IncontinenceMarc Evans M. Abat, MD, FPCP, FPCGM    Internal Medicine-Geriatric Medicine
Definition and EpidemiologyUrinary incontinence  Involuntary loss of urine in sufficient amount or   frequency to be a s...
Jackson, RA et al. 2004. Urinary  Incontinence in Elderly Women: Findings  From the Health, Aging, and Body  Composition S...
21% reported incontinence at least weekly42% reported predominantly urge incontinence and 40% reported stressNearly twi...
Factors associated with urge incontinence  white race (odds ratio OR 3.1, 95% confidence   interval CI 2.0–4.8)  diabet...
Factors associated with stress incontinence  chronic obstructive pulmonary disease (OR 5.6,   95% CI 1.3–23.2)  white r...
Pathophysiology and ClassificationContinence requires…  Functioning lower urinary tract  Adequate cognitive and physica...
Urination is a complex process and incompletely understoodInfluence by higher centers in the brainstem, cerebral cortex ...
Urination reflex  centered in the sacral micturition center  Afferent pathway (somatic and autonomic)   carry bladder ...
Normal urination is a dynamic process  During filling, pressure remains low (<15 cm)  First urge usually at 150-250 cc ...
Basic CausesUrologic, neurologic, psychological and functional factors may contribute↓bladder capacity, ↑residual urine,...
Involuntary bladder contractions + impaired mobility  a substantial proportion of incontinent elderlyDecline in bladder...
In men, related to prostatic enlargement  Associated nocturia, low urine flow rate and   detrussor instability  leads t...
Acute and reversible causesAcute incontinence  Sudden onset, related to acute illness or   iatrogenesis and subsides onc...
Condition                         ManagementConditions affecting lower urinarytractUTI                                  An...
Persistent incontinenceSeveral types which may occur in combination in a patientBasic types  Stress  Urge  Overflow  ...
2 basic abnormalities in these types  Failure to store urine  Failure to fully empty the bladder
Definition                                    CausesStress                                  Weakness of pelvic floor muscl...
EvaluationIncludes thorough history, PE, urinalysis and postvoid residual determinationObjectives  Identify potentially...
 All patients    History, PE, urinalysis, postvoid residual determination Selected patients    Lab studies       Urin...
Patient history should also include  Characteristic of incontinence: timing,   frequency, amount  symptoms of voiding d...
PE should include   Abdominal, rectal, genital exam   Exam of lumbosacral innervation   In women, examine for POP, inf...
Urinalysis  Clear relationship between incontinence and   UTI  Controversial for asymptomatic bacteriuria    No benefi...
Postvoid determination  May be done using UTZ  Done within a few minutes of a spontaneous   (continent or incontinent) ...
Criteria                       Definition                      RationaleHistoryRecent lower urinary tract or   Surgery or ...
Criteria            Definition                 RationaleUrinalysisHematuria               >5 RBCS per HPF in the    Pathol...
ManagementAcute incontinence in elderly in acute care   Catheterization   Toilet accessibility or substitutes   Bed pa...
Behavioral interventionsMay be patient-dependent or caregiver- dependent  Goal of the former is to restore normal voidin...
Patient-dependent interventions  Require a functional and motivated patient and   a skill trainer  Relies on education,...
Biofeedback  Use recordings of bladder, rectal or vaginal pressure   or electrical activity to train patients to contrac...
Hay-Smith EJC, and C. Dumoulin. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urin...
To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatmen...
Caregiver-dependent interventions  Prevent incontinence episodes  Motivated caregivers are essential  Includes schedul...
Prompted voiding  Involves focusing the patient’s attention on their   bladders and prompting the patient to attempt   v...
JAMA, February 25, 2004—Vol 291, No. 8 989
Drug TreatmentPrescribed in conjunction with one or more behavioral interventionsFor urge incontinenceanticholinergic a...
Stress incontinencecombination of α-agonist and estrogen   Pseudoephedrine most commonly used   Appropriate for patien...
May combine several drug classes for mixed incontinenceDrug therapy for chronic overflow incontinence not usually effect...
