The Urinary problems associated with Geriatrics is described.

1. Urinary Function &
Dysfunction
DR ANEEQA AQDAS
HU LAHORE

2.  Continence:
 Normal ability of a person to store urine and faeces temporarily,
with conscious control over the time and place of micturition and
defaecation.
 Continence of urine and faeces is fundamental to:
 Sociological
 Psychological
 Physical well-being
 Infants do not have such control, but develop the neurological
maturity and form the habits necessary, usually by 3 or 4 years of
age.

3.  Incontinence:
 Involuntary or inappropriate passing of urine or faeces, or
both.
 Incontinence is a symptom or a sign with a cause, not a
condition or a specific disease
 May be a temporary state associated with a transient cause:
 Transient unconsciousness
 Infection
 Drug side-effects
 May be persistent resulting from longer-lasting or even
permanent causes:
 Trauma in childbirth
 Stroke

4. Normal Lower Urinary Tract Function
 The Micturition Cycle:
 Consists of two phases:
Bladder filling
The detrusor muscle is compliant
The first mild desire to void is
commonly felt at volume of 150–
200mL
Bladder emptying

5.  Eventually, with increasing stored volume, the
pressure within the bladder begins to rise and the
sensation of fullness becomes more consciously
apparent and persistent. A decision to void is
taken, a socially acceptable site is found and
necessary preparations are made.
 The levator ani and urethral sphincter muscles
relax and then the detrusor muscle contracts. On
completion of the void the levator ani and
sphincter muscle contract and the detrusor
muscle stops contracting and is ready to store
again.

6. Normal Lower Urinary Tract Function
 Storage Of Urine:
 Elastic ability of the bladder to accommodate an increasing
volume of fluid without a rise of pressure is called
Compliance.
 The normal bladder’s compliance accommodates and stores
the incoming urine without a significant rise in pressure
within the bladder.
 The effective pressure in the bladder is produced by the
bladder wall and is usually less than 15cm H2O.
 Reflux of urine up the ureters is prevented by peristaltic
waves of muscular contraction that pass down the walls of
the ureters.

7.  Voiding Of Urine:
 Normally achieved by voluntary, cortically
mediated relaxation of:
External urethral sphincter
Levator ani muscles
 Followed by a detrusor contraction
 In the absence of stressful environmental or other
factors (e.g. urethral obstruction), the detrusor
contraction, combined with the normal slight
shortening and opening up of the relaxing urethra,
empties the bladder in a continuous steady stream in
a short time.

8.  Contraction of the detrusor also opens up the
bladder neck so that urine is funnelled into the
relaxed urethra.
 When micturition is complete, the PFMs and
urethral sphincter contract and the detrusor
muscle relaxes ready for the next storage phase,
and the bladder base returns to its higher
position. Some women develop the habit of
bearing down or contracting the abdominal
muscles, or both, at the end of micturition in an
attempt to squeeze out a final drop

9. Neurological Control of Continence
 Continence is controlled neurologically at three
levels:
 Spinal
 Pontine
 Cerebral
 A combination of somatic and autonomic pathways
 Urine is stored and micturition initiated periodically,
usually four to six times a day.

10. Factors – Normal Urinary Function
 The bladder and urethra are structurally sound and healthy.
 The nerve supply to the bladder, urethra, external sphincter and
PFM is intact.
 The bladder is positioned and tethered so the neck is well
supported and able to close, and the urethra is not kinked.
 The bladder is positioned and supported high enough in the
abdominal cavity that intra-abdominal pressure is transmitted
both to it and to the proximal portion of the urethra.
 Bladder size and capacity are normal.
 There are no pathological changes in surrounding structures

11. Factors – Normal Urinary Function
 The woman has the ability to move sufficiently quickly
and freely to a socially acceptable site in order to void.
 The woman is able to adjust clothing and position
herself for voiding unaided.
 The woman does not suffer from faecal impaction, for
this can cause urinary incontinence.
 The woman is in good general physical health, alert,
and free from confusion, depression or serious stress.
 There is a fluid intake of about 1 and 1⁄2 litres per day,
and avoidance of excess alcohol or caffeine.

12. Lower Urinary Tract Dysfunction
 Storage symptoms:
 Experienced during the storage phase
Abnormal bladder sensations
Frequency
Urgency
Leakage of urine etc.

13. Lower Urinary Tract Dysfunction
 Voiding symptoms:
 Experienced during the voiding phase
 Include any description or deviation from a speedy and
continuous flow of urine
 A slow or intermittent stream
 Hesitancy at the start of micturition
 Terminal dribble etc.
 Postmicturition symptoms:
 Experienced immediately after micturition
 A feeling of incomplete emptying
 Postmicturition dribble etc.

14. Lower Urinary Tract Dysfunction
 Some Useful Definitions:
 Enuresis:
 Involuntary loss of urine.
 Nocturnal enuresis:
 Involuntary loss of urine during sleep.
 Nocturia:
 Individual has to wake at night one or more times
to void.
 It is different from a habit of always waking at a
certain time to void

15. Lower Urinary Tract Dysfunction
 Increased daytime frequency (pollakisuria):
 The complaint by patients who consider that they void too
often during the day.
 Frequency as the passage of urine seven or more times during
the day, or the need to wake more than twice at night to
void.
 Urgency:
 A compelling desire to pass urine which is difficult to control.
 A normal desire to void:
 The feeling that leads a person to pass urine at the next
convenient moment, but voiding can be delayed if necessary.

16. Lower Urinary Tract Dysfunction
 The urinary voiding stream:
 Slow, spitting or spraying, or intermittent
 Stops and starts.
 Hesitancy:
 Difficulty in initiating flow.
 Dysuria:
 Pain on passing urine.
 A postvoid residual (PVR):
 The volume of urine left in the bladder at the end of
micturition.

