Urinary incontinence


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Urinary incontinence in elderly

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Urinary incontinence

  1. 1. URINARY INCONTINENCEURINARY INCONTINENCE Dr. Doha RasheedyDr. Doha Rasheedy lecturer of geriatric medicinelecturer of geriatric medicine Geriatric medicine departmentGeriatric medicine department Ain Shams UniversityAin Shams University
  2. 2. URINARY INCONTINENCE • Urinary incontinence (UI), defined as the involuntary leakage of urine, is a common clinical condition that occurs frequently in older adults • Urinary incontinence is not a normal part of aging. It is a loss of urine control due to a combination of: -Age related changes. -Genitourinary pathology. -Comorbid conditions and medications. -Environmental Obstacles. •
  3. 3. Epidemiology • Estimates suggest that at least 25% to 30% of all adults will experience UI at some point in their lives. • In people older than 65 years, the estimated prevalence of UI ranges from approximately 35% for those who reside in the community to more than 60% for those who live in long term care facilities
  4. 4. Impact of UI • UI is associated with a dramatic reduction in overall and health-related quality of life for older adults. • UI has been linked to many other important health risks, including depression and functional disability, which may result in social isolation and inability to participate in desired activities. • Elderly individuals with UI have a higher risk for falls and fractures compared with those who do not leak urine. • Incontinence may have a negative effect on sexual health in men and women. • UI may also be a marker for increased mortality risk in some patients.
  5. 5. Classification Two broad categories of UI seen in older adults include: • transient incontinence • chronic incontinence. Both can be subdivided into several additional categories.
  6. 6. Transient Incontinence • Potentially Reversible Causes of incontinence ( DRIPS Mnemonic): 1. Delirium 2. Infection (acute, symptomatic) 3. Atrophic vaginitis, urethritis 4. Pharmaceuticles for e.g: alpha-adrenergic agonists, alpha- adrenergic blockers, anticholinergics, calcium channel blockers, loop diuretics,NSAIDs, sedative hypnotics, narcotic analgesics,antidepressants, antipsychotics 5. Excess urine (diabetes mellitus, caffeine intake, volume overload). 6. Restricted mobility (illness, injury, gait disorder, restraint) 7. Stool Impaction
  7. 7. Chronic or established UI
  8. 8. Stress Incontinence • Stress incontinence is characterized by loss of urine with activities that increase intraabdominal pressure. Examples include coughing, sneezing, lifting, or laughing. the pressure inside the abdomen exceeds the closure pressure at the urethral outlet leading to leakage of urine • The cause is often due to inadequate closure of the external urethral sphincter. Urethral hypermobility with loss of support of the urethra is also seen in some women with stress incontinence. • In men, the most common associated risk factors include a history of either radical prostatectomy for treatment of prostate cancer or transurethral resection of the prostate for treatment of benign prostatic hyperplasia.
  9. 9. URGE UI • Urge incontinence is typically associated with sudden onset of a sensation of needing to void, with loss of urine occurring before the patient is able to reach toilet facilities.
  10. 10. • Caused by uninhibited contractions of the bladder detrusor muscle. • The term ‘‘overactive bladder,’’ this condition due to irritation of the reflex arc. There are two forms, including OAB-dry, which is characterized by urinary urgency and frequency but no leakage of urine, and OAB-wet, which includes UI (causes include UTI, Stone) • The term bladder hyperreflexia due to activation of neuronal regulation above level of reflex arc : Common causes, multiple sclerosis, Parkinson disease, stroke, spinal cord injuries, and disorders such as spinal stenosis. Dementia may also be associated with urge incontinence
  11. 11. Overflow Incontinence • Overflow incontinence is typically associated with either outlet obstruction or poor detrusor contractility and incomplete bladder emptying. • In men, benign prostatic hyperplasia may lead to outlet obstruction and overflow incontinence. Urethral strictures are more common in men. in women , prior incontinence surgery or large cystocele. • Patients typically experience frequent loss of small volumes of urine, in contrast to the larger volumes of urine leakage associated with urge incontinence
  12. 12. Functional Incontinence • urinary leakage that occurs as a result of factors not directly associated with the bladder, which may prevent independent toilet use. The most common examples in older adults include limitations in either mobility or cognition
  13. 13. Mixed UI • more than one type of UI occurs at a time, the combination of stress and urge UI is extremely common. Some patients can describe the predominant symptom and this may be amenable to initial therapy. • Another unique form of mixed incontinence that is more common in older adults is termed ‘‘detrusor hyperactivity with impaired contractility (DHIC)’’. In this condition, patients experience urinary urgency and frequency caused by uninhibited contractions of the detrusor. However, when they try to void voluntarily, the bladder does not contract adequately, and therefore does not empty completely. This may lead to associated overflow incontinence
  14. 14. Asking The Right Questions “Do you leak with you cough, laugh, or sneeze?” “Do you ever get the feelings of gotta go, gotta go, gotta go!?!” “Do you not always make it when you are racing for the bathroom?” “How many times do you get up during the night?” “Do you feel a bulge?” “Do you have to shift your upper body to urinate?”
