What is frequency?
The need to void very often, typically affecting QOL (>8x / day)
What is nocturia?
Need to void during night, typically affecting QOL (>2x)
What is urgency?
Sensation to void that is so strong that fear of urine loss is imminent
What is incontinence?
Involuntary loss of any amount of urine
What is the prevalence of UI in community-dwelling older adults?
15%-30%
What is prevalence of UI in residents of long-term-care institutions?
60-70%
Does prevalence of UI increase with age?
Yes
Does UI affect more women or men?
-More women than men (2:1) until 80, then it’s 1:1
How many people with UI seek medical attention?
Fewer than half
What are 2 categories of impact of UI on older adults?
- Morbitidy
2. Cost: Over 26 billion annually
What are the morbidities associated with UI?
- Cellulitis, pressure ulcers, UTIs
- Sleep deprivation, falls with fractures (fall while going to bathroom at night), sexual dysfunction
- Depression, social withdrawal, impaired quality of life
What is required for continence?
- Mobility
- Manual Dexterity: To undress, use cane, ect.
- Cognitive Ability
- Motivation: Psychiatric spectrum
- Health
- Control of bladder contraction & urethral closure mechanisms
In normal micturiction, what is the bladder under control of?
The detrusor muscle
What does the detrusor muscle contract via?
PS nerves (S2-S4)
What does the proximal urethral smooth muscle contract via?
Sympathetic stimulation: T11-L2
What does the distal urethral striated muscle contract via?
Cholinergic somatic stimulation: S2-S4
In women, what does musculofascia do?
Supports and compresses the urethra when abdominal pressure increases
What is urine storage under control of and how does this function?
Sympathetic control:
- Inhibits detrusor contraction
- Increases sphincter contraction
What is voiding under control of and how does this function?
Paraympathetic control:
- Induces detrusor contraction
- Induces sphincter relaxation
As the bladder fills, what does sympathetic nerve activity do?
Increases the outlet resistance and inhibits detrusor contraction
When does somatic nerve activity increase?
As the bladder fills to tighten the pelvic floor
What changes occur with the aging process which can contribute to urinary incontinence?
- Decreased mobility
- Inability to postpone voiding
- Prostate hypertrophy
- Urethral dysfunction
- Increased night time urine volume
What are some age related lower urinary tract changes?
- Detrusor overactivity
- Benign prostatic hypertrophy
- Urine output shifted later in the day
- Atrophic vaginitis and urethritis
- (Modest) increase postvoid residual (PVR)
- Decreased ability to postpone voiding
- Decreased total bladder capacity
- Decreased detrusor contractility
What are 3 categories of factors contributing to or causing UI in older persons?
- Comorbid disease
- Neurological/Psychiatric
- Function and environment
What are some examples of comorbid disease that can contribute to or cause UI in older persons?
- Diabetes: Peripheral neuopathy
- Congestive heart failure: Increased noctural peeing due to edema
- Degenerative joint disease
- Sleep apnea
- Severe constipation: Mega-colon…functional bladder capacity is decreased
What are some examples of neurological/psychiatric conditions that can contribute to UI in older persons?
- Stroke
- Parkinson’s disease
- Normal pressure hydrocephalus
- Dementias
- Depression: Lack of motivation
WHat are some examples of function and environment that can contribute to or cause UI in older persons?
- Impaired cognition: Recognize the need to urinate and what to do
- Impaired mobility
- Inaccessible toilets
- Lack of caregivers: Maybe need nighttime assistance?
What are come medications that can cause or worsen UI?
- Alcohol
- α-Adrenergic agonists
- α-Adrenergic blockers
- ACE inhibitors
- Anticholinergics
- Antipsychotics
- Calcium-channel blockers: Peripheral edema goes intravascularly
- Cholinesterase inhibitors
- Estrogen
- GABAergic agents
- Loop diuretics: Increased urine output
- Narcotic analgesics
- NSAIDs
- Sedative hypnotics
- Thiazolidinediones
- Tricyclic antidepressants
What are 3 categories of causes of nocturia?
- Noctural polyuria (normal output >35% of total 24 hour output- 1/3 of normal daily output is at night)
- Sleep Disturbance
- Lower urinary tract
What are some causes of nocturnal polyuria?
- Late day/evening fluids, especially with caffeine or alcohol
- Pedal edema (i.e. due to medications, venous stasis, heart failure)
- Heart failure
- Obstructive sleep apnea : Interruption to sleep
What are some causes of sleep disturbances that can lead to nocturia?
- Medications
- Cardiac or pulmonary disease
- Pain
- Restless leg syndrome
- Depression
- Obstructive sleep apnea
- Sleep partner
- If you wake up at any point in the night with urine in your bladder, you will probably go to the bathroom
What are some causes of lower urinary tract issues that can lead to nocturia?
