URINARY

INCONTINENCE
IN ELDERLY

Dr dr RA Tuty Kuswardhani SpPD

KGer;
MARS
RS PTN UNUD BALI
Divisi Geriatri SMF llmu Penyakit Dalam FK
UNUD

CASE
Mrs. L,80 yo; explains that, on the night of the falls and gets fracture, she

woke up to urinate around midnight, and the broke her shoulder.

The conversation reminded Mrs. L that she experienced frequent nocturnal
urination during the hospitalization and on several occasions was unable to
get to the toilet on time and become incontine
she develops urinary urgency as soon as the key goes into the lock
. She has occasionally experienced leakage when sneezing, standing, or
coughing but this most commonly occurs when she is trying to hold her
urine during one of her urgent episodes.
Still, she did not view her urinary pattern as a big problem until her recent
hospitalization.
Mrs. L visited her gynecologist 1 year ago. She has no cystocele, rectocele,
or uterine prolapse. She denies dysuria, fever, or constipation.

Question
1. What factors contributed to the patients urinary incontinence?
2. How should her problem be approached? What non pharmacologic

approaches could be of benefit to this patient?

Definition of UI
UI - unconsencius
not wanted to induce
social and problem
hygiene
(International
Continence Society,
2002)

Prevalence Urinary
@ Data Geriatry SANGLAH Hospital Denpasar :
Incontinence
UI FEMALE IN
60-85 YO (2011) Prevalens 21 %
@ USA prevalens: 47% post menopause (2012)

Incontinence pada pria di

kanada ( 2011)

18%
54%

29%

18 - 40
th
41 64th

Incontinence pada wanita di Kanada ( 2011)

15%
53%

32%

18 - 40
th
41 64th

CLINICAL IMPLICATION UI

Clinical significant : health physic and emosional

Incontinence Urine stress, depression ,limitation
function sex, risk falls
mortality

Embarrassment Contributes to
Rationalization of Condition as
not worth medical attention
Dirty
Sign of
old age

Smell
Embarassem
ent

Disgust

Not worth disturbing

the Doctor
Astellas Market Research : Branding Science 2006

Child-like

Type of Urinary Incontinence

(Peet et al ; 2005):

Rule out of Transient

Causes
D elirium
I nfection
A trophy
P harmaceuticals
P sychologic
E ndocrine or excess urine

output
R estricted mobility
S tool impaction

Neurogenic Bladder

Over active Bladder

Normal Bladder

Overflow Bladder

Stress Bladder

Images Of Bladder Condition in Normal and Four Types of Urinary Incontinence

UI AND SKIN INFECTION

SKIN: Urinary Incontinence : iritation, mechanic
,fraillty, infection Dermatitis Perineum/ Incontinence
Dermatitis Infection 1 - 2 organisme: Tinea and
Candida Albicans

Healthy

UnHealthy

Incontinens Urin in MAN

BPH : Gland prostat >
> 60 YO: 60%
> 90 %: 80 YO, LUTS and BPH
SIGN :

Obstruction, < path

urinary urgency ; .>
urinary at night;
incontinence

UI IN FEMALE
Menopause
estrogen in menopause
women caused in
supportive:
tissue,
thinning of urethral and
vaginal epitel,
vascularisation of urethral
submucosa, cellular
Estrogen defisiensi is an
important ethiology of
lower urinary tract disease
including urge
symptoms(frequency,
nocturia, urgency,
incontinence urge)

DIAGNOSIS

Assesment : History and

Pertanyaan : Apakah anda mengompol / BAK atau BAB tanpa disadari
Physical :
?
0 tidak pernah
1,0 kadang-kadang kehilangan kontrol berkemih/menggunakan alat bantu
untuk berkemih & BAB
2,5 kehilangan kontrol berkemih sedikitnya sekali dalam sebulan
4,0 kehilangan kontrol berkemih sedikitnya 2 kali sebulan/kadang-kadang
kehilangan kontrol BAB
5,0 kehilangan kontrol BAB sedikitnya sekali dalam sebulan
5,5 kehilangan kontrol berkemih sedikitnya sekali dalam seminggu
6,5 kehilangan kontrol BAB sedikitnya 2 kali sebulan
8,0 kehilangan kontrol BAB sedikitnya sekali seminggu/kehilangan kontrol
berkemih
sedikitnya sekali setiap hari
10 kehilangan kontrol BAB sedikitnya sekali sehari
10,5 tidak bisa mengontrol fungsi berkemih sama sekali
11,5 tidak bisa mengontrol BAB sama sekali
(Johnston B, UCSF. 2009)
Total
Skor
Incontinence Scanning
Incontinence classified :
1 2,5 : Mild Incontinence

