Geriatric Urinary Incontinence &

Overactive Bladder
Joseph G. Ouslander, M.D.
Professor of Medicine and Nursing
Director, Division of Geriatric Medicine and Gerontology
Chief Medical Officer,
Wesley Woods Center of Emory University
Director, Emory Center for Health in Aging
Research Scientist, Birmingham/Atlanta VA GRECC

Geriatric Urinary Incontinence &

Overactive Bladder (OAB)
An Update

Prevalence & impacts

Pathophysiology
Diagnostic evaluation
Management

Geriatric Urinary Incontinence

Prevalence
Women

Men

Community (General)

Community N H
(Frail)/
Acute Hospital

Overactive Bladder (OAB)

Urinary Frequency
>8

voids/24 hrs

Nocturia
awakening

at night to void

Urgency, with or
without urge
incontinence

Overactive Bladder
Prevalence
Telephone survey of 16,776 adults age 40+

Women

17%

Men

16%

Milsom et al: BJU International, 87:760, 2001

Overactive Bladder
Prevalence

Women

Men

Top Chronic Conditions in the U.S.

40
35

Millions

30

OAB

25
20
15
10

c itis nce
i
n h
o
ne
c
r
i
t
h n
C ro con
b In

be
t

i
le
d
o
h
rt
c
a
e
H
gh
i
H

e
st

l
o
r

D
ia

a
se

se

ic itis
n
o us
th
r
r
r
A
c
Ch sin
gi
r
lle
A

tis
i
n
hi

hm

s
ir ti

A
st

es

ce
l
U

OAB: Dry vs Wet (Urge Incontinence)

OAB

Adapted from Stewart W et al. ICI 2001

Dry
(63%)

Wet
(37%)

Spectrum of OAB and Urinary Incontinence

OAB
OAB
Stress UI z Mixed

Incontinence

Urge UI

Urgency
Frequency
Nocturia

Impact of UI & OAB on Quality of Life

Physical
Discomfort,

odor
Falls and injuries

Sexual
Avoidance

of sexual
contact and intimacy

Occupational
Decreased

productivity
Absence from work

Psychological
Fear

and anxiety
Loss of self-esteem
Depression

Quality of Life
Social
Limited

travel and
activity around toilet
availability
Social isolation

Adverse Consequences of UI & OAB

87 Y.O. woman living at

home, with minimal
assistance from family
Incontinent rushing to the
toilet at 2 a.m., slipped and
fell in urine
Sustained a hip fracture
Now confined to a wheelchair
and required admission to a
nursing home

Urge Incontinence, Falls, and Fractures

6,049 women, mean age 78.5

25% reported urge UI (at least weekly)
Followed for 3 yrs
55% reported falls, 8.5% fractures
Odds ratios for urge UI and
Falls: 1.26
Non-spine fracture:
1.34

Brown et al: JAGS 48: 721 725, 2000

Geriatric Urinary Incontinence and OAB

Predispose
Gender
Racial
Neurologic
Anatomic
Collagen
Muscular
Cultural
Environmental

Multi-factorial
Pathophysiology
Incite
Childbirth
Nerve damage
Muscle damage
Radiation
Tissue disruption
Radical surgery

Promote
Constipation Menstrual cycle
Occupation
Infection
Recreation
Medications
Obesity
Fluid intake
Surgery
Diet
Lung disease Toilet habits
Smoking
Menopause

Intervene
Behavioral
Pharmacologic
Devices
Surgical

Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.

Decompensate
Aging
Dementia
Debility
Disease
Environment
Medications

Geriatric Urinary Incontinence & OAB

Urinary
Tract

Functional/
Behavioral

Neurological

Drugs/Other
Conditions

Geriatric Urinary Incontinence & OAB

Pathophysiology
Lower urinary tract

Bladder pathology (infection, tumor, etc)

Detrusor overactivity
Women atrophic urethritis, sphincter
weakness
Men prostate enlargement
Urinary retention

Obstruction
Impaired bladder contractility

Geriatric Urinary Incontinence & OAB

Detrusor Overactivity
100

Normal
voluntary void

Bladder pressure

Involuntary
bladder contractions

100

200

300
Volume

400

Geriatric Urinary Incontinence & OAB

DHIC
% bladder emptying

100
80
60
40
20
0
Resnick, Yalla JAMA 1987;148:3076

DHIC

DH

Pathophysiology of Detrusor Overactivity

Neurogenic
Myogenic
Combination
Unknown

Geriatric Urinary Incontinence & OAB

Sphincter Weakness

Geriatric Urinary Incontinence & OAB

Pathophysiology
Neurological
Brain

Spinal cord

Stroke, dementia, Parkinsons

Injury, compression, multiple sclerosis

Peripheral innervation

Diabetic neuropathy

Geriatric Urinary Incontinence & OAB

Pathophysiology
Functional/Behavioral
Mobility impairment
Dementia
Fluid intake

Amount and timing

Caffeine, alcohol

Bowel habits/constipation
Psychological (anxiety)