- Detrusor overactivity: Constant feeling have to go (mimics a full bladder)
- BPH: Functional decrease in bladder (it fills quicker)
- Impaired bladder emptying
What are the clinical types of UI
- Reversible or Transient (less than 2 months)- Self Limiting
- Pure Urge
- Pure Stress
- Mixed Stress and Urge
- Incomplete emptying: Outlet obstruction or Detrusor underactivity
What constitutes a functional UI?
Patients who are unable to reach the toilet due to physical or mental impairment
What constitutes a total UI?
Continuous leakage, usually congenital or due to a fistula
What are the causes of reversible (transient) incontinence?
DIPAERS
- Delirium
- Infection
- Atrophic Vaginitis
- Pharmacological/Psychological
- Excessive urine output
- Restricted mobility
- Stool impaction (decreased functional size of bladder)
What is the most common type of UI in older persons?
Urge incontinentce
What is urge incontinence associated with?
Uninhibited bladder contractions, called detrusor overactivity (DO)
What are signs and symptoms of urge incontinence?
- Abrupt/compelling urgency- Running to the bathroom
- Frequency
- Nocturia
What are some causes of urge incontinence?
Detrusor overactivity may be:
- Age-related
- Idiopathic
- Central inhibitory pathway lesion (i.e. stroke, cervical stenosis)
- Local bladder irritation (i.e. bladder stones, infection, inflammation, tumors)- Transient
What is the second most common type of UI in older women?
Stress incontinence
What other patient population is stress incontinence seen in?
Post-protatectomy stress UI is increasing common in men (but still rare with advanced surgical techniques)
What does stress incontinence occur with?
Increased intra-abdominal pressure in absence of bladder contraction and incompetent bladder outlet
Why does stress incontinence affect so many women?
Because of pelvic floor incompetence, the supporting structures don’t support the bladder
What does stress incontinence often coexist with?
Urge UI (mixed UI)
What are 2 mechanisms of leakage in stress incontinence?
- Impaired pelvic supports
2. Failure of urethral closure
What does impaired pelvic supports lead to in stress incontinence?
Episodic leakage with increased abdominal pressure- This is “genuine” stress incontinence
What can cause failure of urethral closure?
- Intrinsic sphincter deficiency from trauma
- Scarring from anti-incontinence surgery in women and prostatectomy in men
- Interruption of sphincter innervation (rare)
What is seen with failure of urethral closure?
Continual leakage may occur while sitting or standing
What can impaired bladder emptying result from?
- Detrusor underactivity
- Bladder outlet obstruction
- Both
What is the leakage like in impaired bladder emptying?
Small, but can be continual
Is post void residual elevated in impaired bladder emptying?
YES
What are the symptoms of impaired bladder emptying?
Dribbling, frequency, hesitancy, nocturia, weak urinary stream
What other kinds of leakage may occur with impaired bladder emptying?
Urge and stress
What is the second most common cause of UI in older men?
Outlet obstruction
Are most obstructed men incontinent?
NO…most obstructed men are not incontinent, they just have frequency and are up all night
What are the causes of outlet obstruction in men?
BPH, prostate cancer, urethral stricture
If outlet obstruction common in women?
No
If seen in women, what is outlet obstruction usually do to?
Previous anti-UI surgery or large cystocele (invagination of the bladder or rectum)
What 3 things can detrusor underactivity result from?
- Intrinsic bladder smooth muscle damage (i.e. from ischemia, scarring, fibrosis)- Much less common
- Peripheral neuropathy (i.e. diabetes, Vitamin B12 deficiency, alcoholism)
- Damage to spinal cord or spinal bladder efferent nerve (i.e. disc herniation, spinal stenosis, tumors or degenerative neurologic disease)
What can detrusor underactivity be treated?
Medication or bladder training
What are the components of a comprehensive assessment of UI?
- History
- Physical exam
- Testing
- Optional tests: PVR, urodynamics, cytology, other lab or radiologic tests
Why is it important to initiate discussion about UI (including QOL)?
Because 50% of patients don’t report UI
What things need to be done in a history for UI?
- Ask about specific symptoms
- Determine UI characteristics to determine type of UI
- Identify associated factors: bowel function, medical conditions, medications
- Ask about quality of life: patient’s, caregiver’s
What systems must be examined in UI evaluation?
- General
- CV
- Abdominal and rectal
- MSK
- Neuro
- GU
What must be assessed in the general portion of the PE?
Cognitive and functional status
What must be assessed in the CV portion of the PE?
Volume overload, peripheral edema, CHF
What must be assessed in the Abdominal and rectal portion of the PE?
Masses, tenderness, rectal masses or impaction, rectal tone
What must be assessed in the MSK portion of the PE?
Mobility and manual dexterity
What must be assessed in the neurologic portion of the PE?