0 : No Incontinence

UI DAILY CARD

Warning Time
The time between
the onset of
urgency and or
incontinence
Significant to
patients since it
represents the
time they have to
find a bathroom
and avoid possible
incontinence

Using the Urgency Perception

Score (UPS)
with a Patient in Practice
The Urgency Perception Scale (UPS)
Describes the ability of a patient to

hold urine and finish tasks before

going to the toilet

Cardozo L et al BJU Int 2005; 95:591-596

EVALUATIO
N

PHYSICAL
ABDOMEN : peritonitis, FLUID, mass
Rectum : impaksion, sphincter tonus,

sensasi perineal, prostat

Man: skin perineum

Female: prolapsus utery
Atrophy organ: pelvis, mass , muscle
Volume urine : test cough

VOLUME PVR
URINALYSIS

1.NON PHARMACOLOGY
INTERVENTION
1. THERAPY type functional

in

man Condom Cateter

2. Female tampon , pampers
Technic Toileting
Bladder Training
Kaegel Exercise

THERAPY NON
Kaegel exercise
PHARMACOLOGY
Menemukan MUSCLE
yang tepat
Menahan otot yang digunakan
Jika merasakan perasaan tertarik maka siap latihan pelvic
Jangan lakukan pada otot lain pada waktu bersamaan atau

menahan nafas
Hanya tekan otot pelvic, tarik otot pelvic dan tahan selama 3
detik
Kemudian rileks selama 3 detik, Ulangi jangan berlebihan,
Latihan sampai 3 X -10 X

2. THERAPY PHARMACOLOGY

agonist cholinergic , inhibitor alpha

adrenergic,
anti muscarinic

Name

Agonis cholinergic
Dosis 10 25 mg/oral 6 8 hrs in elderly
SE: UlCus PeptiCum, hYpotensi on OF Postural

Inhibitor alpha adrenergic

Dosis 1 mg/oral 8 12 hrs
hypotenti on postural

Oxybutinin

Antimuscarinic effect relaxation

Metabolite in Reseptor M
antagonist muscarinic selective receptor M1, M3, M4
Dosis :2,5 5 mg/oral, 24 x perday, patch 3 mg,9 mg/
day
syrup 5mg / 15ml, transdermal gel 3%, 9%

Solifenacin

Solifenacin Succinate receptor antagonist cholinergic

Dosis : 510 mg/oral /12 x per day

BetaneCol
Prazosin

PHARMACOLOGY
Name

agonist cholinergic , inhibitor alfa

adrenergic, anti muscarinic

o Antagonis kompetitif anti muscarinik

selective
Tolterod o dosis 2 mg/ day Tolterodine : frecuension
urine
ine
o tolerance >, withdrawl <
o Patient with CKD dosage 1 mg/ day

Estroge
o incontinencia urin type Stress
n
Testos

o therapy Estrogen in menopause /

controversi
o Cream topical Estrogen and Testosterone

3.SURGERY MODULATION THERAPY

Denervation
Accupuncture / Electro Accupuncture
Electrical stimulation / neuromodulation
Cystoplastic augmentation

Denervation

SURGERY / MODULATION THERAPY

Acupuncture / Electro acupuncture

Electrical Stimulation / Neuromodulation Urinary Incontinence

Cytoplastic augmentation Urinary

THANK
YOU

Answer :
1. Mrs L, contributed UI : old, pharmacy, exercise, emosional, obesity, kognitif,

DM,

fluid intake
2. Mrs L. also

has occasional stress incontinence, which can coexist with detrusor

instabillity in women, and which may present in the perimenopausal years and even
earlier. This true stress incontinence (in contrast to stress incontinence in the
presence of urinary retention) is characterized by leakage of urine in association with
sudden increased intra-abdominal pressure during coughing, sneezing, laughing, or,
in severe cases, merely standing up.
It is due to insufficiency of the internal uretheral sphincter or pelvicfloor weakness

. Mrs L is acute incontinence was partially functional in nature an precipitated by

circumstances associated with hospitalization. Functional

(also called pseuduincontinence)

urinary incontinence

. In Mrs. Ls case, ambulatory problem due to arthritis, now complicated by problems

with her right arm and deconditioning during hospitalization, prevented her from
toileting quickly enough and she became incontinent. In addition to her ambulatory
limitation, detrusor instability, diuretic
3. Non pharmacological: Kegel exercise, pelvic floor exercise, bladder training,
catetheritation :
o. Intermitten,Indwelling,Decubitus ,Pampers
Medication that relax the detrusor muscle, such as oxybutinin or tolterodine, can
sometimes detrusor instabillity but can cause dry mouth, visual bluuring, and other
anticholinergic effects