Urinary Incontinence In The Elderly

Front 1

how common is incontinence

Back 1

-prevalence increases with age
-25-30% of community dewling older women and 10-15% of men
-Common cause of institutionalization, social isolation, and decline in function
-it is underdiagnosed and undertx
-80% of urinary incontinence can be cured or improved!

Front 2

importance of incontinence

Back 2

1. social stigma
2. medical complications: skin breakdown, inc UTIs, falls
3. institutionalization
4. economic
5. effects ALL aspects of QOL

Front 3

urethrovesicle junction

Back 3

-support by fascia
-normally an acute angle is formed between bladder and urethra, which helps maintain continence

Front 4

neural control

Back 4

-local stretch receptors (reflex arc)
-parietal recognition center
-frontal lobe inhibits
-micturition center in pons
-detrusor under cholinergic control
-urethra under alpha adrenergic control
-external sphincter under voluntary control
FILLING OF BLADDER -> SYMPATHETIC
EMPTYING --> PARASYMPATHETIC

Front 5

Filling of the bladder

Back 5

-Bladder neck, sphincters close, detrusor relaxes
-fill under low P
-first urge around 250cc
-capacity 400-600cc

Front 6

emptying of bladder

Back 6

-Bladder neck, sphincters relax, detrusor contracts
-When bladder pressure exceeds urethral pressure, voiding occurs

Front 7

requirements for continence

Back 7

1. intact GU anatomy
2. intact neural control
3. mobility/dexterity
4. reasonable environment
5. motivational

Front 8

urologic changes with age

Back 8

1. dec bladder compliance and capacity
2. inc residual vol
3. uninhibited bladder contractions
4. prostatic enlargement
5. dec urethral P
6. dec estrogen
7. pelvic laxity with vaginal childbirth
8. neurologic: dec nerve cell #, dec NT concentration, dec autonomic function
9. altered immune function

Front 9

basic causes of incontinence

Back 9

1. failure to store
2. failure to empty
3. failure of coordination

Front 10

risk factors for incontinence

Back 10

1. female
2. >60
3. parity
4. UTI/CU surgery
5. chronic illness/immobility
6. meds

Front 11

types of incontinence

Back 11

1. acute (reversible/ transient)
2. fixed

Front 12

potentially reversible causes

Back 12

D delerium
I infx/inflam
A atrophic vaginitis or urethritis
P phamaceuticals
P psyc disorders
E endocrine disorders
R restricted mobility
S stool impaction

Front 13

meds that may cause incontinence

Back 13

1. diuretics
2. anticholinergics
3. sedatives
4. CNS depressants
5. alcohol
6. narcotics
7. aadrenergic agonists
8. CCBs

Front 14

categories of fixed incontinence

Back 14

1. urge incontinence
2. stress
3. overflow
4. reflex
5. functional
6. mixed

Front 15

urge incontinence

Back 15

-most common cause if UI <75 yo
-sudden urge to void
-idiopathic (uninhibited bladder contractions)
-other causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

Front 16

stress incontinence

Back 16

-most common type in women >75
-occurs with increase in abdominal P, cough, sneeze
-hypermobility of bladder neck and urethra
-intrinsic sphincter problems

Front 17

overflow incontinence

Back 17

-over distention of bladder
-bladder outlet obstruction
-non-contractible bladder

Front 18

reflex incontinence

Back 18

-Involuntary loss of urine without urge or stress
-Patient is unaware that they need to void
-Usual cause: suprasacral spinal cord lesion

Front 19

functional incontinence

Back 19

-Does not involve pathology of lower urinary tract
-Result of psychological, cognitive or physical impairment

Front 20

mixed incontinence

Back 20

-combo
-esp see urge + stress in older women

Front 21

eval of incontinence

Back 21

1. hx
-Onset, duration, severity, previous treatment, medications, GU surgery
-assoc sx
-3 P's: position when leakage, protection, problem)
2. PE
3. labs/xrays
4. beside urologic disgnostic test
4. formal urodynamics

Front 22

how to ask

Back 22

Do you lose (leak) urine with very little warning?
Do you lose (leak) urine before you can reach the bathroom?
Do you lose (leak) urine when you cough, sneeze, …………………?
Do you constantly lose small amounts of urine?
After you go to the bathroom, do you dribble small amounts or feel you need to go again?
Are there times you feel you need to void, but are unable or unwilling to get to the bathroom ?
Location/accessibility of toilet?
Difficulty removing clothing?

