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Understanding Urinary Incontinence in Seniors

The document discusses urinary incontinence, particularly in the elderly, highlighting its causes, assessment, and treatment options. It emphasizes the importance of understanding the underlying factors, including age-related changes and comorbidities, while outlining a multidisciplinary approach for management. Additionally, it provides case studies to illustrate different diagnoses related to urinary incontinence.

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Khim V.
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11 views17 pages

Understanding Urinary Incontinence in Seniors

The document discusses urinary incontinence, particularly in the elderly, highlighting its causes, assessment, and treatment options. It emphasizes the importance of understanding the underlying factors, including age-related changes and comorbidities, while outlining a multidisciplinary approach for management. Additionally, it provides case studies to illustrate different diagnoses related to urinary incontinence.

Uploaded by

Khim V.
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Urinary Incontinence

In the field of geriatrics, the terms used are often not useful clinical.

Currently, most discharge summaries list urinary incontinence were poorly as urinary incontinence is
not a diagnosis
An alternative discharge summary if chest pain and haematemesis is presented the way urinary
incontinence is usually presented.

Ageing bladder
- Decline in
 Detrusor contraction
 Capacity
 Flow rates
 Sensory function
- Increase
 Post-micturition volume
 Urethral resistance
 Uninhibited contraction
 Nocturia
- Other
 Prostatic hypertrophy – In males
 Vaginal mucosa atrophy – In females
 Reduction in acetylcholinesterase nerves
 Less compliant bladder

As one gets older


- Less warning of a full bladder
- Prostatic symptoms
- Increase frequency
- Nocturia
- Less agile
- But patients tend to get wiser
Standard causes of urinary incontinence
- Urge
 Detrusor instability
 Overactive bladder (OAB) – Idiopathic
 Detrusor hyperreflexia
 Upper motor neurology
 Stroke
 Dementia
 Multiple sclerosis (MS)
 High cord
 Detrusor hyperactivity with hypo-contractility
- Stress  When patients cough, it can result in leakage
 Sphincter deficiency
 Post-operative
 Trauma (obstetric)
 Ageing
 Radiation
 Neurology low spinal cord
 Neuropathy
 Radiation
- Retention
 Obstruction
 Detrusor hyperactivity with hypo-contractility
 Dyssynergy
 Neurological
 Lower cord
Continence is controlled by the autonomic nervous system (ANS)

For urinary incontinence in the elderly, consider


- Acute/Reversible vs persistent
- Medical history/comorbidities
- Drugs
- Environment
- Social
Acute/reversible causes – DIAPPERS
- D: Delirium
- I: Infection
- A: Atrophic vaginitis
- P: Pharmaceuticals
- P: Psychological
- E: Excess fluid and out
- R: Restricted mobilty/dexterity
- S: Stool impaction
Takes a history
- DIAPPERS
- Urgency symptoms
- Stress
- Neurological symptoms
Examination
- Per rectal
- Per vaginal

AXR can be used as part of work-up as well


Geriatric assessment includes
- Pre-morbid function
- Cognitive
- Drugs
- Other
 Social
 Sensory
 Vision
 Hearing
 Dentition

Comorbidities affect continence


- Impaired
 Physical
 Cognitive
 Sensory/motor deficits
 Communication
- Raised abdominal pressures
 Chronic lung disease
- Increased nocturia
 Diabetes mellitus (DM)
 Heart failure
 Hypercalcaemia
 Venous insufficiency

Urinary incontinence red flags


- Sudden onset
- Neurological symptoms
- Pain
- Haematuria

Physical examination
- Central nervous system
 Sensory/motor
- Rectal
 Anal ring power
 Prostate – in males
- Genito urinary
 Lesions
 Prolapse
- Functional ability
 Balance
 Dexterity
 Activities of daily living (ADLs)
Investigations
- Urinalysis
- Bladder diaries (if patient is relatively well)
 Time
 Volume
 Incontinence
 Urgency
 Triggers
- Imaging
- Urodynamics
- Pre- and post-void volumes

Urodynamics are usually done by surgical teams to help differentiate the need for surgical vs medical
management
Treatments are dependent on the cause
- Generic/non-medical
 Weigh loss
 Bladder retraining
 Pelvic floor muscle exercises (Kegel exercises)
 If cognitive impaired
 Regular voiding
 Double voiding
 Voiding another time after patient thinks they are initially finished
 Psychology
- Specialised treatments
 Bladder botox
 Useful for hyperactive bladders
 Sacral nerve remodulation – I.e., “Pacemaker” for the bladder
 Surgery
 Usually for stress incontinence