Geriatric Urinary Incontinence & OAB

Pathophysiology
Other Conditions

Diabetes (polyuria)
Volume overload (polyuria, nocturia)

Congestive heart failure

Venous insufficiency with edema

Sleep disorders (nocturia)

Sleep apnea
Periodic leg movements

Requirements for Continence

Adequate:

Lower urinary tract function

Mental function
Mobility, Dexterity
Environment
Motivation (patients, caregivers)

Reversible Causes (DRIP)

D elirium
R estricted mobility, R etention
I nfection, I nflammation, I
mpaction

P olyuria, P harmaceuticals

Geriatric Urinary Incontinence & OAB

Drugs

Diuretics
Narcotics
Anticholinergics
Psychotropics
Cholinesterase inhibitors
Alpha adrenergic drugs

Persistent Incontinence
Urge

Functional

Stress

Overflow

Geriatric Urinary Incontinence & OAB

Diagnostic Assessment

History (Bladder Diary in selected patients)

Physical exam
Cough test for stress incontinence
Non-invasive flow rate (helpful in men)
Measurement of voided and post-void
residual volumes
Urinalysis

History

Most bothersome symptom (s)

Treatment preferences and goals
Medical history for relevant conditions and
medications
Onset and duration of symptoms
Prior treatment and response
Characterization of symptoms

Overactive bladder
Stress incontinence
Voiding difficulty
Other (pain, hematuria)

Bowel habits
Fluid intake

Physical Exam

Cardiovascular

Abdominal

Neurological

Perineal skin condition

External genitalia

Pelvic exam

Atrophic vaginitis

Pelvic prolapse

Rectal exam

Sphincter control

Prostate

Post-Void Residual Determination

Diabetics
Neurological conditions
(e.g. post acute stroke,
multiple sclerosis, spinal
cord injury)
Men (especially those who
have not had a TUR)
Anticholinergics and narcotics
History of urinary retention or
elevated PVR

Urinalysis
Infection
Sterile

hematuria
Glucosuria

Geriatric Urinary Incontinence and OAB

Examples of criteria for further evaluation
Recurrent UTI
Recent pelvic surgery
Severe pelvic prolapse
Sterile hematuria
Urinary retention
Failure to respond to initial therapy,
and desire for further improvement

Management of Geriatric Incontinence and OAB

Reversible causes

Supportive
measures

Behavioral
interventions

Pharmacologic
therapy

Surgical
interventions

Devices

Education

Environmental

Toilet substitutes

Catheters

Garments/pads

Management of Geriatric Incontinence and OAB

Treat Reversible Causes

Modify

fluid intake
Modify drug regimens (if feasible)
Reduce volume overload (for nocturia)
e.g.

take furosemide in late afternoon in patients

with nocturia and edema

Treat:
Infection

(new onset or worsening symptoms)

Constipation
Atrophic

vaginitis (topical estrogen)

Management of Geriatric Incontinence and OAB

Supportive Measures
Education
Environmental
Clear

well-lit path to toilet

Bedside

commodes, urinals

Catheters
For

skin problems, retention, palliative

care/patient preference

Garments/pads

Chronic Indwelling Catheters

Appropriate indications

Significant, irreversible retention

Skin lesions/surgical wounds
Patient comfort/preference

Management of Geriatric Incontinence and OAB

Undergarments and Pads

Nonspecific
Foster dependency
Expensive

Management of Geriatric Incontinence and OAB

Surgical Interventions

Stress incontinence

Periurethral injections
Bladder neck suspension
Sling procedure
Artificial sphincter

Urge incontinence

Implantable stimulators
Augmentation cystoplasty

Management of Geriatric Incontinence and OAB

Behavioral Interventions

Bladder Training

Education

Urge suppression techniques

Pelvic muscle rehabilitation

With

and without biofeedback

Toileting programs

Prompted voiding (and others)

Pelvic Muscle Exercises

Locate pelvic muscles

Squeeze muscles
tightly for up to
10 seconds

Repeat in sets
of up to 10
3-4 times/day,
and use in
everyday life
Relax completely for

Management of Geriatric Incontinence and OAB

Behavioral vs. Drug Treatment

Burgio et al: JAMA 280: 1995, 1998

Management of Geriatric Incontinence and OAB

Behavioral vs. Drug Treatment
Patient Perceptions

Behavior Drug Control

Much better

74

51

27

Better

26

31

39

Able to wear fewer pads

76

56

34

Completely satisfied

78

49

28

Continue treatment

97

58

43

Wants another treatment

14

76

76

Burgio et al: JAMA 280: 1995, 1998

Prompted Voiding
Protocol

Opportunity (prompt) to
toilet every 2 hours
Toileting assistance if
requested
Social interaction and
verbal feedback
Encourage fluid intake

