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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.
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