Cervical disease, lower extremity motor or sensory deficity
What must be assessed in the male GU portion of the PE?
- Prostate consistency, masses (cannot tell size by DRE); if uncircumcised, check for phimosis, paraphimosis, balanitis
- These can all cause outlet obstruction
What must be assessed in the female GU portion of the PE?
-Vaginal mucosa for atrophy, pelvic support, prolapse (cystocele versus rectocele)
What is a cystocele?
When the anterior vaginal wall prolapses into and through the vaginal introitus
What is a urethral caruncle?
A small violaceous nodule at the urethral meatus that is a benign finding associated with vaginal atrophy
In women with intact pelvic support, the bottom of the tissues supporting the urethra should be what shape?
U-shaped (in women who have lost pelvic support, these can become flat or even inverted U)
What is a rectocele?
The bulging of the posterior wall of the vaginal through the introitus
What must be assessed as part of the GU exam for both men and women?
Sacral reflexes
What is testing that should be performed as part of the work-up for UI?
Bladder diary, stress test, urinalysis, renal function
What is a bladder diary?
-Have patient keep record for least 2 days and nights, recording time and volume of all voids and incontinence episodes- How often and how much
What can be placed in the toilet to help[ patients gauge the amount voided when keeping a bladder diary?
A hat (receptacle)
For UI episdoes, what are some things the patient can use to esitmate the amount?
Drops, tablespoon, soaked pad, soaked through clothes
What are some optional tests that can be done to evaluate UI?
PVR, urodynamics, cytology, other lab or radiologic tests, clinical stress tests
Who should a clinical stress be done in?
Women and post-prostatectomy men
What is the best technique for a clinical stress test?
Best if bladder is full, patient relaxes perineum, and a single vigorous cough is used
When is the clinical stress test specific for stress incontinence?
If leakage is instantaneous with cough
When is the clinical stress test insensitive?
If the patient cannot cooperate, is inhibited, or if bladder volume is low
What does a several-second delay before leakage suggest with a clinical stress test?
Stress-induced detrusor overactivity
How is post-void residual (PVR) done?
By catheterization or US
What does a PVR under 200mL suggest?
Detrusor weakness and/or outlet obstruction
What does a PVR of 50-100mL contribute to?
Frequency or nocturia, exacerbate urge and stress UI (incomplete emptying)
What are routine lab tests done for UI?
Urinalysis and renal function
Besides urinalysis and renal function, what is required for diagnose UI?
Additional signs and symptoms
Do you treat asymptomatic bacteriuria?
NO (only in preggos)
What other lab tests might you consider?
Glucose and vitamin B12
Why are routine urodynamics not needed in evaluation of UI?
- UI in older adults is usually multifactorial
- Lower urinary tract is rarely the only cause
- Lower urinary tract abnormalities, especially DO, may exist in absence of UI
When would you consider urodynamic testing in the evaluation of UI?
- Empiric therapy has failed
- Specific dx is unclear and would change management
- Before surgical intervention
What is the goal of management of UI?
To relieve the most bothersome aspects
What is the stepped management strategy in UI?
Lifestyle–> Behavior –> Drugs –> Surgery (last resort)
What is the efficacy of treatment with behavioral versus drug versus control?
Behavioral: 81% reduction in accidents/week
Drug: 69%
Control: 38%
What must be corrected/addressed that may contribute to UI?
Underlying medical illnesses, functional impairments, and medications
Why is weight loss important for moderately obese in UI?
In patients with a BMI over 30, a 5% decrease in weight, decreases UI by 50%
With regards to fluid intake, what should be done in UI?
Avoid caffeine and alcohol and minimize evening intake
What foods should be avoided in UI?
Ones that irritate the bladder like citrus, peppers, curry and chocolate
In smokers with UI, is it important that they stop?
YES
What types of UI is bladder training and pelvic muscle exercise (PME) important for?
Urge, stress, and mixed UI
What is the only behavioral treatment with proven efficacy in cognitively impaired patients?
Prompted voiding
What are the 2 types of bladder training for cognitively intact patients?
- Urgency suppression
2. Scheduled voiding while awake
What are the “steps” with urgency suppression?
- Be still, don’t run to the bathroom
- Do pelvic muscle contractions
- When urgency decreases, then go to the bathroom
What is the initial toileting frequency with scheduled voiding while awake?
About 2 hours or use the shortest interval between voids from the bladder diary
After 2 days with out leakage, how should the time be changed with scheduled voiding?
Increased time between scheduled voids by 30-60 min, until you can go 4 hours without leakage
What must you tell your patients doing scheduled voiding?
- Bladder is a muscle, it can be trained
- Success may take several weeks… reassure patient about any initial failures
What is the only proven effective bladder training for cognitively impaired patients?
Prompted voiding
How is prompted voiding done?
