Geriatric Urinary Incontinence & Overactive Bladder

1. Geriatric Urinary Incontinence &Overactive Bladder Joseph G. Ouslander, M.D. Professor of Medicine and Nursing Director, Division of Geriatric Medicine and Gerontology Chief Medical Officer, Wesley Woods Center of Emory University Director, Emory Center for Health in Aging Research Scientist, Birmingham/Atlanta VA GRECC

2. Geriatric Urinary Incontinence &Overactive Bladder (OAB) • Prevalence & impacts • Pathophysiology • Diagnostic evaluation • Management An Update

3. Geriatric Urinary Incontinence Prevalence Women Men Community (Frail)/ Acute Hospital N H Community (General)

4. Overactive Bladder (OAB) • Urinary Frequency • >8 voids/24 hrs • Nocturia • awakening at night to void • Urgency, with or without urge incontinence

5. Overactive Bladder Prevalence Telephone survey of 16,776 adults age 40+ Women Men 17% 16% Milsom et al: BJU International, 87:760, 2001

6. Overactive Bladder Prevalence Women Men

7. Top Chronic Conditions in the U.S. 40 35 30 OAB 25 Millions 20 15 10 5 0 Asthma Diabetes Chronic bronchitis Ulcer Chronic sinusitis Arthritis Heart disease Incontinence High cholesterol Allergic rhinitis

8. OAB: “Dry” vs “Wet” (Urge Incontinence) Wet (37%) Dry (63%) OAB Adapted from Stewart W et al. ICI 2001

9. Spectrum of OAB and Urinary Incontinence OAB OAB z • Urgency • Frequency • Nocturia Urge UI Stress UI Mixed Incontinence

10. Impact of UI & OAB on Quality of Life Physical • Discomfort, odor • Falls and injuries Psychological • Fear and anxiety • Loss of self-esteem • Depression Sexual • Avoidance of sexual contact and intimacy Quality of Life Social • Limited travel and activity around toilet availability • Social isolation Occupational • Decreased productivity • Absence from work

11. Adverse Consequences of UI & OAB • 87 Y.O. woman living at home, with minimal assistance from family • Incontinent rushing to the toilet at 2 a.m., slipped and fell in urine • Sustained a hip fracture • Now confined to a wheelchair and required admission to a nursing home

12. Urge Incontinence, Falls, and Fractures • 6,049 women, mean age 78.5 • 25% reported urge UI (at least weekly) • Followed for 3 yrs • 55% reported falls, 8.5% fractures • Odds ratios for urge UI and • Falls: 1.26 • Non-spine fracture: 1.34 Brown et al: JAGS 48: 721 – 725, 2000

13. Geriatric Urinary Incontinence and OAB Promote Constipation Occupation Recreation Obesity Surgery Lung disease Smoking Menstrual cycle Infection Medications Fluid intake Diet Toilet habits Menopause Multi-factorial Pathophysiology Incite Childbirth Nerve damage Muscle damage Radiation Tissue disruption Radical surgery Predispose Gender Racial Neurologic Anatomic Collagen Muscular Cultural Environmental Decompensate Aging Dementia Debility Disease Environment Medications Intervene Behavioral Pharmacologic Devices Surgical Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.

14. Geriatric Urinary Incontinence & OAB Urinary Tract Neurological Functional/Behavioral Drugs/Other Conditions

15. Geriatric Urinary Incontinence & OAB Pathophysiology Lower urinary tract • Bladder pathology (infection, tumor, etc) • Detrusor overactivity • Women – atrophic urethritis, sphincter weakness • Men – prostate enlargement • Urinary retention • Obstruction • Impaired bladder contractility

16. Geriatric Urinary Incontinence & OAB Detrusor Overactivity 100 Involuntarybladder contractions Normal voluntary void Bladder pressure 0 0 100 200 300 400 Volume

17. Geriatric Urinary Incontinence & OAB DHIC 100 80 60 % bladder emptying 40 20 0 DHIC DH Resnick, Yalla JAMA 1987;148:3076

18. Pathophysiology of Detrusor Overactivity • Neurogenic • Myogenic • Combination • Unknown

19. Geriatric Urinary Incontinence & OAB Sphincter Weakness

20. Geriatric Urinary Incontinence & OAB Pathophysiology Neurological • Brain • Stroke, dementia, Parkinson’s • Spinal cord • Injury, compression, multiple sclerosis • Peripheral innervation • Diabetic neuropathy

21. Geriatric Urinary Incontinence & OAB Pathophysiology Functional/Behavioral • Mobility impairment • Dementia • Fluid intake • Amount and timing • Caffeine, alcohol • Bowel habits/constipation • Psychological (anxiety)

22. Geriatric Urinary Incontinence & OAB Pathophysiology Other Conditions • Diabetes (polyuria) • Volume overload (polyuria, nocturia) • Congestive heart failure • Venous insufficiency with edema • Sleep disorders (nocturia) • Sleep apnea • Periodic leg movements

23. Requirements for Continence Adequate: • Lower urinary tract function • Mental function • Mobility, Dexterity • Environment • Motivation (patients, caregivers)

24. D elirium R estricted mobility, R etention I nfection, I nflammation, I mpaction P olyuria, P harmaceuticals Reversible Causes (“DRIP”)

