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Flashcards in Urinary Incontinence Deck (47):

prevalence of UI

o The prevalence of UI increases with age
o Affects more women than men (2:1)
o Affects men & women equally after age 80


Impact of UI on older adults

o Morbidity
o Cellulitis, pressure ulcers, UTIs
o Sleep deprivation, falls with fractures, sexual dysfunction
o Depression, social withdrawal, impaired quality of life
o Costs: $26 billion annually


Continence requires

o Mobility
o Manual dexterity
o Cognitive ability to recognize and react to bladder sensation
o Motivation to stay dry
o Absence of medical conditions and factors affecting bladder and general function
o Balance and coordination of bladder smooth muscle & urethral sphincter mechanisms, and their central & peripheral control


Normal micturition

Bladder smooth muscle (detrusor)
-Contracts via parasympathetic nerves (S2–S4)

Urethral sphincter
-Proximal urethral smooth muscle contracts via sympathetic stimulation (T11–L2)
-Distal urethral striated muscle contracts via cholinergic somatic stimulation (S2–S4)
-In women: musculofascia supports and compresses the urethra when abdominal pressure increases

Central nervous system coordination:
-Parietal lobes & thalamus receive and coordinate detrusor afferent stimuli
-Frontal lobes & basal ganglia provide signals to inhibit voiding
-Pontine micturition center integrates these inputs to coordinate urethral & detrusor function

Urine storage is under sympathetic control
-Inhibits detrusor contraction
-Increases sphincter contraction

Voiding is under parasympathetic control
-Induces detrusor contraction
-Induces sphincter relaxation


Age related changes that may lead to UI

o Detrusor overactivity
o Benign prostatic hyperplasia
o More urine output later in the day → taking more Lasix later in the day, etc.
o Atrophic vaginitis and urethritis
o Increased postvoid residual (PVR)
o Decreased ability to postpone voiding
o Decreased total bladder capacity
o Decreased detrusor contractility


UI: comorbid disease

-Diabetes – polyuria
-Congestive heart failure – Lasix is tx – polyuria
-Degenerative joint disease – too painful to walk to toilet
-Sleep apnea
-Severe constipation – whenever there’s constipation there’s an increase in intraabdominal pressure


UI: function and environment

-Impaired cognition
-Impaired mobility
-Inaccessible toilets
-Lack of caregivers


UI: neurological/psychiatric

-Parkinson’s disease
-Normal pressure hydrocephalus


medications commonly associated with UI

o Alcohol
o α-adrenergic agonists
o α-adrenergic blockers
o ACE inhibitors
o Anticholinergics
o Antidepressants
o Antipsychotics
o Calcium-channel blockers
o Loop diuretics
o Narcotic analgesics
o Sedative hypnotics
o Thiazolidinediones


clinical types of UI

3 types

-Urge – testing procedure for urge is the STRESS test (yes, confusing)
-Overflow: Outlet obstruction, Detrusor underactivity
-This is a spectrum – everyone here has had urge incontinence but not everyone has had stress incontinence (The spectrum is urge → stress → mixed)


urge incontinence

-Most common type of UI in older persons
-Signs and symptoms: Abrupt urgency, Frequency, Nocturia, Volume of leakage may be large or small
-Note: “Overactive bladder” refers to a condition with urgency, usually with frequency and nocturia, with or without UI


causes of urge incontinence

-Detrusor overactivity may be: Age-related, Idiopathic, Secondary to lesion in central inhibitory pathways (eg, stroke, cervical stenosis), Due to local bladder irritation (eg, bladder stones, infection, inflammation, tumors), Stress-related (occurs after a several-second delay following a stress maneuver)
-Less common causes: Interstitial cystitis, Spinal cord injury (Impaired detrusor compliance, Detrusor-sphincter dyssynergia)
-Urge incontinence triggered by stress related maneuvers