Patient is prompted to void, placed on toilet, and given positive feedback after voiding
What the schedule based on in prompted voiding?
Frequency of UI
What does propted boiding requrie?
Caregiver training, motivation, continued effort
What can pads and diapers do in UI?
Maintain skin integrity
What can the number of pads used and type of pads used help the physician elucidate in UI?
The severity of the problem
What do antimuscarinic medications for urge UI do?
They increase functional bladder volume (DO NOT ABLATE DETRUSOR OVERACTIVITY)
If the efficacy of antimuscarinic agents similar across agents?
Yes, the efficacy is generally similar across agents, but they differ by side effects, cost, and ease of use
Does lack of response to one antimuscarinic agent preclude response to another?
NO
What are some examples of antimuscarinic agents used for UI?
Oxybutynin, tolterodine, trospium, darifenacin, solifenacin, fesoterodine
What are some side effects of antimuscarinic agents?
- Dry mouth
- Blurry vision
- Constipation
- Cognitive
- Dental Caries
- These are all less frequent with extended release and topical
What type of drug-drug interactions do antimuscarinic agents used for UI have?
They all have interactions with CYP3A4 an 2D6
*Only exception is trospium, which is renally cleared and should be dose-reduced in renal insufficiency
If UI worsens with antimuscarinic medications what do you need to monitor?
PVR
What are antimuscarinic medications used for?
Urge UI
What should be first line treatment for UI?
LIFESTYLE: Behavioral and bladder training
* Drugs are often used 1st line INAPPROPRIATELY
Did the use of anticholinergics in urge incontinence show a huge improvement?
Not a dramatic one…
- 32 trials of 6,800 patients, double-blind:
- Decrease episodes/24 hrs = 0.6
- Decrease voids/24 hrs = 0.6
- Increase max capacity = 54 ml
What are 4 types of stress incontinence management?
- Pelvic muscle exercises
- Biofeedback, pessaries, other adjuncts
- Medications
- Surgery for women
What do pelvic muscle exercises for stress incontinence management requries?
A motivated patient and careful instruction and monitoring by health professionals
What is another work for pelvic muscle exercises?
KEGALS
Describe exercise prescription for pelvic muscle exercises
- Focus on isolation of pelvic muscles: Avoid buttock, abdomen, thigh muscle contraction
- Repetitions of strongest possible contraction: 3 sets of 8–10 contractions, aiming for 6–8 seconds (usually 1-2 to start)
- Start doing PME 3–4 times per week, increasing duration and frequency of contractions
Are any medications currently available for stress incontinence?
NO
What has been hypothesized for use in stress incontinence?
Estrogen
Should oral estrogen be used for stress incontinence?
No, it was shown to increase UI in randomized trials and shouldn’t be used
What benefit might topical estrogen have for stress incontinence?
It might reduce atropic vaginitis, urethritis, but the impact on UI is unclear
What has the highest cure rates for stress incontinence in women?
Surgery
What does the approach to surgery in women for stress incontinence depend on?
The underlying defect and coexistent prolapse
What are the most common surgeries done for stress incontinence in women?
- Colposuspension
2. Slings
What is a short term (under 1 year) alternative to surgery for women for stress incontinence?
Periurethral injection (collagen)
What can be done as pre-operative prophylaxis for post-prostatectomy stress incontinence?
Pelvic muscle exercises
What can be done for mild-moderate UI post-prostatectomy?
Pelvic muscle exercises
What can be done for severe UI post-postatectomy?
Artificial sphincter replacement can be effective but has a high re-operation rate (there is emerging data on sling operations)
What are 5 features in management of UI with impaired bladder emptying?
- If obstruction present, treat underlying cause
- Reduce or stop drugs that impair detrusor contractility and/or increase urethral tone
- Treat constipation
- Intermittent clean catheterization (sterile for frailer, institutionalized patients) if acceptable
- Last resort—protective garments
Why must catheterization be used with caution?
Significant morbidity
What is the significant morbidity related to catheterization due to?
Polymicrobial bacteriuria, nephrolithiasis, bladder stones, epididymitis, chronic renal inflammation, pyelonephritis
What 4 patient groups should indwelling catheters be used for?
- Short-term decompression of acute urinary retention
- Chronic retention not surgically/medically remediable
- Patients with wounds that must be kept clean of urine
- Very ill/end of life patients who cannot tolerate garment changes
What was his summary points?
- Urinary incontinence is common in older adults & results in impaired quality of life, morbidity, and increased costs
- Age-related changes & common disorders/impairments increase an older person’s risk of incontinence
- Evaluation is based on history, physical, and focused testing
- Treatment is stepwise, starting with remediation of comorbid and lifestyle factors, progressing to behavioral therapy, medications, and, if necessary, surgery
- Indwelling catheters should be used with caution, only when absolutely necessary
