1	URINARY INCONTINENCE July 2003 Deb Mostek
2	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.
3	Definition UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. International Continence Society
4	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
5	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
6	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.
7	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
8	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
9	Types of Urinary Incontinence Transient UI Established UI Urge UI Stress UI Mixed UI Overflow UI “Functional” UI
10	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
11	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.
12	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
13	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
14	Pharmacologic Causes, Continued alpha-agonists urethral sphincter tone ® retention and Overflow alpha-antagonists ¯ urethral sphincter tone ® Stress
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,?Vitamin B12 level Clinical urinary stress test Post-void residual 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	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)
21	2) CONDITIONS To CONSIDER: EARLY UROLOGIC, or GYN,or URODYNAMIC EVALUATION PROBLEM Recurrent. 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
22	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
23	Stress UI 2^nd 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, a-adrenergic agonists, pessary, surgical interventions.
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25	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.
26	Overflow UI Detrusor underactivity and/or outlet obstruction Continuous small volume leakage Dribbling, weak stream, hesitancy, nocturia Outlet obstruction=2^nd most common cause of UI in Males Detrusor underactivity ®Urinary retention & overflow Incontinence in 12%F; 29%M Management: Obstruction—Treat cause; a-antagonists. Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.
27	“Functional” Incontinence Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers No underlying GU dysfunction Diagnosis of exclusion
28	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.
29	Rare Causes Bladder fistulas Detrusor-sphincter dyssynergia
30	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
31	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.
32	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.
33	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.
34	3)FUNCTION FOCUSED APPROACH TO REMAINING CAUSES
35	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.
36	Further Urological Evaluation PVR > 400 cc Poor response to treatment Cystometry, cystoscopy, urodynamic studies Evidence of GU tract pathology
37	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
38	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
39	Acknowledgments Wendy Adams, MD MPH who also contributed slides DuBeau CE. Urinary Incontinence. Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148