25. Geriatric Urinary Incontinence & OAB Drugs • Diuretics • Narcotics • Anticholinergics • Psychotropics • Cholinesterase inhibitors • Alpha adrenergic drugs

26. Persistent Incontinence Stress Urge Functional Overflow

27. Geriatric Urinary Incontinence & OAB Diagnostic Assessment • History (Bladder Diary in selected patients) • Physical exam • Cough test for stress incontinence • Non-invasive flow rate (helpful in men) • Measurement of voided and post-void residual volumes • Urinalysis

28. History • Most bothersome symptom (s) • Treatment preferences and goals • Medical history for relevant conditions and medications • Onset and duration of symptoms • Prior treatment and response • Characterization of symptoms • Overactive bladder • Stress incontinence • Voiding difficulty • Other (pain, hematuria) • Bowel habits • Fluid intake

29. Physical Exam • Cardiovascular • Abdominal • Neurological • Perineal skin condition • External genitalia • Pelvic exam • Atrophic vaginitis • Pelvic prolapse • Rectal exam • Sphincter control • Prostate

30. Post-Void Residual Determination • Diabetics • Neurological conditions (e.g. post acute stroke, multiple sclerosis, spinal cord injury) • Men (especially those who have not had a TUR) • Anticholinergics and narcotics • History of urinary retention or elevated PVR

31. Urinalysis • Infection • Sterile hematuria • Glucosuria

32. Geriatric Urinary Incontinence and OAB Examples of criteria for further evaluation • Recurrent UTI • Recent pelvic surgery • Severe pelvic prolapse • Sterile hematuria • Urinary retention • Failure to respond to initial therapy, anddesire for further improvement

33. Reversible causes Supportive measures Education Environmental Toilet substitutes Catheters Garments/pads Behavioral interventions Pharmacologic therapy Surgical interventions Devices Management of Geriatric Incontinence and OAB

34. Modify fluid intake Modify drug regimens (if feasible) Reduce volume overload (for nocturia) e.g. take furosemide in late afternoon in patients with nocturia and edema Treat: Infection (new onset or worsening symptoms) Constipation Atrophic vaginitis (topical estrogen) Management of Geriatric Incontinence and OAB • Treat Reversible Causes

35. Education Environmental Clear well-lit path to toilet Bedside commodes, urinals Catheters For skin problems, retention, palliative care/patient preference Garments/pads Management of Geriatric Incontinence and OAB • Supportive Measures

36. Chronic Indwelling Catheters Appropriate indications • Significant, irreversible retention • Skin lesions/surgical wounds • Patient comfort/preference

37. Management of Geriatric Incontinence and OAB Undergarments and Pads • Nonspecific • Foster dependency • Expensive

38. Management of Geriatric Incontinence and OAB Surgical Interventions • Stress incontinence • Periurethral injections • Bladder neck suspension • Sling procedure • Artificial sphincter • Urge incontinence • Implantable stimulators • Augmentation cystoplasty

39. Management of Geriatric Incontinence and OAB Behavioral Interventions • “Bladder Training” • Education • Urge suppression techniques • Pelvic muscle rehabilitation • With and without biofeedback • Toileting programs • Prompted voiding (and others)

40. Pelvic Muscle Exercises Squeeze muscles tightly for up to 10 seconds Repeat in sets of up to 10 3-4 times/day, and use in everyday life Relax completely for at least 10 seconds Locate pelvic muscles

41. Management of Geriatric Incontinence and OAB Behavioral vs. Drug Treatment Burgio et al: JAMA 280: 1995, 1998

42. Management of Geriatric Incontinence and OAB Behavioral vs. Drug Treatment Patient Perceptions Behavior Drug Control Much better Better Able to wear fewer pads Completely satisfied Continue treatment Wants another treatment 74 26 76 78 97 14 51 31 56 49 58 76 27 39 34 28 43 76 Burgio et al: JAMA 280: 1995, 1998

43. Prompted Voiding Protocol • Opportunity (prompt) to toilet every 2 hours • Toileting assistance if requested • Social interaction and verbal feedback • Encourage fluid intake

44. Prompted Voiding Efficacy in Research Studies • Reduces severity by half • 25%-40% of frail nursing home patients respond well • UI episodes decrease from 3 or 4 per day to 1 or fewer • Responsive patients can be identified during a 3-day trial Ouslander JG et al. JAMA 273:1366-70

45. Management of Geriatric Incontinence and OAB • Drug Therapy

46. Lower Urinary Tract Cholinergic and Adrenergic Receptors Μ=muscarinic =1-adrenergic Detrusor muscle(M) Trigone() Bladder neck() Urethra ()

47. Motor Innervation of the Bladder Neurotransmitter:Acetylcholine Receptors:Muscarinic Contraction Pelvic Nerve

48. Motor Innervation of the Bladder Ouslander J. N Engl J Med. 2004;350:786-799

49. Sensory Innervation of the Bladder Ouslander J. N Engl J Med. 2004;350:786-799

50. Drug Therapy for Stress Incontinence • Limited efficacy • Two basic approaches: • Estrogen to strengthen periurethral tissues (not effective by itself) • Alpha adrenergic drugs to increase urethral smooth muscle tone (no drugs are FDA approved for this indication) • Pseudoephedrine (“Sudafed”) • Duloxitene (“Cymbalta”)