  15. 15. Evaluation • History: 1.onset, frequency, volume, timing, precipitants ( eg, caffeine, diuretics, alcohol, cough, medications). 2.Character: • Sudden, compelling urgency suggests urge UI. • Loss with cough, laugh, or bend suggests stress UI. • Continuous leakage suggests intrinsic sphincter insufficiency or overflow.
  16. 16. Physical Examination • Functinal status ( e.g, mobility) • Mental status • Findings as: bladder distension, cord compression, rectal mass or impaction, anal sphincter tone, perineal sensation, volume overload, edema. • Male Genitourinary system: prostate consistency, symmetry , check phimosis, paraphimosis, balanitis. • Female Genitourinary system: atrophic vaginitis, pelvic support, cystocele, rectocele, prolapse.
  17. 17. Laboratory • UA and urine C&S, glucose and calcium if polyuric : renal function tests and B12 if urinary retention ; urine cytology if hematuria or pain.
  18. 18. Testing include: • bladder diary which record time and volume of incontinent and continent voids, activities and time of sleep, knowing oral intake is sometimes helpuful • standing full bladder stress Test ( for patients with symptoms of stress UI ) relax perineum and cough once immediate loss suggests stress, several seconds delay suggests detrusor overactivity.
  19. 19. Postvoid residual •bladder ultrasound after voiding is preferred to catheterization. If > 100 ml repeat if still > 100 suggests detrusor weakness , neuropathy, medications, fecal impaction, outlet obstruction, or DHIC.
  20. 20. Urodynamic Studies • not routinely indicated ; indicated before corrective surgery, when diagnosis is unclear, when empric therapy is ineffective or if postvoid residual volume > 200-300 ml ( possibly lower in men ). • This may range from simple urodynamics, with measurement of bladder capacity or noninvasive uroflowmetry, to more complex multichannel studies that examine storage and emptying capabilities. • Simultaneous measurement of detrusor pressure and urinary flow may be particularly helpful to differentiate between outlet obstruction and detrusor insufficiency in patients with symptoms of overflow incontinence
  21. 21. uroflowmetery
  22. 22. • Male <40 years max flow rate 25 ml/s • Male > 60 years max flow rate 15 ml/s • Female is higher by 5-10 ml/s and increased in stress incontinence when outlet resistance is minimal.
  23. 23. Characteristic flow pattern • Fast bladder= stress UI, DO • Prolonged flow= BOO, DU • Intermittent flow= BOO, DU compensated with abdominal straining. • Flat plateau= urethral structure • NB: error occur with total volume <150 ml or >400ml • NB: free flow vs. non free flow
  24. 24. • a normal flow rate can be present in the early stages of obstruction as a consequence of a compensatory increase in voiding pressure by hypertrophied detrusor which will maintain of an apparently normal flow rate. Ultrasound scan of the bladder will show a thickened bladder wall and cystoscopy will confirm the bladder out flow obstruction due to BPH or stricture urethra despite of a normal flow rate
  25. 25. Ultrasound cystodyanamogram • Ultrasound scan of urinary tract is combined with a flow rate to provide more practical information of bladder function. This investigation is performed routinely to all patients with lower urinary tract symptoms
  26. 26. Urethral pressure measurement • Research tool • Urethral pressure measurement and the Urethral Pressure Profile are techniques used to provide information about the ability of the urethra to prevent leakage. • Urethral pressure can be measured with balloon catheters, membrane catheters, perfusion techniques, or micro-transducers
  27. 27. • The urethral pressure profile (UPP) is another procedure commonly used to measure the competency of the urethral sphincter (outflow resistance). • Urethral pressure profile (UPP) -- indicates the intraluminal pressure along the length of the urethra with the bladder at rest. • Pressure transmission ratio (PTR) -- is the increment in urethral pressure on stress as a percentage of the simultaneously reported increment in vesical pressure.
