Urinary Incontinence

1. Kathleen Pace Murphy, PhD, MS, APRN
Assistant Professor, UT Medical School
Geriatric and Palliative Medicine

2. Prevalence
 Increases with age and affects women more than men
(2:1) until age 80
 15-30% in community dwellers age 65 and older
 60-70% in older adults age 65 and older in long term
care
 Significantly impairs quality of life

3. Risk Factors
 Obesity
 Functional impairment
 Dementia
 Medications
 Environmental barriers to toilet access

4. Age related LUT changes
 Bladder contractility decreases
 Uninhibited bladder contractions increase
 Diurnal urine output occurse later in day
 Bladder capacity decreases
 Sphincteric striated muscle attenuates
 PVR increases

5. Age related LUT changes- Women
 In addition to the physiologic changes already
discussed:
 Urethral closure pressure decreases
 Vaginal mucosal atrophy

6. Age related LUT changes- Men
 In addition to the physiologic changes already
discussed:
 Benign prostatic hyperplasia
 Prostate hypertrophy

7. LUT Pathophysiology in UI
Urge UI
 Urge UI with detrusor overactivity (uninhibited
bladder contractions)
 40% on urodynamic testing
 Suggest detrusor overactivity PLUS impaired
compensatory mechanisms.
 Idiopathic, age-related, secondary to lesions in
cerebral and spinal pathways.
 Due to bladder outlet obstruction or bladder irritation
(infection, stones, tumor)

8. LUT Pathophysiology in UI
Stress UI
 Etiology
 Damage to the pelvic floor supports
 Sphincter failure
 Leakage associated with coughing,
sneezing, laughing, physical activity
 Second most common form in
women
 Seen in men after prostectomy

9. LUT Pathophysiology in UI
Mixed UI with both detrusor overactivity
and impaired sphincter support
 Leakage occurs with both urgency and activity
 Seen in women

10. LUT Pathophysiology in UI
UI with impaired bladder emptying
 Increase PVR (200mL)
 Intermittent small dribbling
 Frail elderly: coexistence of urge UI and PVR (in the
absence of bladder outlet obstruction)= detrusor
hyperactivity with impaired contractility (DHIC)
 Men
 prostate hypertrophy
 Women
 urethral surgical scarring
 Large cytocele/prolapse

11. UI Screening and Evaluation
 Multifactorial evaluation
 Comorbidity
 Funciton
 Medication
 Questions to ask
 Do you have any problems with bladder control?
 Do you have any problems making it to the bathroom on
time?
 Do you ever leak urine?

12. Medications Associated with UI
 Alcohol
 Alpha-adrenergic agonists
 Alpha-adrenergic blockers
 ACE Inhibitors
 Anticholinergic
 Antipsychotics
 CCB
 Cholinesterase inhibitors
 Estrogen
 Gabapentin
 Loop diuretics
 Narcotics
 NSAIDs
 Sedative hypnotics
 Thiazolidinediones
 TCA

13. UI Red Flags
 Abrupt onset
 Pelvic pain (constant, worsened, or improve with
voiding)
 Hematuria

14. Physical Examination
 Rectal Exam
 Masses, fecal loading, prostate nodules or firmness
 Neuro Exam
 Sacral cord integrity (sensory)
 Perianal wink (motor)
 Pelvic Exam
 Labial and vaginal lesions
 Pelvic organ prolapse
 Psychological Exam
 Association between depression and UI
 Sleep apnea- nocturia association

15. Diagnostic Testing
 Urinalysis
 Hematuria, glycosuria
 Bladder diaries (time, volume & UI episode x 48 hr)
 Urodynamics
 Only in uncertain diagnosis

16. UI Treatment and Management
 Lifestyle Management
 Weight loss (SOE=A)
 Extreme fluid intake
 Limit caffinated beverages
 Limit ETOH
 Limit evening fluid intake
 Quit smoking (stress UI)

17. UI Treatment and Management
 Behavioral Therapies
 A. Bladder training and pelvic muscle exercises
 1. Effective urge, mixed, and stress UI (SOE=A)
 B. Prompt timed voiding in cognitively impaired
 C. Biofeedback for PME
 1. Medicare covers (SOE=Unkown)

18. Medications
Anti Muscarinics
 MOA
 Increase bladder capacity by decreasing basal excretion of Ach from
urothelium
 Contraindicated
 Narrow angle glaucoma
 Impaired gastric emptying
 Known urinary retention
 Patient taking cholinesterase inhibitor
 Drugs
 Oxybutynin
 Tolterodine
 Fesoterodine
 Trospium
 Darifenacin
 Solifenacin

19. Medications
 Rx UI and OAB
 MOA
 Stimulation of beta 3 receptors in the detruor mediates
bladder relaxation:
 Myrbetriq 25-50mg QD
 ADE
 Increase blood pressure
 Prescribe carefully in patient with renal and hepatic
impairment
 Many drug-drug AE like muscarins

20. Other Treatments
 Intravesical injection of botulinum toxin
 Sacral nerve neuromodulation
 Surgery (stress UI)
 Colpsuspension (Burch Operation)
 Slings (synthetic mesh, or autologus or cadaveric fascia)

21. References
 Flaherty E & Resnick B Geriatric Nursing Review Syllabus (4th Ed). New
York: American Geriatric Society; 2014.
 Gulur DM, Mevcha AM, Drake MJ. Nocturia as a manifestation of
systemic disease. BJU Int. 2011; 107 (50): 702-13.
 Ham, RJ, Sloan, PD, Warshaw, GA, Potter, JE & Flaherty E. Primary
Care Geriatrics: A case-based approach (6th Ed.). 2014. Philadelphia:
Elsevier Saunders.
 Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Strauss SE. What type
of urinariy incontinence does this woman have? JAMA, 2008 : 299:
1446-56.
 Landefeld CS, Bowers BJ, Feld AD et al. NIH state-of-the-science-
conference statement: Prevention of fecal and urinary incontinence in
adults. Ann Intern Med 2008:148: 449-58.
 Shamliyan T, Wyman J, Kane RL. Benefits and harms of pharmacologic
treatment for UI in women: A systematic review. Ann Intern Med 2012:
156(12): 861-74.