Stress incontinence

-Second most common type in older women
-Results from failure of sphincter mechanisms to preserve outlet closure during bladder filling – failure to close: Women do not have a prostate – the prostate acts as a secondary sphincter for men
-Occurs with increased intra-abdominal pressure, in the absence of a bladder contraction
-Often coexists with urge UI (mixed UI)
-Leakage is due to one or both mechanisms: Impaired pelvic supports (“Genuine” stress incontinence, Episodic leakage with increased abdominal pressure), Failure of urethral closure (Intrinsic sphincter deficiency from trauma; scarring from anti-incontinence surgery in women and prostatectomy in men, Continual leakage may occur while sitting or standing)


overflow incontinence

o Results from detrusor underactivity, bladder outlet obstruction, or both
o Leakage is small but continual; PVR is elevated
o Symptoms: dribbling, weak urinary stream, intermittency, hesitancy, frequency, nocturia
o Associated urge and stress leakage may occur
o Associated with bladder capacity, not control


outlet obstruction

o Second most common cause of UI in older men
o Most obstructed men are not incontinent
o Causes (men): BPH, prostate cancer, urethral stricture
o Uncommon in women; usually due to previous anti-UI surgery or large cystocele


detrusor underactivity

-Causes UI in 5%–10% of older adults
-Results from: Replacement of detrusor smooth muscle by fibrosis and connective tissue (eg, with chronic outlet obstruction), Neurologic causes (eg, peripheral neuropathy), Damage to spinal detrusor efferents (eg, from disc herniation, spinal stenosis, tumor)


Comprehensive assessment of UI includes

o History: including quality of life
o Physical examination: include cardiovascular, abdominal, musculoskeletal, neurologic, & genitourinary exams
o Testing: bladder diary, stress test, PVR, urinalysis, renal function
o Optional: urodynamics, cytology, other lab tests


Assessment: history

o Initiate discussion (50% do not report UI)
o Ask about specific symptoms: urgency (eg, with running water), frequency, nocturia, slow stream, terminal dribbling
o Determine UI characteristics: type (with urgency, stress maneuvers, insensate), onset, frequency, volume, timing, precipitants
o Identify associated factors: bowel & sexual function, medical conditions, medications
o Ask about quality of life: patient’s, caregiver’s


Assessment: physical

-General: cognitive and functional status
-Cardiovascular: volume overload, peripheral edema, congestive heart failure: Rales and edema
-Abdominal & rectal: masses, tenderness, rectal masses or impaction, rectal tone: Musculoskeletal: mobility, manual dexterity, Neurologic: cervical disease suggested by limited lateral rotation & lateral flexion, interossei wasting, Hoffmann's or Babinski’s sign; lower extremity motor or sensory deficits, Genitourinary: Men: prostate consistency, masses; if uncircumcised, check for phimosis, paraphimosis, balanitis, Women: vaginal mucosa for atrophy, pelvic support, prolapse, Sacral reflexes (Anal wink, Bulbocavernosus reflex)


testing sacral reflexes

reflexes assesses the integrity of roots S2-S4, the site of the sacral micturition center and the original of the pelvic and pudendal nerves. To do the anal wink, instruct the patient to relax his/her perineum, then lightly scratch along the side of the rectum. You should see the anus contract (“the wink”). Repeat on the other side. False-negative results can be due to the patient’s failing to relax. If the anal wink is negative, then the bulbocavernosus reflex can be done as a backup. The stimulus for the BC is to lightly squeeze the clitoris in a woman or the glans penis in a man; you are looking for the same reflex anal contraction as in the anal wink. If the BC is negative, it can be double-checked by palpation: insert a finger in the patient’s rectum, repeat the BC stimulus, and assess for anal contraction.


Assessing pelvic floor support in women

-assessed by using only the bottom blade of the speculum. First, insert the bottom blade and pull it down slightly to support the posterior vaginal wall. This will give you a good view of the urethra and anterior vaginal wall. Have the patient cough or strain.
-anterior vaginal wall prolapses into and through the vaginal introitus; this is a cystocele. Also note a small violaceous nodule at the urethral meatus—this is a urethral caruncle, a benign finding associated with vaginal atrophy. Note that the bottom of the tissues supporting the urethra are flat, and almost an inverted “U”; in women with intact pelvic support, these tissues would in fact be “U” shaped, and analogous to the musculofascial “hammock” that provides urethral support.


