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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:

Adequate mobility
Mentation
Motivation
Manual dexterity
Intact lower urinary tract function

Urinary Incontinence
Medical Complications

Rashes
Pressure ulcers
UTI
Falls
Fractures

Urinary Incontinence
Psychosocial complications

Embarrassment
Stigmatisation
Isolation
Depression
Institutionalisation risk

Incontinence
is never normal

Urinary Incontinence
AGEING BLADDER CHANGES
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 (50100ml)
Also:
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
IA
P
P
E
R
S-

Delirium
Infection
Atrophic Urethritis/vaginitis
Pharmaceuticals
Psychological (rare)
Excessive urine output
Restricted mobility
Stool impaction

Urinary Incontinence
Urinary tract causes of
incontinence:

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

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

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

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
cases)

(<10% of incontinence

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 patients 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)

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

Alertness
Responsive
Motivation
Direction
Mobility
Recognition
Dressing

Urinary Incontinence
Indications for Urodynamics

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

Alpha blockers
delay surgery
benefit in weeks
Prazosin
Tamsulosin
Terazosin
Finasteride 5 alpha reductase inhibitor
-

Less effective
Delayed benefit
Side-effects esp. impotence.

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