URINARY INCONTINENCE - PowerPoint PPT Presentation

About This Presentation
Title:

URINARY INCONTINENCE

Description:

URINARY INCONTINENCE Dr Mark Donaldson Consultant Physician in Geriatric Medicine Urinary Incontinence Affects: 15%-30% elderly living at home 30% - 35% elderly in ... – PowerPoint PPT presentation

Number of Views:758
Avg rating:3.0/5.0
Slides: 25
Provided by: he11
Category:

less

Transcript and Presenter's Notes

Title: URINARY INCONTINENCE


1
URINARY INCONTINENCE
  • Dr Mark Donaldson
  • Consultant Physician in Geriatric Medicine

2
Urinary Incontinence
  • Affects 15-30 elderly living at home
  • 30 - 35 elderly in acute care gt50 in RCF

3
Urinary Incontinence
  • Continence requires
  • Adequate mobility
  • Mentation
  • Motivation
  • Manual dexterity
  • Intact lower urinary tract function

4
Urinary Incontinence
  • Medical Complications
  • Rashes
  • Pressure ulcers
  • UTI
  • Falls
  • Fractures

5
Urinary Incontinence
  • Psychosocial complications
  • Embarrassment
  • Stigmatisation
  • Isolation
  • Depression
  • Institutionalisation risk

6
  • Incontinence
  • is never normal

7
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 (50-100ml)
  • Also
  • Increased fluid excretion at night
  • Age associated sleep disorders
  • Detrusor muscle changes

8
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

9
Urinary Incontinence
  • Transient Incontinence
  • Common e.g. 30 community dwellers
  • 50 of inpatients
  • At risk cases especially anti-cholinergics
  • diuretics
  • worsening mobility

10
Urinary Incontinence
  • Transient Incontinence
  • D - Delirium
  • I - Infection
  • A - Atrophic Urethritis/vaginitis
  • P - Pharmaceuticals
  • P - Psychological (rare)
  • E - Excessive urine output
  • R - Restricted mobility
  • S - Stool impaction

11
Urinary Incontinence
  • Urinary tract causes of incontinence
  • Detrusor overactivity
  • Detrusor underactivity
  • Genuine stress incontinence
  • (low urethral resistance)
  • Obstruction
  • (high urethral resistance)

12
Urinary Incontinence
  • Detrusor OveractivityCommonest cause of urinary
    incontinence
  • (60-70).
  • Seen with - neurologic disorders
  • - obstruction
  • - ageing
  • - GSI
  • - DHIC

13
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

14
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

15
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

16
Urinary Incontinence
  • Detrusor Underactivity (lt10 of incontinence
    cases)
  • Usually idiopathic
  • Caused by degenerative muscle and axonal changes
  • Clinically Overflow incontinence
    Frequency Nocturia Frequent leakage of
    small amounts
  • PVR usually gt 450ml
  • In men, differentiated by urodynamics rather than
    cystoscopy or IVP.

17
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

18
Urinary Incontinence
  • Clinical Management
  • 1. Exclude overflow incontinence (e.g. PVR gt
    450ml) Where appropriate, Urologist
    referral Remainder - catheterise

19
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 lt100ml then
    obstruction is excluded. If PVR gt 200ml,
    exclude hydronephrosis. Remainder, treat for OAB
    warn about retention avoid bladder relaxants
    if PVR gt150ml.

20
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

21
Urinary Incontinence
  • Drug Treatment of OABAnti-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

22
Urinary Incontinence
Voiding and Dementia
  • Alertness
  • Responsive
  • Motivation
  • Direction
  • Mobility
  • Recognition
  • Dressing

23
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.

24
Urinary Incontinence
  • Pharmacologic Treatment Obstruction
  • Alpha blockers - delay surgery - benefit in
    weeksPrazosinTamsulosinTerazosinFinasteride
    5 alpha reductase inhibitor
  • - Less effective - Delayed
    benefit - Side-effects esp. impotence.
Write a Comment
User Comments (0)
About PowerShow.com