Surgery and periurethral injectionElderly women with stress incontinence who are  Unresponsive to nonsurgical treatment ...
Indicated in men whose incontinence is associated with outflow obstruction  Complete retention  Those with significant ...
Catheters and Catheter Care3 basic types  External catheters  Intermittent straight catheterization  Chronic indwellin...
External catheters  In males, consists of a form of condom  Increased risk of developing symptomatic   infections  For...
Intermittent catheterization  Can be done 2-4x daily  Goal is to keep residual urine to <300 cc  Straight catheter sho...
Chronic indwelling catheterization  Indications    Urinary retention causing persistent overflow     incontinence, cann...
Increased complications like  Chronic bacteriuria  Bladder stones  Periurethral abscess
Fecal IncontinenceLess commonUnusual in elderly patients who are continent of urine30-50% of institutionalized patients...
Causes Fecal impaction Constipation Laxative abuse or overuse Hyperosmotic enteral feedings Neurologic disorders (e....
Evaluation  Detailed history  PE should include perineal examination and   DRE    Done on left lateral or decubitus po...
Diagnostic Testing  Anorectal manometry-assess sphincter tone   and strength  Anorectal ultrasound-assess structural in...
General Measures  Incontinence pads  Barrier preparations like zinc oxide  Topical antifungals for perineal fungal inf...
Biofeedback  To improve perception of rectal sensation and   responsiveness of the rectal sphincter  However most studi...
Surgical methods  Anal sphincteroplasty    Effective for acute fecal incontinence; uncertain     effectivity and durabi...
Surgical replacement using surrounding   muscles and implantation of a stimulator   (dynamic graciloplasty)  Pelvic floo...
Incontinence
Incontinence
Incontinence
Incontinence
Incontinence
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Incontinence

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Overview of incontinence in the elderly.

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Incontinence

  1. 1. IncontinenceMarc Evans M. Abat, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine
  2. 2. Definition and EpidemiologyUrinary incontinence Involuntary loss of urine in sufficient amount or frequency to be a social and/or health problemIncreases with ageWomen (30%)> men (15%)As much as 60% among nursing home elderly
  3. 3. Jackson, RA et al. 2004. Urinary Incontinence in Elderly Women: Findings From the Health, Aging, and Body Composition Study. Obstet Gynecol 104: 301–7.
  4. 4. 21% reported incontinence at least weekly42% reported predominantly urge incontinence and 40% reported stressNearly twice as many white women as black women (27% versus 14%, P < .001)
  5. 5. Factors associated with urge incontinence white race (odds ratio OR 3.1, 95% confidence interval CI 2.0–4.8) diabetes treated with insulin (OR 3.5, 95% CI 1.6 –7.9) depressive symptoms (OR 2.7, 95% CI 1.4 – 5.3) current oral estrogen use (OR 1.7, 95% CI 1.1– 2.6) arthritis (OR 1.7, 95% CI 1.1–2.6) decreased physical performance (OR 1.6 per point on 0–4 scale, 95% CI 1.1–2.3)
  6. 6. Factors associated with stress incontinence chronic obstructive pulmonary disease (OR 5.6, 95% CI 1.3–23.2) white race (OR 4.1, 95% CI 2.5– 6.7) current oral estrogen use (OR 2.0, 95% CI 1.3– 3.1) Arthritis (OR 1.6, 95% CI 1.0 –2.4) high body mass index (OR 1.3 per 5 kg/m2, 95% CI 1.1–1.6).
