URINARY
INCONTINENCE
Dr Mark Donaldson
Consultant Physician in Geriatric
Medicine
Urinary Incontinence
Affects:
15%-30% elderly living at home
30% - 35% elderly in acute care
>50% in RCF
Urinary Incontinence
Continence requires:
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Adequate mobility
Mentation
Motivation
Manual dexterity
Intact lower urinary tract function
Urinary Incontinence
Medical Complications
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Rashes
Pressure ulcers
UTI
Falls
Fractures
Urinary Incontinence
Psychosocial complications
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Embarrassment
Stigmatisation
Isolation
Depression
Institutionalisation risk
Incontinence
is never normal
Urinary Incontinence
AGEING BLADDER CHANGES
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Bladder capacity decreases
Bladder compliance decreases
Ability to postpone voiding decreases
Urethral closing pressure decreases in women
Prostate enlarges in men
Involuntary bladder contractions increase
Post-voiding residual volume increases (50-100ml)
Also:
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Increased fluid excretion at night
Age associated sleep disorders
Detrusor muscle changes
Urinary Incontinence
Incontinence is a Geriatric syndrome:
i.e. Predisposed by above factors
Precipitated usually by disease outside
the urinary tract.
Frequent adverse drug reactions that affect the urinary
tract
It is these factors OUTSIDE the urinary tract that are
amenable to intervention e.g. arthritis/immobility
Urinary Incontinence
Transient Incontinence
Common e.g.
30% community dwellers
50% of inpatients
At risk cases: especially
anti-cholinergics
diuretics
worsening mobility
Urinary Incontinence
Transient Incontinence:
D
I
A
P
P
E
R
S
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Delirium
Infection
Atrophic Urethritis/vaginitis
Pharmaceuticals
Psychological (rare)
Excessive urine output
Restricted mobility
Stool impaction
Urinary Incontinence
Urinary tract causes of incontinence:
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Detrusor overactivity
Detrusor underactivity
Genuine stress incontinence
(low urethral resistance)
Obstruction
(high urethral resistance)
Urinary Incontinence
Detrusor Overactivity
Commonest cause of urinary incontinence
(60%-70%).
Seen with:
- neurologic disorders
- obstruction
- ageing
- GSI
- DHIC
Urinary Incontinence
Detrusor Overactivity
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Clinically:
- sudden onset
- immediate need to void
Leakage is episodic, moderate to large
Nocturnal frequency
Urge incontinence common
PVR low in absence of DHIC
Urinary Incontinence
Stress Incontinence
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Common in women
In men, only after sphincteric damage complicating
prostatic resection
Clinically: Instantaneous with stress manoeuvres
Delayed - suggests stress induced detrusor
overactivity
In men, ‘leaky tap’ worsened by standing or straining
Often co-exists with urge incontinence i.e. mixed
Urinary Incontinence
Urethral Obstruction
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Common in men
In women, after bladder neck suspension or kinking
associated with severe prolapse
Prostatic encroachment
Clinically:
(1) Filling symptoms
(i.e. urgency, frequency, nocturia)
(2) Voiding symptoms
(i.e. poor stream, intermittency,
dribbling post void
(3) Overflow
Urinary Incontinence
Detrusor Underactivity (<10% of incontinence cases)
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Usually idiopathic
Caused by degenerative muscle and axonal changes
Clinically:
Overflow incontinence
Frequency
Nocturia
Frequent leakage of small amounts
PVR usually > 450ml
In men, differentiated by urodynamics rather than
cystoscopy or IVP.
Urinary Incontinence
Evaluation of the older incontinent patient
GOALS:
Investigate and treat transient and
established causes.
Assess patient’s environment and support
To detect uncommon but serious
underlyhing conditions:
- Brain
lesions
- Spinal cord lesions
- Carcinoma bladder/prostate
- Bladder stones
- Decreased bladder compliance
Urinary Incontinence
Clinical Management
1.
Exclude overflow incontinence
(e.g. PVR > 450ml)
Where appropriate, Urologist referral
Remainder - catheterise
Urinary Incontinence
Clinical Management
2.
Remaining 90%-95% depends on gender.
Females: either OAB or GSI
GSI excluded by observing for leakage with full
bladder and vigorous cough
Males: either OAB or obstruction.
If flow normal, PVR <100ml then obstruction is
excluded.
If PVR > 200ml, exclude hydronephrosis.
Remainder, treat for OAB – warn about retention –
avoid bladder relaxants if PVR >150ml.
Urinary Incontinence
Non-Drug Treatment of OAB
Bladder Drill (re-training)
 Timed voiding
 Deferment technique
Cognitively impaired
 Prompted voiding
Non-Drug Treatment of GSI
 Pelvic floor exercises especially if mild :
- 30-200 times per day
- Indefinitely
- Limited efficacy
- Repair procedures less invasive
Urinary Incontinence
Drug Treatment of OAB
Anti-cholinergic (anti-muscarinics)
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Oxybutynin
Solifenacin
Darifenacin
Tolterodine
Best as adjuncts to bladder drill.
Dose escalation by titration
Most NOT on PBS
Newer ones better tolerated
CI Glaucoma – Dry mouth, confusion
Urinary Incontinence
Voiding and Dementia
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Alertness
Responsive
Motivation
Direction
Mobility
Recognition
Dressing
Urinary Incontinence
Indications for Urodynamics
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Persistent diagnostic uncertainty.
Morbidity associated with potentially.
misdirected medical therapy is high.
When empiric therapy has failed.
When surgical intervention is planned.
Overflow incontinence.
Urinary Incontinence
Pharmacologic Treatment Obstruction
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Alpha blockers
delay surgery
benefit in weeks
Prazosin
Tamsulosin
Terazosin
Finasteride 5 alpha reductase inhibitor
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Less effective
Delayed benefit
Side-effects esp. impotence.