assess posterior vaginal wall

turn the single speculum blade around and use it to support the anterior wall. Again have the patient cough or strain. In the right-side photo, note bulging of the posterior wall, again just through the introitus. This is an example of a rectocele.


bladder diary

o Have patient keep record for least 2 days (3 preferable)
o For downloadable bladder diaries and other tools, see:
o A receptacle placed in the toilet (“hat”) can help patients gauge the amount voided
o In cases of leakage, have them estimate the amount (drops, tablespoon, soaked pad, soaked through clothes)


clinical stress test

o For women and post-prostatectomy men
o Best if bladder is full, patient relaxes perineum, and single vigorous cough is used
o Specific for stress incontinence if leakage is instantaneous with cough
o Insensitive if patient cannot cooperate, is inhibited, or if bladder volume is low
o Several-second delay before leakage suggests stress-induced detrusor overactivity


postvoid residual (PVR)

o Done by catheterization or ultrasound
o PVR > 50 mL may contribute to frequency or nocturia, exacerbate urge & stress UI
o PVR > 200 mL suggests detrusor weakness and/or outlet obstruction (In men, hydronephrosis should be excluded, In women, hydronephrosis is rare)


laboratory tests for UI

o Routine: renal function, urinalysis (Asymptomatic bacteriuria: prevalence in women is 20%, Dx of UTI requires additional signs and symptoms)
o Optimal: glucose, calcium, vitamin B12
o Urine cytology & cytoscopy only if hematuria or pelvic pain is present
o Prostate-specific antigen (PSA) in men, if cancer screening appropriate or desirable


urodynamic testing

-Routine urodynamics are usually not needed (Incontinence in older adults is usually multifactorial, Lower urinary tract is rarely the only cause, Lower urinary tract abnormalities may exist in absence of UI)
-Consider urodynamic testing: When empiric therapy has failed, If diagnosis is unclear, Before surgical intervention


management of UI

o Goal: relieve the most bothersome aspect(s)
o Stepped management strategy


addressing reversible and lifestyle factors

o Correct underlying medical illnesses and medications that may contribute to UI
o Manage fluid intake: avoid caffeine, alcohol; minimize evening intake
o Reduce constipation


behavioral therapy

o Bladder training: effective for urge and stress UI
o Prompted voiding: cognitively impaired patients
o Pelvic muscle exercise: effective for urge and stress UI


bladder training for cognitively intact patients

o Urgency suppression: Be still, Contract pelvic floor, Focus on relaxation of urgency
o Scheduled voiding while awake: Initial toileting frequency: use the shortest interval between voids from bladder diary if possible, After 2 days without leakage: increase time between scheduled voids by 30–60 min, until can go 2–4 hours without leakage, Success may take several weeks; reassure patient about any initial failures


bladder training for cognitively impaired patients

o Only prompted voiding proven effective
o Patient is prompted to void, placed on toilet, and praised after voiding
o Schedule optimally based on frequency of UI
o Requires training, motivation, continued caregiver effort


antimuscarininc medications for urge UI

o Most effective when combined with behavioral therapy
o Usually do not ablate detrusor overactivity
o Efficacy generally similar across agents; differ by side effects, cost, ease of use
o Lack of response to one agent does not preclude response to another



-antimuscarinic medication
-3 formulations:
Immediate release: 2.5–5 mg BID–QID, up to 20 mg/day, Extended release (ER) (Ditropan XL): 5–20 mg/day, Topical patch (Oxytrol): 3.9 mg, applied 2x/week
-Side effects (less frequent with ER and topical): Dry mouth, Blurry vision, Constipation, Possibly cognitive
-Interactions with CYP34A and 2D6
-Monitor PVR if UI worsens


Tolterodine (detrol)

-antimuscarinic medications
-Initial dose: 1–2 mg BID immediate release, 2–4 mg QD for ER (Detrol LA)
-Side effects similar to those of oxybutynin-ER; possible decreased xerostomia
-Interactions with CYP34A and 2D6


Trospium (sanctura)

-antimuscarinic medications
-Dose is 20 mg twice daily; can dose once daily in elderly because of renal clearance
-Must be taken on an empty stomach
-Associated with 56%–60% reduction in weekly urge incontinence episodes
-No data in long-term-care populations
-Adverse events: dry mouth, constipation, headache, abdominal pain