  7. 7. Pathophysiology and ClassificationContinence requires… Functioning lower urinary tract Adequate cognitive and physical functioning Motivation Appropriate environment
  8. 8. Urination is a complex process and incompletely understoodInfluence by higher centers in the brainstem, cerebral cortex and cerebellum Cerebral cortex  predominantly inhibitory Brainsterm  facilitates urination
  9. 9. Urination reflex  centered in the sacral micturition center Afferent pathway (somatic and autonomic) carry bladder filling info to the spinal cord Sympathetic tone  closes bladder neck and inhibits parasympathetic tone (bladder dome relaxes) Pelvic muscle tone maintained  also inhibits parasympathetic tone On urination, the reverse occurs
  10. 10. Normal urination is a dynamic process During filling, pressure remains low (<15 cm) First urge usually at 150-250 cc Normal bladder capacity 300-600cc Detrussor muscle contracts and exceeds urethral resistance  urine flow
  11. 11. Basic CausesUrologic, neurologic, psychological and functional factors may contribute↓bladder capacity, ↑residual urine, ↑prevalence of involuntary bladder contractions In 40-75% of incontinent elderly But also 5-30% of continent elderly
  12. 12. Involuntary bladder contractions + impaired mobility  a substantial proportion of incontinent elderlyDecline in bladder outlet and urethral resistance in women Relate to laxity of pelvic muscle due to childbirth, obesity, deconditioned muscles, and hysterectomy
  13. 13. In men, related to prostatic enlargement Associated nocturia, low urine flow rate and detrussor instability  leads to overflow and/or urge incontinenceIn both sexes, detrussor hyperactivity with impaired contractility
  14. 14. Acute and reversible causesAcute incontinence Sudden onset, related to acute illness or iatrogenesis and subsides once cause is resolvedPersistent incontinence Unrelated to an acute cause and persist over time
  15. 15. Condition ManagementConditions affecting lower urinarytractUTI AntibioticsAtrophic vaginitis/urethritis Topical estrogenPostprostatectomy Behavioral, avoid more surgeryStool impaction Disimpaction, fiber intake, etc.Drug side effects Discontinue or change drug therapyIncreased urine productionMetabolic (hyperglycemia, Treat DM, treat cause of hypercalcemiahypercalcemia)Excess fluid intake Reduce intake of diuretic fluidsVolume overload Medical and supportive therapyImpaired ability or willingness toreach toiletDelirium Diagnosis or treatment of causeChronic illness or immobility Regular toileting, environment alteration Appropriate therapypsychological
  16. 16. Persistent incontinenceSeveral types which may occur in combination in a patientBasic types Stress Urge Overflow Functional
  17. 17. 2 basic abnormalities in these types Failure to store urine Failure to fully empty the bladder
  18. 18. Definition CausesStress Weakness of pelvic floor muscles andInvoluntary loss of urine with urethral hypermobilityincreases in abdominal pressure Bladder outlet or urethral sphincter weakness(e.g. coughing) PostprostatectomyUrge Detrussor hyperactivity, isolated or with theleakage of urine due to inability to following: local genitourinary condition, CNSdelay voiding after sensation of disordersbladder fullness is perceivedOverflow Anatomic obstructionUrine leakage from mechanical Acontractile bladder due to DM or SCIforces on an overdistended bladder Detrusor-sphincter dyssynergy associatedor other effects of urinary retention with MS or other suprasacral spinal lesionson bladder and sphincter function Medication effectFunctional Severe dementia and other neurologicalAssociated with inability to toilet disordersdue to impaired cognition or Depressionphysical functioning and hostilityenvironmental barriers orpsychological unwillingness
  19. 19. EvaluationIncludes thorough history, PE, urinalysis and postvoid residual determinationObjectives Identify potentially reversible conditions Identify conditions that require further diagnostic test or urologic/gynecologic evaluation Develop a management plan
  20. 20.  All patients  History, PE, urinalysis, postvoid residual determination Selected patients  Lab studies Urine culture, urine cytology, serum glucose and calcium, renal function tests, renal ultrasound  Gynecologic evaluation  Urologic evaluation  Cystourethroscopy  Urodynamic tests Simple • Observation of voiding • Cough test for stress incontinence • Simple cystometry • Urine flowmetry (for men) Complex • Multichannel cystometrogram • Pressure-flow study • Leak point pressure • Urethral pressure profilometry • Sphincter electromyography • videourodynamics