Prompted Voiding
Efficacy in Research Studies

Reduces severity by half

25%-40% of frail nursing
home patients respond well
UI episodes decrease
from 3 or 4 per day to 1
or fewer
Responsive patients can be
identified during a 3-day
trial

Ouslander JG et al. JAMA 273:1366-70

Management of Geriatric Incontinence and OAB

Drug Therapy

Lower Urinary Tract Cholinergic and

Adrenergic Receptors
=muscarinic

Detrusor
muscle (M)

= 1-adrenergic

Trigone ()
Bladder neck ()

Urethra ()

Motor Innervation of the Bladder

Neurotransmitter: Acetylcholine
Receptors: Muscarinic

Pelvic Nerve

Contraction

Motor Innervation of the Bladder

Ouslander J. N Engl J Med. 2004;350:786-799

Sensory Innervation of the Bladder

Ouslander J. N Engl J Med. 2004;350:786-799

Drug Therapy for Stress Incontinence

Limited efficacy
Two basic approaches:

Estrogen

to strengthen periurethral

tissues (not effective by itself)

Alpha adrenergic drugs to increase
urethral smooth muscle tone (no drugs
are FDA approved for this indication)
Pseudoephedrine (Sudafed)
Duloxitene (Cymbalta)

Drug Therapy for Urge UI and OAB

Antimuscarinic/Anticholinergics
-Blockers

Estrogen (topical)

Men with concomitant benign prostatic

enlargement
May be a helpful adjunct for women with
severe vaginal atrophy and atrophic vaginitis

DDAVP (Off label in the U.S.)

Carefully selected patients with primary

complaint of nocturia

Drug Therapy for Urge UI and OAB

Darifenacin (Enablex)
Oxybutynin (Ditropan)
IR
ER ( XL)
Patch (Oxytrol)
Solifenacin (Vesicare)
Tolterodine (Detrol)
IR
Long-acting (LA)
Trospium (Sanctura)

Drug Therapy for UI and OAB

Several factors influence the decision to use

pharmacologic therapy:
Degree

and bother of symptoms

Patient/family
Risk

preference

for side effects/co-morbidity

Responsiveness
Cost

to behavioral interventions

Drug Therapy for Urge UI and OAB

Anticholinergics: meta-analysis

32 trials; most double-blind; 6,800 subjects

Significant effects on:
Incontinence

and voiding frequency

Cure/improvement
Bladder capacity

Modest clinical efficacy vs. placebo

Measured over short time periods

Herbison P, et al. BMJ. 2003;326:841-844

Drug Therapy for Urge UI and OAB

Efficacy

~ 60 - 70% reduction in urge UI

~ 30 - 50% placebo effect

Efficacy is similar in elderly vs. younger

Adverse events

Dry mouth ~ 20-25% (~ 5% severe)

Others less common

Potential Side Effects of Antimuscarinic Drugs

CNS
Somnolence
Impaired Cognition

Iris/Ciliary Body = Blurred Vision

Lacrimal Gland = Dry Eyes
Salivary Glands = Dry Mouth
Heart = Tachycardia
Stomach = GERD
Colon = Constipation
Bladder = Retention

Antimuscarinics and Cognition

Antimuscarinic drugs used for the

bladder can theoretically cause
cognitive impairment
ACh is a pivotal mediator of shortterm memory and cognition
Cholinergic system involvement
in Alzheimers disease has been
clearly established
Of the 5 muscarinic receptors M1
appears most involved in memory
and learning

Antimuscarinic Drugs and Cognition

Vasculature

Tolterodine

Darifenacin

+ +
+
+ + +
+ +

High lipophilicity,
Neutral
Relatively small

Oxybutynin,
Solifenacin
Trospium

Low lipophilicity
Charged
Relatively bulky

BBB

++

Relatively bulky
Highly polar
Lipophilic, small
M3 selective

++ ++ ++
++ ++
++
++

++

CNS

Summary
1.

2.
3.

4.

5.

UI and OAB are common conditions in the geriatric

population, and are associated with considerable
morbidity and cost
The pathophysiology is multifactorial, and many
potentially reversible factors can contribute
All patients should have a basic diagnostic
assessment, and selected patients should be referred
for further evaluation
A variety of treatment options are available; behavioral
interventions and drug therapy for urge UI and OAB
are most commonly prescribed
Treatment should be guided by patient preference,
their most bothersome symptoms, and the
pathophysiology felt to underlie these symptoms