,80 230 2 4-5  80,90 230 2 4-5 90,100 230  2 5-6  80,120 230 2 5-6 150,80 230 2 5-6  80,120 230 2 6-7 100,80, 100 460  3 6-7  80,120,50 460  3 6-7 100,80,60 230 3 7-8  100,100 230  2 7-8  100,80 230  2 7-8  100,80 230 2 8-9  80,100 230  2 8-9 100,120 230  2 8-9 60,120 230 2 9-10 100,50,150 460  4 9-10  150,120,80 460 3 9-10  100,80,120 460 3 10-11 10-11 10-11 11-12 11-12 11-12 睡 眠 cc/次 1400/7次 睡 眠 cc/次  1300/6次 睡 眠 cc/次 1300/6次 Polydipsia, Nocturnal polyuria, Small functional capacity

  11. Incontinence • Detruror instability • Urethral incompetence • Mixed detrusor instability and urethral incompetence (DHIC) • Low bladder compliance • Detrusor underactivity and overflow • Bladder outlet obstruction

  12. Detrusr overactivity in elderly • Unknown etiology • Increased incidence with age • May relate with poor cortical perfusion • Bladder outlet obstruction in men and women should be considered • Urethral relaxation in women • Frequency urgency and/or urge incontinence

  13. Detrusor Overactivity & Pseudodyssynergia after Stroke

  14. Detrusor overactivity in senile dementia

  15. Detrusor instability & BPH • Asymptomatic BPH may result in detrusor changes with ageing • A low Qmax is frequently encountered in the elderly • Patients may have frequency urgency but not difficult urination • Small functional capacity in BPH

  16. BPH with Detrusor overactivity

  17. Low Bladder Compliance and Low contractility

  18. Poor cortical perfusion & Detrusor overactivity • Senile dementia • Multiple strokes • Post-intracranial hemorrhage • Chronic illness in systemic disease and increased incidence of incontinence • Schizophrenia and cortical dysfunction

  19. Low detrusor contractility and low urethral resistance

  20. Geriatric Incontinence • Poor cortical perfusion • Sequale of previous stroke • Parkinson’s disease • Benign prostatic obstruction • Weak urethral striated sphincter • Loss of cortical arousal of bladder fullness

  21. Detrusor overactivity in woman with ISD

  22. Dysfuncional voiding with Detrusor overactivity

  23. Postprostatectomy incontinence • Detrusor overactivity not relieved after TURP • Intrinsic sphincteric insufficiency • Newly developed detrusor overactivity • Poor cortical function with ageing • Urinary tract infection in non-ISD postprostatectomy men • Neurological lesions

  24. Postprostatectomy incontinence due to urethral incompetence

  25. Detrusor overactivity in Post-TURP patient

  26. Transient incontinence (Diappers) • Delirium • Infection • Atrophic vaginitis • Psychological disorders • Pharmacological effects • Excessive urine output • Restricted motility • Stool impaction

  27. Management of Geriatric Incontinence • Medical treatment: anticholinergics (Ditropan, Detrustol, Tofranil, etc.) • On diaper or external appliance • On Foley catheter or cystostomy • Intravesical resiniferatoxin therapy • Detrusor injection of botulinum toxin • Surgical treatment

  28. Anticholinergics • Effectively reduced intravesical pressure and contractility • Increased postvoid residual urine and possible urinary retention • Increased risk of UTI and upper tract deterioration • Adverse effects of dry mouth, constipation, blurred vision, weakness

  29. Diaper and external appliance • Suitable for patients with detrusor overactivity and low urethral resistance • Not indicated in patients with low detrusor contractility and large PVR • Perineal eczema and cutaneous infection including candidiasis • Prepuce erosion and urethral injury • Frequent change of diaper and external appliance is needed

  30. Urethral Foley catheterization or Suprapubic cystostomy • Active hydration • Regular change of catheter • Acidic solution irrigation of bladder • Intermittent antibiotics for turbid urine or hematuria • Prevention of genital tract infection in men, such as vasectomy • Prevent fecal soiling in women

  31. Intravesical resiniferatoxin therapy • 10-7M RTX bladder instillation • Effective in spinal cord lesion induced detrusor hyperreflexia • Less effective in non-traumatic neurogenic detrusor overactivity • May be effective in detrusor overactivity due to bladder outlet obstruction • Low detrusor contractility may occur after high concentrations RTX instillation

  32. Intravesical RTX therapy for DI

  33. Botulinum A toxin Detrusor injection • Effectively reduced detrusor overactivity and detrusor contractility via blocking Ach release • Large residual urine may occur after 300 U botulinum toxin (Botox) injection • Periodic injection is needed • Not clinical applicable so far

  34. Response of Botulinum A toxin Detrusor injection in DH

  35. Nocturia • A result of excessive amount of urine production at night • Noctural polyuria >35% daily urine • Abnormal lower urinary tract function • A combination of two etiologies

  36. Definition of Assessing Nocturia

  37. Voiding Diary Analysis of Nocturia

  38. Causes of Nocturnal Polyuria

  39. Homeostatic Controls of Urine Output

  40. Desmopressin • The circardian rhythm of vasopressin was lost in the elderly with nocturnal polyuria • Atrial natriureteric peptide in the elderly was higher during night time • Use of arginine vasopressin analogue patients with nocturnal enuresis and nocturnal polyuria become dry

  41. Etiologies of Nocturia • Detrusor instability • Hypersensitive bladder • Bladder outlet obstruction • Nocturnal polyuria • Small bladder capacity

  42. Impact of Nocturia on the Elderly • Elderly patients are likely to be exposed to serious health risks • Nocturia causes fatigue due to sleep deprivation • Increase chance of traumatic injury through falling from 10 to 21% with >2 voids per night

  43. Side Effects of Desmopressin • Hyponatremia • Water retention • Side effects can be eliminated after discontinuing medication • Federal law cautions against its use in patients over 65 years

  44. Effects of Urodynamics on Therapeutic Effects of Desmopressin • Patients with small bladder capacity and detrusor instability might not benefit from desmopressin if no nocturnal polyuria • Children with NE have been noted to be cured after DDAVP therapy • Can the bladder learn to hold more urine and reduce nocturnal voiding frequency

  45. Materials and Methods • Patients with severe nocturia refractory to previous treatment • All patients had > 3/N nocturia and nocturnal urine volume > 35% daily voided volume • Urodynamic pressure flow study, patients with BOO or residual urine >100mL were excluded

  46. Desmopressin Treatment • A one week entry test • A 3-day voiding diary was recorded and nocturnal urine amount was calculated • A nocturnal urine sample taken for U/A and specific gravity test • Serum BUN, Cr, Na, K were measured • Patients with both nocturnal frequency and polyuria were enrolled

  47. Therapeutic Effects of Desmopressin in NocturnalPolyuria

  48. Effects of Bladder Capacity after Desmopressin Therapy

  49. Changes of Nocturnal Frequency after Desmopressin Therapy

  50. Common Causes of Low Nocturnal Bladder Capacity • Infravesical obstruction • Idiopathic nocturnal DI • Neurogenic bladder dysfunction • Cystitis (Bacterial, interstitial, TB, radiation) • Cancer of bladder, prostate, urethra • Learned voiding dysfunction • Anxiety disorders • Pharmacological: xanthines (theophylline, caffeine), beta-blockers • Bladder or lower ureteral calculi

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