  21. 21. Patient history should also include Characteristic of incontinence: timing, frequency, amount symptoms of voiding difficulty: hesitancy, intermittent voiding, straining to void Symptoms of stress vs urge incontinence
  22. 22. PE should include  Abdominal, rectal, genital exam  Exam of lumbosacral innervation  In women, examine for POP, inflammation suggestive of atrophic vaginitis  Cough test Leakage with coughing documents stress incontinence Delayed leakage (>3 seconds after) indicates cough- induced bladder contraction  Mobility and mental status  In patients with nocturia, examine for CHF or venous insufficiency
  23. 23. Urinalysis Clear relationship between incontinence and UTI Controversial for asymptomatic bacteriuria No benefit in treating nursing home elderly with stable bacteriuria May be reasonable to treat initially in non- institutionalized patients
  24. 24. Postvoid determination May be done using UTZ Done within a few minutes of a spontaneous (continent or incontinent) void <100 cc in the absence of straining generally reflect adequate bladder emptying >200 cc is abnormal
  25. 25. Criteria Definition RationaleHistoryRecent lower urinary tract or Surgery or irradiation within Structural abnormality related pelvic surgery/iiradiation the past 6 months to the procedureRecurrent symptomatic UTI 3 or more symptomatic Structural abnormality episodes in 12 months predisposing to UTIPhysical ExaminationMarked POP Prominent cystocele Abnormality may underlie the descending entire height of pathophysiology of vaginal vault with coughing incontinence; may benefit on speculum exam from surgery Gross enlargement on DRE; Evaluation to exclude cancerProstatic enlargement or induration or assymetry of possible cancer lobesPostvoid residualDiffuculty inserting 14F Unable to pass through, Anatomick block of the straight catheter requiring more force or urethra or bladder larger, stiffer catheterResidual >200cc Anatomic or neurogenic obstruction
  26. 26. Criteria Definition RationaleUrinalysisHematuria >5 RBCS per HPF in the Pathology of urinary tract absence of UTI should be excludedTherapeutic TrialFailure to respond Persistence of symptoms Urodynamic evaluation after adequate trial
  27. 27. ManagementAcute incontinence in elderly in acute care  Catheterization  Toilet accessibility or substitutes  Bed pads or diapers  Causes or contributing factors should be treatedSupportive measures  Education  Environment manipulation  Avoidance of iatrogenesis  Modification of fluids and diuretics  Skin care
  28. 28. Behavioral interventionsMay be patient-dependent or caregiver- dependent Goal of the former is to restore normal voiding and continence The latter is to keep patient and environment dry
  29. 29. Patient-dependent interventions Require a functional and motivated patient and a skill trainer Relies on education, counselling and frequent patient contact Kegel exercises are effective for stress, urge or mixed incontinence 3-5 sets of 10 contractions throughout the day, each contraction 3-10 seconds in duration
  30. 30. Biofeedback Use recordings of bladder, rectal or vaginal pressure or electrical activity to train patients to contract pelvic floor muscles with the abdominal muscles relaxed Limited by requirement for equipment and trained personel; may also be invasive and unacceptableBladdder training Uses the pelvic muscle exercises and strategies to manage urgency Persistence of voiding difficulties despite the protocol should prompt urologic referral
  31. 31. Hay-Smith EJC, and C. Dumoulin. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654
  32. 32. To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments.403 women in six trials of varying age and types of incontinenceUse of PFMT lead to more reports of cureGreater benefit in younger populationsStudies heterogenous and needs further investigation
  33. 33. Caregiver-dependent interventions Prevent incontinence episodes Motivated caregivers are essential Includes scheduled toileting, habit training and prompted voiding Scheduled toileting Putting the patient to toiletting at scheduled intervals regardless of expressed desire to void Habit training A schedule of toileting based on patient’s pattern of continent voids and incontinent episodes
  34. 34. Prompted voiding Involves focusing the patient’s attention on their bladders and prompting the patient to attempt voiding and giving feedback by personal interaction
  35. 35. JAMA, February 25, 2004—Vol 291, No. 8 989
  36. 36. Drug TreatmentPrescribed in conjunction with one or more behavioral interventionsFor urge incontinenceanticholinergic and bladder smooth muscle relaxants 60-70% reduction in incontinence episodes Systemic anticholinergic side effects (constipation, dry mouth, urinary retention); drug-induced delirium in patients with dementia
