URINARY INCONTINENCE

July 2003

Deb Mostek

Objectives Discuss screening for urinary incontinence

in the geriatric patient. Identify transient UI and review

management. Describe the types of established UI,

evaluation and management.

Definition UI is the involuntary loss of

urine that is objectively demonstrable and a social or hygienic problem.

International Continence Society

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

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

Physiology and Anatomy:1. Filling (150-200 cc)--

sympathetic reflex--body relaxes, sphincter tightens, detrusor inhibited.

2. Further filling(350-500 cc)--somatic (voluntary) tone increases (external sphincter)

3. Voiding--detrusor contraction with coordinated reflex— somatic and sympathetic tone, parasympathetic action.

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

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

Types of Urinary Incontinence Transient UI Established UI

Urge UI Stress UI Mixed UI Overflow UI “Functional” UI

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

Causes of Reversible 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.

Pharmacologic Causes Opioids Calcium channel

blockers Anti-Parkinsons

drugs Anti-cholinergics Prostaglandin

inhibitors

Depress detrusor activity & produce urinary retention and overflow incontinence

Culligan PJ Urinary Incontinence in women Evaluation and Management AFP 12-1-01

Pharmacologic Causes 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, Continued

alpha-agonists urethral sphincter

tone retention and Overflow

alpha-antagonists urethral sphincter

tone Stress

Screening Ask sensitively worded questions

Detailed History Duration, previous evaluation/treatment? Volume, how often, what situations? Urgency, dysuria, straining?

EVALUATION:THE APPROACHFocused H & P for: 1) Reversible conditions2) Conditions that require Urologic or

Gynecologic consult or Urodynamics early on.

3) Function focused approach to the remaining cases

4) Contributing factors

Evaluation, continued

UA, C&S Creatinine, BUN, Glucose, Calcium, ?

PSA,?Vitamin B12 level Clinical urinary stress test Post-void residual Voiding record

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

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

Evaluation, continued Voiding record (48 hours, timing of

incontinence episodes and normal voids, voided volume, frequency, day & nocturnal urinary output, associated activities, or Q 2-hour continence status in those with cognitive impairment)

2) CONDITIONS To CONSIDER:EARLY UROLOGIC, or GYN,or

URODYNAMIC EVALUATIONPROBLEMRecurrent. symptomatic uti’s

with U.I. Pelvic Prolapse (marked)

Suspected prostate ca.

Hematuria (sterile)

Urinary retention (that does not respond to acute management).

REFERAL for/to: GU Imaging & cystoscopy

Gyn surgical eval. or pessary

Urologic evaluation

GU Imaging & Urology (cystoscopy )

Urologic evaluation. and treatment

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

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, vaginal cones, electrical stimulation, -adrenergic agonists, pessary, surgical interventions.

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.1996. Stress Urinary Incontinence figure 11.2, p156.

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.

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 Management: Obstruction—Treat cause; -

antagonists. Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.

“Functional” Incontinence

Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers

No underlying GU dysfunction Diagnosis of exclusion

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.

Rare Causes Bladder fistulas

Detrusor-sphincter dyssynergia

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

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.

SH: lives with daughter and grandson. Dependent on family for assistance with ADL’s.

Mrs. V 89 y/o with severe low back pain and difficulty

walking which started after a fall 6 weeks ago. Was hospitalized for 1 ½ weeks for pain control and mobilization. Currently residing at a nursing home for OT/PT rehabilitation. Initially was progressing with therapy until she fell again at NH. Now difficulty with ambulation, requiring assistance of 2 for transfers.

PMH: Degenerative disc disease of spine, Stress UI.

Mrs. V Current meds: Oxycontin 20 mg q 12 hrs,

Oxycodone 5 mg q 4 hrs for breakthru pain. SH: Widowed. Was living independently 6

weeks ago, traveling, very active & social. Has concerned, involved daughter.

ROS: Notes worsening of her UI, now has continuous leakage. Depressed ideation. Otherwise negative.

3)FUNCTION FOCUSED APPROACH TO REMAINING CAUSESSymptoms: URGE (REFLEX

or NEUROGENIC)STRESS OVERFLOW

leakage variable volumes small volume small volume pattern of urine loss unpredictable with intrabd. pressure

(cough, sneeze, laugh)almost continuous

delay voiding? unable able except with intrabd. pressure

able, (at times)

voiding volumes(normally)

variable normal small

N o c t u r n a lincontinence 1

Yes (pt. is unaware) Rare Yes (dribbling)

1.Rovner ES, Wein AJ, The treatment of Operative bladder in the geriatric patient . Clinical Geriatrics Vol. 10Number 1 Jan 20022.DuBeau C.E. Urinary Incontinence Geriatric Review Syllabus Fifth Ed. 2002-2004 pp139-148

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 usually last.

Further Urological Evaluation PVR > 400 cc Poor response to treatment Cystometry, cystoscopy, urodynamic

studies Evidence of GU tract pathology

UI Summary Look for reversible causes and Rx Check PVR (>100 cc investigate further) Start with behavioral interventions before

pharmacologic agents Referral and urodynamic studies if no

response to usual measures Early referral if underlying GU tract

pathology present

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

Acknowledgments Wendy Adams, MD MPH who also

contributed slides DuBeau CE. Urinary Incontinence.

Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148