Darifenacin (enablex)

-Antimuscarinic medications
o Dose is 7.5 or 15 mg/day
o Median reduction in weekly UI episodes 55%–58% in patients on 7.5 mg and 60%–70% in patients on 15 mg
o No data in long-term-care populations
o Adverse events: dry mouth, constipation; may have limited cognitive effects
o Interactions with CYP34A and 2D6


Solifenacin (Vesicare)

-Antimuscarinic medications
o Dose is 5 mg/day; may be titrated to 10 mg/day
o Reduction in daily UI episodes 57%–69%, depending on dose
o No data in long-term-care populations
o Adverse events: dry mouth, constipation, nausea, and blurred vision; possible increase QTc
o Interactions with CYP34A and 2D6


stress incontinence management

o Pelvic Muscle Exercises
o Biofeedback, Pessaries, Other Adjuncts (Pessaries are little rubber things that are inserted behind the cervix to hold up the uterus)
o Medications (3rd line)
o Surgery for Women
o Post-prostatectomy


pelvic muscle exercises

o Requires motivated patient & careful instruction and monitoring by health professionals
o Exercise prescription: Focus on isolation of pelvic muscles; avoid buttock, abdomen, thigh muscle contraction; Moderate repetitions of strongest possible contractions: 3 sets of 8–10 contractions held for 6–8 seconds; start 3–4 times per week; Hold contractions for progressively longer times, up to 10 seconds if possible, and increase frequency


adjuncts to pelvic muscle exercises

o Biofeedback: may be helpful for teaching
o Electrical stimulation: no additional benefit
o Weighted vaginal cones: not tested in older women
o Pessaries: for symptomatic pelvic organ prolapse


stress incontinence medications

o No medical treatment currently available
o Estrogen – used for vaginal or urethral atrophy (Oral—shown to increase UI in randomized trials, Topical—may reduce atrophic vaginitis, urethritis; impact on UI is unclear
o alpha-Adrenergic Agonists: Stimulate urethral smooth-muscle contraction, No pure alpha-agonists are available


stress incontinence surgery

o Highest cure rates; complication rate ~10%
o Approach depends on underlying defect and coexistent prolapse
o Best evidence: Colposuspension, Slings
o Periurethral injection (eg, collagen) is short-term (≤1 yr) alternative


stress incontinence post-prostatectomy

o Milder cases: pelvic muscle exercises, periurethral injections
o More severe cases: protective garments, catheters
o Artificial sphincter replacement can be effective but has high re-operation rate
o Emerging data on sling operations


overflow UI: management

o If obstruction present, treat underlying cause
o Reduce or stop drugs that impair detrusor contractility and increase urethral tone; treat constipation
o Bethanechol chloride is generally ineffective
o Intermittent clean catheterization (sterile for frailer, institutionalized patients) if acceptable
o Bladder emptying may improve with double or unhurried voiding
o Last resort—protective garments


use catheterization with caution

Significant morbidity: polymicrobial bacteriuria, nephro-lithiasis, bladder stones, epididymis, chronic renal inflammation, pyelonephritis

Reserve indwelling catheters for:
-Short-term decompression of acute urinary retention
-Chronic retention not manageable surgically/medically
-Patients with wounds that must be kept clean of urine
-Very ill patients who cannot tolerate garment changes
-Patients who request catheterization despite informed consent regarding risks


catheter care

o To reduce infection: Closed drainage systems, Keep long-term-care residents with catheters in separate rooms from each other
o Bacteriuria is universal in catheterized patients: Do not treat in absence of clear symptoms of infection, Do not routinely culture
o Culture symptomatic patients after old catheter is removed and new catheter is placed
o Changing catheters: Generally about once a month, Can be longer in absence of UTI, Every 7–10 days if there is recurrent blockage
o Prophylactic antibiotics: for short-term catheterization (eg, acute retention) only in high-risk patients (eg, prosthetic heart valves)
o Risk factors for catheter blockage: alkaline urine, female gender, poor mobility, calciuria, proteinuria, copious mucin, Proteus colonization, preexistent bladder stones