URINARY INCONTINENCE

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. 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 Pharmacologic Causes

13. 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 Pharmacologic Causes

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. 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 2) CONDITIONS To CONSIDER:EARLY UROLOGIC, or GYN,or URODYNAMIC EVALUATION

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 • 2nd 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, -adrenergic agonists, pessary, surgical interventions.

24. Ahronheim JC. Aging. In Epps RP, Stewart SC eds. Women’s Complete Healthbook, • The Philip Lief Group, Inc. and the American Medical Women’s Association, Inc. • Stress Urinary Incontinence figure 11.2, p156.

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=2nd most common cause of UI in Males • Detrusor underactivity Urinary retention & overflow Incontinence in 12%F; 29%M • Management: Obstruction—Treat cause; -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 FOCUSEDAPPROACH 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