Drugs used for detrusor instability

- β3-agonist: Mirabegron
- M3 blocker: Anticholinergic agents
Drugs used for OAB – Effectiveness of anticholinergics
- Oxybutynin
- Propantheline
- Tolterodine
- Trospium
- Propiverine
- Solifenacin

- Improvements in
 Leakages in 24h: ~1
 Number of voids/24h: ~1
 Volume of voids: 40-60ml
- Conclusion
 “For many of the outcomes studied, the observed difference between anticholinergics
and placebo may be of questionable clinical significance”
- M1:
 Brain
 Salivary glands
- M2:
 Smooth muscle
 80% of detrusor
 Heart
 Midbrain
- M3:
 Smooth muscle
 20% of detrusor
 Salivary glands
 Some brain tissues
 Ocular lens
- M4:
 Forebrain
- M5:
 Substantia nigra
 Eyes

Anticholinergic agents are antimuscarinic and hence anti-parasympathetic. Hence, sympathetic


effects predominate
- As such, side effects include
 Constipation
 Xerostomia
 Blurred vision
 Tachycardia
 Urinary retention
Anticholinergics and the brain
- Mild cognitive impairment (MCI)
 Memory
 Language
 Visuospatial
 Reaction time
 Attention
- Dementia
 Oppose the cholinesterase inhibitors
 Increased risk of delirium
- Delirium
 Increased
 Hosptial stay
 Functional decline
 Morbidity and mortality
 Nursing home placements

Many drugs have anti-cholinergic effects including


- Oxybutinin
- Nifedepine
- Amytryptilline
- Atropine
- Diltiazem
- Benztropine
- Isosorbide dinitrate
- Dihenhydramine
Ageing has important effects on drugs
- Changes in ageing
 Renal and hepatic ageing
 Fat/water and albumin
 Receptors and transport less efficient
Drug history – Simplify
- Do the drugs match the diagnosis?
 Are they appropriate?
- Are there side effects and are they worth it?
- Can the drugs be stopped?

Non-medical issues affecting continence


- Who they live with
- Privacy
- Anxiety
 Fear of being incontinent

Incontinence requires a multidiscplinary approach


- Occupational therapists (OT)
- Physiotherapists
- Pharmacist
- Speech pathologist
- Nurse specialist
- Social worker
- Dietician
- Dentist
- Optician
- Auditory specialisit

Environment – Indoor
- Toilet modification
 Rails
 Raised seats
- Personal
 Mobility
 Velcro/aids
 Commodes/bottle
 Pads/catheter
- Staff/centre involvement
 Prompt/ timed and double voids
 Good signage and pictures

As a doctor it is important to understand the causes and exacerbations of urinary incontinence in


order to be able to properly manage it.
First line advice – to all patients
- Drink less
 Stop drinking after 6pm
 Including alcohol
- Avoid caffeine
- Stop smoking
- Additional
 Pelvic floor exercises
 Lose weight
 Bladder retraining  Can be done for all patients
 Prompt/double voiding
Case 1
80 year old female
Gives a 3 year history of urinary urgency
Now has a 1 year history of urge incontinence, small frequency volumes, urgency and nocturia but
no pain.

Diagnosis? – Overactive bladder

Case 2
79 year old male
Presented to the hospital ED with following symptoms
- Not passing urine for 24 hours
- Abdomen really bloated and suprapubic pain and tenderness
Further history
- 2 years of decreased urinary flow, dribbling and nocturia

Diagnosis? – BPH

Case 3
49 year old male
Presented to ED with the following symptoms
- 3 days of incontinence and poor flow
- 3 days “off legs” now unable to walk overnight and can’t feel legs
Further History
- 1 year of cough, smoker, weight loss

Diagnosis – Cord Compression

Case 4
60 year female presented to their GP clinic with the following symptoms for 3 years
- Worsening incontinence
- No warning to incontinence
- Occurs with standing or coughing
- Has had 8 children via normal vaginal birth
- May have a prolapse

Diagnosis? – Weak pelvic floor

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