Front 23

PE

Back 23

-mental status
-mobility
-fluid overload
-abd exam
-neuro exam
-genital/pelvic
-rectal

Front 24

diagnostic tests

Back 24

1. blood tests: lytes, Ca, glucose, BUN, Cr
2. UA and culture
3. ? radiologic testing
4. bedside cystometrics:
-flow rate (male)
-post-void residual
-filling under low P

Front 25

intepretation of post-void residual

Back 25

PVR < 50cc - Adequate bladder emptying
PVR > 150cc - Avoid bladder relaxing drugs
PVR > 200cc - Refer to Urology
PVR > 400cc - Overflow UI likely

Front 26

stress test

Back 26

-remove catheter, pad in front of urethra, cough
-look for leakage on pad
-if leakage, repeat after Marshall maneuver
-if not leakage, but suspicion of SI, standing

Front 27

characteristics- Urge

Back 27

1. sudden urge to void
2. leakage frequent, mod to large amts
3. nocturnal frequency
4. sacral sensation/ reflexes preserved
5. PVR low
6. evidence of uninhibited contractions

Front 28

characteristics- reflex

Back 28

No urge to void, no sensation of fullness, no stress
Leakage frequent, moderate amounts
Nocturnal as well as during the day
Perineal sensation may be decreased; reflexes are preserved
Detrussor hyperreflexia, sphincter dyssynergia
PVR increased

Front 29

characteristics- stress

Back 29

Daytime loss of small to moderate amounts with increased intra-abdominal pressure
PVR low
Positive stress test
Correction with Marshall maneuver is 90% predictive of correction with surgery
Look for stress-induced detrussor instability

Front 30

characteristics- overflow

Back 30

+/- hesitancy, decreased/interrupted flow
sensation of fullness, need to strain to void, incomplete emptying
Leakage frequent, small amounts
Nocturnal as well as during the day
If neurologically mediated, perineal sensation, sacral reflexes, and anal sphincter control may be decreased
Palpable bladder
PVR LARGE

Front 31

referral for urodynamics

Back 31

1. any pt with relfex incontinence
2. any pt with overflow incont
3. when initial dx is unclear
4. when risk from empiric therapy is high
5. when empiric therapy has failed

Front 32

treatment goals for incontinence

Back 32

1. maintain renal function
2. help pt become dry
3. establish nml voiding pattern
4. improvement of sx vs. cure

Front 33

treatment options

Back 33

1. eval amt and timing if fluid intake
2. avoid bladder stimulants
3. use diuretics judiciously
4. reduce physical barriers to toilet
5. resolve other functional prob
6. bladder training
7. pelvic floor (Kegel)
8. biofeedback
9. caregiver interventions

Front 34

Meds for stress incontinence

Back 34

Phenylpropanolamine (Ornade)
Pseudo-Ephedrine (Sudafed)
Estrogen (orally, transdermally or transvaginally

Front 35

meds for urge incontinence

Back 35

Propantheline (Pro-Banthine)
Imipramine (Tofranil)
Oxybutynin (Ditropan)
Tolterodine (Detrol)
Trospium (Sanctura)
Solifenacin (Vesicare) , darifenacin (Enablex)
Alpha-adrenergic antagonists (men with BPH)

Front 36

Adverse effects of meds

Back 36

1. dry mouth
2.HA
3. dizziness
4. GI complaints
5. somnolence
C/I: urinary retention, GI disturbances, glaucoma

Front 37

surgical interventions

Back 37

-Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years.
1. Urethral hypermotility:
-Marshall-Marchetti-Kantz procedure
-Needle neck suspension
2. Intrinsic sphincter deficiency
-sling procedure

Front 38

other interventions

Back 38

1. Pessaries
2. Periurethral bulking agents
-injection of collagen, fat or silicone
3. Diapers or pads (can be temporary)
4. Chronic catheterization
-Last resort!
-Periurethral or suprapubic
-Indwelling or intermittent