URINARY INCONTINENCE

1. URINARY INCONTINENCE Dr Mark Donaldson Consultant Physician in Geriatric Medicine

2. Urinary Incontinence Affects:15%-30% elderly living at home 30% - 35% elderly in acute care >50% in RCF

3. Urinary Incontinence Continence requires: • Adequate mobility • Mentation • Motivation • Manual dexterity • Intact lower urinary tract function

4. Urinary Incontinence Medical Complications • Rashes • Pressure ulcers • UTI • Falls • Fractures

5. Urinary Incontinence Psychosocial complications • Embarrassment • Stigmatisation • Isolation • Depression • Institutionalisation risk

6. Incontinence is nevernormal

7. Urinary Incontinence AGEING BLADDER CHANGES • Bladder capacity decreases • Bladder compliance decreases • Ability to postpone voiding decreases • Urethral closing pressure decreases in women • Prostate enlarges in men • Involuntary bladder contractions increase • Post-voiding residual volume increases (50-100ml) Also: • Increased fluid excretion at night • Age associated sleep disorders • Detrusor muscle changes

8. Urinary Incontinence Incontinence is a Geriatric syndrome:i.e. Predisposed by above factors Precipitated usually by disease outside the urinary tract. Frequent adverse drug reactions that affect the urinary tract It is these factors OUTSIDEthe urinary tract that are amenable to intervention e.g. arthritis/immobility

9. Urinary Incontinence Transient Incontinence Common e.g. 30% community dwellers 50% of inpatients At risk cases: especially anti-cholinergics diuretics worsening mobility

10. Urinary Incontinence Transient Incontinence: D - Delirium I - Infection A - Atrophic Urethritis/vaginitis P - Pharmaceuticals P - Psychological (rare) E - Excessive urine output R - Restricted mobility S - Stool impaction

11. Urinary Incontinence Urinary tract causes of incontinence: • Detrusor overactivity • Detrusor underactivity • Genuine stress incontinence (low urethral resistance) • Obstruction (high urethral resistance)

12. Urinary Incontinence Detrusor OveractivityCommonest cause of urinary incontinence (60%-70%). Seen with: - neurologic disorders - obstruction - ageing - GSI - DHIC

13. Urinary Incontinence Detrusor Overactivity • Clinically: - sudden onset - immediate need to void • Leakage is episodic, moderate to large • Nocturnal frequency • Urge incontinence common • PVR low in absence of DHIC

14. Urinary Incontinence Stress Incontinence • Common in women • In men, only after sphincteric damage complicating prostatic resection • Clinically: Instantaneous with stress manoeuvres Delayed - suggests stress induced detrusor overactivity • In men, ‘leaky tap’ worsened by standing or straining • Often co-exists with urge incontinence i.e. mixed

15. Urinary Incontinence Urethral Obstruction • Common in men • In women, after bladder neck suspension or kinking associated with severe prolapse • Prostatic encroachment • Clinically:(1) Filling symptoms (i.e. urgency, frequency, nocturia)(2) Voiding symptoms (i.e. poor stream, intermittency, dribbling post void (3) Overflow

16. Urinary Incontinence Detrusor Underactivity(<10% of incontinence cases) • Usually idiopathic • Caused by degenerative muscle and axonal changes • Clinically: Overflow incontinence Frequency Nocturia Frequent leakage of small amounts • PVR usually > 450ml • In men, differentiated by urodynamics rather than cystoscopy or IVP.

17. Urinary Incontinence Evaluation of the older incontinent patient GOALS:Investigate and treat transient and established causes. Assess patient’s environment and support To detect uncommon but serious underlyhing conditions:-Brain lesions - Spinal cord lesions - Carcinoma bladder/prostate - Bladder stones - Decreased bladder compliance

18. Urinary Incontinence Clinical Management 1. Exclude overflow incontinence (e.g. PVR > 450ml) Where appropriate, Urologist referral Remainder - catheterise

19. Urinary Incontinence Clinical Management 2. Remaining 90%-95% depends on gender.Females: either OAB or GSI GSI excluded by observing for leakage with full bladder and vigorous coughMales: either OAB or obstruction. If flow normal, PVR <100ml then obstruction is excluded. If PVR > 200ml, exclude hydronephrosis.Remainder, treat for OAB – warn about retention – avoid bladder relaxants if PVR >150ml.

20. Urinary Incontinence Non-Drug Treatment of OABBladder Drill (re-training) • Timed voiding • Deferment technique Cognitively impaired • Prompted voiding Non-Drug Treatment of GSI • Pelvic floor exercises especially if mild : - 30-200 times per day - Indefinitely - Limited efficacy - Repair procedures less invasive

21. Urinary Incontinence Drug Treatment of OABAnti-cholinergic (anti-muscarinics) • Oxybutynin • Solifenacin • Darifenacin • Tolterodine • Best as adjuncts to bladder drill. • Dose escalation by titration • Most NOT on PBS • Newer ones better tolerated • CI Glaucoma – Dry mouth, confusion

22. Urinary Incontinence Voiding and Dementia • Alertness • Responsive • Motivation • Direction • Mobility • Recognition • Dressing

23. Urinary Incontinence Indications for Urodynamics • Persistent diagnostic uncertainty. • Morbidity associated with potentially. misdirected medical therapy is high. • When empiric therapy has failed. • When surgical intervention is planned. • Overflow incontinence.

24. Urinary Incontinence Pharmacologic Treatment Obstruction • Alpha blockers - delay surgery - benefit in weeksPrazosinTamsulosinTerazosinFinasteride 5 alpha reductase inhibitor - Less effective - Delayed benefit - Side-effects esp. impotence.