urinary incontinence in the aging patient september 2007 deb mostek
Post on 19-Dec-2015
215 views
TRANSCRIPT
URINARY INCONTINENCE IN THE AGING PATIENT
September 2007Deb Mostek
Definition
UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem.
International Continence Society
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
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
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
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
Types of Urinary Incontinence
Transient UI (Acute) Established UI (Chronic)
Urge UI Stress UI Mixed UI Overflow UI “Functional” UI
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
Causes of Transient (Acute) 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.
Pharmacologic Causes Opioids Calcium channel
blockers Anti-Parkinsons
drugs Anti-cholinergics Prostaglandin
inhibitors
Depress detrusor activity & produce urinary retention and overflow incontinence
Pharmacologic Causes 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, Continued
alpha-agonists urethral
sphincter tone retention and Overflow
alpha-antagonists urethral
sphincter tone Stress
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.
Mrs. R SH: lives with daughter and grandson.
Dependent on family for assistance with ADL’s.
Physical Exam: BP 138/80 P78 R18 T98 Gen: Alert, cooperative, vague historian; Chest: Clear; CV: RRR; Abdomen: Benign; GU: Atrophic changes; Ext: Trace edema
Screening
Ask sensitively worded questions
Detailed History Duration, previous
evaluation/treatment? Volume, how often, what situations? Urgency, dysuria, straining?
EVALUATION:THE APPROACH
Focused H & P for: 1) Reversible conditions2) Conditions that require Urologic
or Gynecologic consult or Urodynamics early on.
3) Function focused approach to the remaining cases
4) Contributing factors
Evaluation, continued
UA, C&S Creatinine, BUN, Glucose, Calcium,
?PSA Post-void residual Clinical urinary stress test Voiding record
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
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
Established Incontinence
URGE STRESS Mixed type (both urge and stress) OVERFLOW (increased PVR) “Functional” incontinence
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
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, electrical stimulation, -adrenergic agonists, pessary, surgical interventions.
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.
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
Overflow UI
Management: Obstruction—Treat cause; -antagonists. Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.
“Functional” Incontinence
Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers
No underlying GU dysfunction Diagnosis of exclusion
3)FUNCTION FOCUSED APPROACH TO REMAINING CAUSES
Symptoms: URGE (REFLEXor NEUROGENIC)
STRESS OVERFLOW
leakage variable volumes small volume small volume pattern of urine loss unpredictable with intrabd. pressure
(cough, sneeze, laugh)almost continuous
delay voiding? unable able except with intrabd. pressure
able, (at times)
voiding volumes(normally)
variable normal small
N o c t u r n a lincontinence 1
Yes (pt. is unaware) Rare Yes (dribbling)
1.Rovner ES, Wein AJ, The treatment of Operative bladder in the geriatric patient . ClinicalGeriatrics Vol. 10 Number 1 Jan 2002
Mrs. J Pleasant, thin 86 y/o with c/o urgency,
frequency, with variable UI for past 2-3 years. PMH: Osteoporosis with old thoracic vertebral
compression fractures, hypertension SH: Widowed, lives alone Meds: Calcium w Vit. D tid; alendronate 70
mg weekly; amlodipine 5 mg daily; MVI daily ROS: Mild fatigue, sleep disturbance, admits
to depressed ideation. Otherwise negative.
Mrs. J PE: BP 126/70 sitting; 118/68
standing. Wt. 44kg Gen: Thin, alert, excellent historian. CV, Pulm, Abd, Neuro: all neg GU: Ext genitalia/BSU/Vag– Atrophic;
no pelvic relaxation; Bimanual exam: consistent with previous hysterecomy, no masses. RV:Confirmatory
Mrs. J
PVR: 250 ml Clinical stress test: Some urine loss
after several seconds delay after cough
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.
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 last.
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
Bladder Retraining
Urge control exercises Scheduled toileting Prompted toileting
Pelvic Muscle Rehabilitation
Detailed instruction of pelvic muscle exercises
Biofeedback techniques Electrical stimulation
Anticholinergic Drugs Oxybutynin Tolterodine Trospium Darifenacin Variety of preparations: Immediate
Release; Extended Release; Transdermal Outcomes same; Try different agent if
one doesn’t work***** ALL these drugs suppress the detrusor contractility and MAY
CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!
Overflow UI
Obstruction—Treat cause; -antagonists; finasteride
Detrusor Underactivity—Review meds, double voiding, intermittent self-catheterization, Crede’s.
Further Urological Evaluation
PVR > 400 cc Poor response to treatment Cystometry, cystoscopy,
urodynamic studies Evidence of GU tract pathology
UI Summary Look for reversible causes and Rx Check PVR (>100 cc investigate
further) Start with behavioral interventions
before meds Referral and urodynamic studies if
no response to usual measures Early referral if underlying GU tract
pathology present
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
Acknowledgments
Wendy Adams, MD MPH who also contributed slides
DuBeau CE. Urinary Incontinence. Geriatric Review Syllabus, Fifth Edition 2002-2004. 139-148