  28. 28. • Maximum urethral pressure (MUP) -- is the maximum pressure of the measured profile. Maximum urethral closure pressure (MUCP) -- is the difference between the maximum urethral pressure and the intravesical pressure. • Functional urethral length -- is the length of the urethra along which the urethral pressure exceeds the intravesical pressure • the anatomic urethral length is the total length of the urethra. •
  29. 29. Valsalva Leak Point Pressure VLPP • Measures the lowest abdominal pressure required during a stress activity (such as coughing) that would cause the urethra to open and, therefore, leak.
  30. 30. Cystometry • continuous measurement of the pressure/volume relationship of the bladder to assess sensations, detrusor activity, bladder capacity and bladder compliance. • All three pressure,1)Bladder pressure, 2)Abdominal pressure and3) detrusor pressure is recorded simultaneously during the test. • Video Cystometry : the bladder can be filled with contrast media, thus allowing the simultaneous screening of the , bladder and outflow tract during filling and voiding
  31. 31. • Bladder sensation is assessed by recording the volume at which the patient experiences: the first sensation of bladder fullness the first desire to void, and a strong desire to void and urgency.
  32. 32. MANAGEMENT
  33. 33. stepped approach 1- Conservative Treatments: •Dietary Modification and Weight Loss: • restriction or elimination of dietary caffeine acidic foods and beverages, including citrus fruits and juices Alcohol fluid intake • Decreasing late-afternoon or evening fluid intake is often advocated for elderly patients with nocturia. • Weight loss may also be helpful for some patients, particularly women with stress UI.
  34. 34. Nonpharmacologic Behavioral Therapy• Bladder retraining: • Timed voiding. • urgency control when urgency occurs, sit or stand quietly, focus on letting urge pass, do muscle contraction when no longer urgent walk slowly to the bathroom and void. • When no incontinence for 2 d, increase voiding interval by 30-60 min until voiding every 3-4 h. • prompted toileting for cognitively impaired individuals: ( ask if patient needs to void, take them to toilet) starting at 2 to 3 hour intervals during day; encourge patients to report continence status; praise patients when continent and responds to toileting. • Pelvic Floor Muscle Exercises (+ Biofeedback training) (Kegel‘s) exercises-isolate pelvic muscles (avoid thigh, rectal , buttocks contractions, 3-4 times/wk for at least 15-20 wk. vaginal weights are an alternative for strengthening pelvic muscles
  35. 35. Pessaries may benefit women with vaginal or uterine prolapse who experience retention or stress UI. DHIC: Treat urge first with behavioral methods; may add detrusor muscle relaxing medications but follow postvoid residual; clean intermittent self-catheterization if needed
  36. 36. Nocturnal Frequency : Two voidings per night is probably normal for older adults. If between bedtime and awaking, the patient voids more than one third of his or her total 24-hr output , this is excessive fluid excretion. All patients should restrict fluid intake 4 h before bedtime. If stasis edema is present , patient should wear pressure graded stockings. a potent , short acting loop diuretic can be used in the afternoon or early evening to induce a diuresis before bedtime, eg, bumetanide 0.5-1.5 mg titrated to achieve a brisk diuresis. Evaluate for other factors contributing to volume overload or diuresis (eg, HF, poorly controlled diabetes).
  37. 37. Pharmacologic Therapy • Eliminate medications causing UI if possible. • Benefit of topical postmenopausal estrogen therapy in urge and possibly stress UI are limited. • Medications as Oxybutynin, Tolterodine, Trospium can be used but with common adverse effects as constipation, dry mouth, delirium , dyspepsia and headache, also should be used with caution in patients with liver dysfunction.
  38. 38. Surgical Therapy: Sling Procedures. Bulking Agent Injection Therapy. Neuromodulation.
  39. 39. Catheter • Catheter should be used only for chronic urinary retention, to protect pressure ulcers and when requested by patients or families to promote comfort ( eg, at end of life).
  40. 40. Pads and Absorbent Products • they do not cure incontinence and are generally not regarded as an ideal form of therapy.
  41. 41. Thank you