  37. 37. Stress incontinencecombination of α-agonist and estrogen  Pseudoephedrine most commonly used  Appropriate for patients With mild to moderate stress incontinence No major anatomic abnormality like cystocele No contraindication to these drugs, e.g. poorly controlled hypertension  Estrogen (topical or oral) combined with α-agonists also effective in women with atrophic vaginitis and urethritis 0.5-1.0 g vaginal cream@HS x 1-2 months
  38. 38. May combine several drug classes for mixed incontinenceDrug therapy for chronic overflow incontinence not usually effective
  39. 39. Surgery and periurethral injectionElderly women with stress incontinence who are Unresponsive to nonsurgical treatment With significant degree of pelvic organ prolapse (POP) Range from periurethral collagen injections and neck suspension to sling procedures Periurethral injection for those with intrinsic urethral weakness
  40. 40. Indicated in men whose incontinence is associated with outflow obstruction Complete retention Those with significant residuals causing recurrent UTI and hydronephrosis Decision should be based on degree of symptomatology, benefits and risks
  41. 41. Catheters and Catheter Care3 basic types External catheters Intermittent straight catheterization Chronic indwelling catheterization
  42. 42. External catheters In males, consists of a form of condom Increased risk of developing symptomatic infections For intractable incontinence in males without retention and are physically dependent Safety and effectiveness in females is not well document in the elderly population
  43. 43. Intermittent catheterization Can be done 2-4x daily Goal is to keep residual urine to <300 cc Straight catheter should be kept clean (not necessarily sterile) Practical and reduces risk of symptomatic infection compared to chronic catheterization Presence of anatomic abnormalities increase risk of infection in the elderly Risk of nosocomial infection also high in institutional settings
  44. 44. Chronic indwelling catheterization Indications Urinary retention causing persistent overflow incontinence, cannot be corrected surgically or medically and cannot be managed practically by intermittent catheterization Wounds or ulcers contaminated by urine Patient preference Care of terminally ill or severely impaired patients in whom bed and clothing changes are disruptive or uncomfortable
  45. 45. Increased complications like Chronic bacteriuria Bladder stones Periurethral abscess
  46. 46. Fecal IncontinenceLess commonUnusual in elderly patients who are continent of urine30-50% of institutionalized patients with urinary incontinence also have fecal incontinence
  47. 47. Causes Fecal impaction Constipation Laxative abuse or overuse Hyperosmotic enteral feedings Neurologic disorders (e.g. dementia, stroke, spinal cord disease) Colorectal disorders (e.g. diarrheal diseases, diabetic autonomic neuropathy, rectal sphincter damage)
  48. 48. Evaluation Detailed history PE should include perineal examination and DRE Done on left lateral or decubitus position Examine for hemorrhoids, patulous anus (indicates denervation), anal deformities or anal dermatitis Test for excessive perineal descent or rectal prolapse by asking patient to strain Test for anocutaneous reflex Examination of the rectal vault
  49. 49. Diagnostic Testing Anorectal manometry-assess sphincter tone and strength Anorectal ultrasound-assess structural integrity EMG-rules out denervation Barium proctography Dynamic pelvic MRI
  50. 50. General Measures Incontinence pads Barrier preparations like zinc oxide Topical antifungals for perineal fungal infections
  51. 51. Biofeedback To improve perception of rectal sensation and responsiveness of the rectal sphincter However most studies have imprecise endpoints and lacked sham controls No superiority over conservative measures No difference between instrumental and non- instrumental biofeedback
  52. 52. Surgical methods Anal sphincteroplasty Effective for acute fecal incontinence; uncertain effectivity and durability in chronic incontinence May have failure rates as high as 50% after 5 years Antegrade colonic irrigation by a cecostomy/appendicostomy Optimal for those with neurogenic fecal incontinence and anorectal deformities Can be complicated by stenosis and infection
  53. 53. Surgical replacement using surrounding muscles and implantation of a stimulator (dynamic graciloplasty) Pelvic floor muscle repair Diverting colostomySacral nerve stimulation

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