URINARY URINARY INCONTINENCEINCONTINENCE

Dr Mark DonaldsonDr Mark Donaldson

Consultant Physician in Consultant Physician in Geriatric MedicineGeriatric Medicine

Urinary IncontinenceUrinary Incontinence

Affects:Affects:

15%-30% elderly living at 15%-30% elderly living at homehome

30% - 35% elderly in acute 30% - 35% elderly in acute carecare

>50% in RCF >50% in RCF

Urinary IncontinenceUrinary Incontinence

Continence requiresContinence requires::

Adequate mobilityAdequate mobility MentationMentation MotivationMotivation Manual dexterityManual dexterity Intact lower urinary tract functionIntact lower urinary tract function

Urinary IncontinenceUrinary Incontinence

Medical ComplicationsMedical Complications

RashesRashes Pressure ulcersPressure ulcers UTIUTI FallsFalls FracturesFractures

Urinary IncontinenceUrinary Incontinence

Psychosocial complicationsPsychosocial complications

EmbarrassmentEmbarrassment StigmatisationStigmatisation IsolationIsolation DepressionDepression Institutionalisation riskInstitutionalisation risk

IncontinenceIncontinence

is is nevernever normalnormal

Urinary IncontinenceUrinary IncontinenceAGEING BLADDER CHANGESAGEING BLADDER CHANGES Bladder capacity decreasesBladder capacity decreases Bladder compliance decreasesBladder compliance decreases Ability to postpone voiding decreasesAbility to postpone voiding decreases Urethral closing pressure decreases in womenUrethral closing pressure decreases in women Prostate enlarges in menProstate enlarges in men Involuntary bladder contractions increaseInvoluntary bladder contractions increase Post-voiding residual volume increases (50-Post-voiding residual volume increases (50-

100ml)100ml)Also:Also: Increased fluid excretion at nightIncreased fluid excretion at night Age associated sleep disordersAge associated sleep disorders Detrusor muscle changesDetrusor muscle changes

Urinary IncontinenceUrinary Incontinence

Incontinence is a Geriatric syndrome:Incontinence is a Geriatric syndrome:

i.e. Predisposed by above factorsi.e. Predisposed by above factors

Precipitated usually by disease Precipitated usually by disease outside outside the urinary tract. the urinary tract.

Frequent adverse drug reactions that affect Frequent adverse drug reactions that affect the urinary the urinary tract tract

It is these factors It is these factors OUTSIDEOUTSIDE the urinary the urinary tract that are amenable to intervention tract that are amenable to intervention e.g. arthritis/immobilitye.g. arthritis/immobility

Urinary IncontinenceUrinary Incontinence

Transient IncontinenceTransient Incontinence

Common e.g. 30% community dwellersCommon e.g. 30% community dwellers

50% of inpatients50% of inpatients

At risk cases: especially At risk cases: especially anti-cholinergicsanti-cholinergics

diureticsdiuretics

worsening mobilityworsening mobility

Urinary IncontinenceUrinary Incontinence

Transient IncontinenceTransient Incontinence::

DD -- DDeliriumelirium

II -- IInfectionnfection

AA -- AAtrophic trophic Urethritis/vaginitisUrethritis/vaginitis

PP -- PPharmaceuticalsharmaceuticals

PP -- PPsychological (rare)sychological (rare)

EE -- EExcessive urine xcessive urine outputoutput

RR -- RRestricted mobilityestricted mobility

SS -- SStool impactiontool impaction

Urinary IncontinenceUrinary Incontinence

Urinary tract causes of incontinenceUrinary tract causes of incontinence::

Detrusor overactivityDetrusor overactivity Detrusor underactivityDetrusor underactivity Genuine stress incontinence Genuine stress incontinence

(low urethral resistance)(low urethral resistance) Obstruction Obstruction

(high urethral resistance)(high urethral resistance)

Urinary IncontinenceUrinary Incontinence

Detrusor OveractivityDetrusor Overactivity

Commonest cause of urinary Commonest cause of urinary incontinenceincontinence(60%-70%).(60%-70%).Seen with:Seen with: - neurologic - neurologic disordersdisorders

- obstruction- obstruction- ageing- ageing- GSI- GSI- DHIC- DHIC

Urinary IncontinenceUrinary Incontinence

Detrusor OveractivityDetrusor Overactivity

Clinically:Clinically: - sudden onset- sudden onset

- immediate need to void- immediate need to void Leakage is episodic, moderate to largeLeakage is episodic, moderate to large Nocturnal frequencyNocturnal frequency Urge incontinence commonUrge incontinence common PVR low in absence of DHICPVR low in absence of DHIC

Urinary IncontinenceUrinary IncontinenceStress Incontinence

Common in women In men, only after sphincteric damage

complicating prostatic resection Clinically: Instantaneous with stress

manoeuvresDelayed - suggests stress induced

detrusor overactivity In men, ‘leaky tap’ worsened by standing or

straining Often co-exists with urge incontinence i.e. mixed

Urinary IncontinenceUrinary IncontinenceUrethral ObstructionUrethral Obstruction

Common in menCommon in men In women, after bladder neck suspension or In women, after bladder neck suspension or

kinking associated with severe prolapsekinking associated with severe prolapse Prostatic encroachmentProstatic encroachment Clinically:Clinically:

(1) Filling symptoms(1) Filling symptoms (i.e. urgency, frequency, (i.e. urgency, frequency,

nocturia)nocturia) (2) Voiding symptoms(2) Voiding symptoms

(i.e. poor stream, intermittency, (i.e. poor stream, intermittency, dribbling post voiddribbling post void

(3) Overflow(3) Overflow

Urinary IncontinenceUrinary Incontinence

Detrusor UnderactivityDetrusor Underactivity (<10% of incontinence (<10% of incontinence cases)cases)

Usually idiopathicUsually idiopathic Caused by degenerative muscle and axonal Caused by degenerative muscle and axonal

changeschanges Clinically: Clinically: Overflow incontinenceOverflow incontinence

FrequencyFrequencyNocturiaNocturiaFrequent leakage of small Frequent leakage of small

amountsamounts PVR usually > 450mlPVR usually > 450ml

In men, differentiated by urodynamics rather than In men, differentiated by urodynamics rather than cystoscopy or IVP.cystoscopy or IVP.

Urinary IncontinenceUrinary Incontinence

Evaluation of the older incontinent patientEvaluation of the older incontinent patient

GOALS: Investigate and treat transient and Investigate and treat transient and established causes.established causes.

Assess patient’s environment and Assess patient’s environment and supportsupport

To detect uncommon but serious To detect uncommon but serious underlyhing conditions:underlyhing conditions:

-- Brain lesionsBrain lesions- Spinal cord lesions- Spinal cord lesions- Carcinoma bladder/prostate- Carcinoma bladder/prostate- Bladder stones- Bladder stones- Decreased bladder compliance- Decreased bladder compliance

Urinary IncontinenceUrinary Incontinence

Clinical ManagementClinical Management

1.1. Exclude overflow Exclude overflow incontinence incontinence

(e.g. PVR > 450ml)(e.g. PVR > 450ml)

Where appropriate, Urologist Where appropriate, Urologist referralreferral

Remainder - catheteriseRemainder - catheterise

Urinary IncontinenceUrinary Incontinence

Clinical ManagementClinical Management

2. 2. Remaining 90%-95% depends on gender.Remaining 90%-95% depends on gender.

Females:Females: either OAB or GSI either OAB or GSIGSI excluded by observing for leakage GSI excluded by observing for leakage

with full with full bladder and vigorous coughbladder and vigorous coughMales:Males: either OAB or obstruction. either OAB or obstruction.If flow normal, PVR <100ml then If flow normal, PVR <100ml then

obstruction is obstruction is excluded.excluded.If PVR > 200ml, exclude hydronephrosis.If PVR > 200ml, exclude hydronephrosis.RemainderRemainder, treat for OAB – warn about , treat for OAB – warn about

retention – retention – avoid bladder relaxants if avoid bladder relaxants if PVR >150ml.PVR >150ml.

Urinary IncontinenceUrinary Incontinence

Non-Drug Treatment of OABNon-Drug Treatment of OAB

Bladder DrillBladder Drill (re-training) (re-training) Timed voidingTimed voiding Deferment techniqueDeferment technique

Cognitively impairedCognitively impaired Prompted voidingPrompted voiding

Non-Drug Treatment of GSINon-Drug Treatment of GSI Pelvic floor exercises especially if mild :Pelvic floor exercises especially if mild :

- 30-200 times per day- 30-200 times per day- Indefinitely- Indefinitely- Limited efficacy- Limited efficacy- Repair procedures less invasive- Repair procedures less invasive

Urinary IncontinenceUrinary IncontinenceDrug Treatment of OABDrug Treatment of OAB

Anti-cholinergic (anti-muscarinics)Anti-cholinergic (anti-muscarinics)

OxybutyninOxybutynin SolifenacinSolifenacin DarifenacinDarifenacin TolterodineTolterodine

Best as adjuncts to bladder drill.Best as adjuncts to bladder drill. Dose escalation by titrationDose escalation by titration Most NOT on PBSMost NOT on PBS Newer ones better toleratedNewer ones better tolerated CI Glaucoma – Dry mouth, confusionCI Glaucoma – Dry mouth, confusion

Urinary IncontinenceUrinary Incontinence

AlertnessAlertness ResponsiveResponsive MotivationMotivation DirectionDirection MobilityMobility RecognitionRecognition DressingDressing

Voiding and Dementia

Urinary IncontinenceUrinary Incontinence

Indications for UrodynamicsIndications for Urodynamics

Persistent diagnostic uncertainty.Persistent diagnostic uncertainty. Morbidity associated with potentially. Morbidity associated with potentially.

misdirected medical therapy is high.misdirected medical therapy is high. When empiric therapy has failed.When empiric therapy has failed. When surgical intervention is When surgical intervention is

planned.planned. Overflow incontinence.Overflow incontinence.

Urinary IncontinenceUrinary Incontinence

Pharmacologic Treatment Pharmacologic Treatment ObstructionObstruction

Alpha blockersAlpha blockers-- delay surgerydelay surgery-- benefit in weeksbenefit in weeks

PrazosinPrazosinTamsulosinTamsulosinTerazosinTerazosin

Finasteride 5 alpha reductase inhibitorFinasteride 5 alpha reductase inhibitor-- Less effectiveLess effective-- Delayed benefitDelayed benefit-- Side-effects esp. Side-effects esp.

impotence.impotence.