17. Incontinence Of Urine
 Groups of patients referred to the physiotherapist
are those with storage symptoms resulting in urine
leakage.
 Involuntary urinary leakage may be a symptom of
which the patient complains or a sign seen on
examination, which may be urethral or
extraurethral leakage.

18. Common Types Of Urinary
Incontinence
 Extraurethral incontinence
 Loss of urine through channels other than the
urethra is called extraurethral incontinence.
 Fistulae between the bladder or urethra
 vaginal trauma at pelvic surgery such as
hysterectomy
 endometriosis
 Infection
 carcinoma.

19.  Detrusor overactivity incontinence
 (symptom)
 Patient with detrusor overactivity complains of urge incontinence,
which is involuntary leakage of urine accompanied by or
immediately preceded by urgency.
 (Sign)
 Detrusor overactivity is confirmed as a sign and observed at
urodynamic assessment as spontaneous or provoked detrusor
contractions during the filling phase.
 (Condition)
 Detrusor overactivity may be further qualified as neurogenic,where
there is a relevant neurological condition, or as idiopathic, when
there is no known cause.

20.  TREATMENT:
 The pharmacotherapy brings the possibility of side-
effects (e.g. a dry mouth, constipation) and is
poorly tolerated by some patients. An alternative
therapy, which is successful in some cases, is
continuous electrical stimulation with a pulse
duration of 500s at 5–10 Hz applied daily for 20–30
minutes

21.  Urodynamic stress incontinence
 (The symptom). The patient complains of
incontinence on stress, that is,when the intra-
abdominal pressure is raised by exertion or effort
(e.g.sneezing, coughing or walking).
 (The sign). An involuntary spurt, dribble or droplet
of urine is observed to leave the urethra immediately
on an increase in intra-abdominal pressure (e.g.
when coughing).
 (The condition). Urodynamic stress incontinence
(USI) is the name coined to denote the condition in
which there is involuntary loss of urine when, in the
absence of a detrusor contraction, the intravesical
pressure (pressure in the bladder) exceeds the
maximum urethral pressure

22.  Mixed urinary incontinence is the complaint of
involuntary leakage associated with urgency and also with
exertion, effort, sneezing or coughing.
 Below are the factors of Weakness and sagging of the
pelvic floor on which physiotherapists have concentrated
their attention.
I)Trauma to muscle or adjacent tissues (e.g. from abuse,
surgery or childbirth)
ii)Damage to the nerve supply to the sphincter or levator ani
muscle (e.g. from surgery, stretching or tearing at
childbirth)
iii)Weakness from underuse (the patient may sit around all
day, perhaps suffering from depression)
iv)Stretching from overuse (e.g. repeated coughing,
straining at the stool because of constipation, heavy lifting
or obesity).

23. Nocturnal enuresis
 Nocturnal enuresis is urinary incontinence during
sleep, or ‘bed wetting’ at an age when a person
could be expected to be dry – usually agreed to
be the developmental age of 5 years.
 The vast majority of children who suffer from
nocturnal enuresis are dry by puberty but the
condition causes great psychological suffering
and social deprivation.

24.  Giggle incontinence
 Girls in particular go through a giggling phase
around puberty, if not before.
 It is thought that giggle incontinence is caused by
detrusor overactivity induced by laughter.
 There is often a positive family history of this
problem.
 Not only should the girl practise PFM exercise
regularly to build up strength and endurance but she
should be encouraged to develop the habit of
contracting these muscles before and while giggling.

25.  Incontinence associated with sexual
activity
 The urethra and bladder lie in close proximity to the
vagina; thus sexual activity can cause urinary
symptoms and lower urinary tract dysfunction, and
this in term may give rise to sexual problems.
 Honeymoon cystitis’or postcoital dysuria, with and
without infection, is common in young women, and
dysuria, urgency and urinary tract infections are
noted by postmenopausal women following
intercourse.

26. VOIDING DIFFICULTIES
 Urine is stored in the bladder and may have difficulty
in escaping. In simple cases this may be due to faecal
impaction, to a large cystocoele kinking the urethra,
to inhibition due to an unsuitable environment, or to
the patient crouching over the toilet.
 More complex problems arise if either the nerve
supply to the detrusor is impaired so it does not
contract or does so too weakly; or the detrusor is so
stretched by virtue of the volume of urine, caused by
the urethra being obstructed, that it cannot contract
effectively.

27.  Urethral dyssynergia, which occurs often with
multiple sclerosis, is a condition in which the
urethral musculature does not relax when the
detrusor contracts for voiding. The result may be
chronic urinary retention
 Eventually the pressure in the bladder rises and
overcomes the urethra closure pressure, and urine
is passed in small amounts as a dribble or spurt,
often on movement or effort,

28. PHYSIOTHERAPY TREATMENT
 For patients with stress urinary incontinence
 If no VPFMC is possible then biofeedback and
electrical stimulation should be considered. If
VPFMC is possible then patients should be
taught ‘the knack’(skills to do something) and
encouraged to follow an intensive programme
of daily exercise individually designed to
increase the strength and endurance of their
PFM

29.  For patients with urgency or urge
incontinence, or both
 Assuming VPFMC is possible, patients should be taught
deferment techniques such as ‘the knack’, series of repeated
strong PFM contractions, distraction, or perineal pressure,
and encouraged to desist from going ‘to the loo just in case’,
to increase the period between voids. In addition, patients
will probably be receiving pharmocotherapy.
 Some patients find the side-effects of medication too
unpleasant to continue; others seem not to benefit at all