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Urinary Incontinence in Older Adults

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Griebling TL, Penn HA: Conservative Therapy for Urinary Stress Incontinence. In: Sciarra JS (ed). Global Library of Women s Medicine (ISSN: 1756-2228) ... – PowerPoint PPT presentation

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Title: Urinary Incontinence in Older Adults


1
Urinary Incontinence in Older Adults
  • Tomas L. Griebling, MD, MPH
  • Department of Urology and
  • The Landon Center on Aging
  • The University of Kansas

2
Module Overview
  • Definitions
  • Epidemiology
  • Physiology of Micturition
  • Types of Urinary Incontinence
  • Clinical Evaluation
  • Treatments
  • Non-Surgical
  • Surgical
  • ACOVE indicators for Urinary Incontinence

3
Definitions
  • Urinary incontinence is defined as the
    involuntary leakage of urine
  • Some definitions have required that this be
    considered a social or hygienic problem
  • More widely accepted definitions assume all
    incontinence fits this criteria
  • However, the degree of bother to the patient and
    caregivers is an important consideration

4
Definitions
  • Overactive bladder OAB
  • Characterized by urinary urgency and frequency
  • May or may not be associated with incontinence
  • OAB wet leakage of urine
  • OAB dry urgency and frequency without
    leakage
  • Urinary incontinence (UI) may be chronic
    (established) or transient (temporary)
  • This module and the ACOVE Indicators focus
    primarily on chronic UI

5
Epidemiology
  • Community-dwelling older adults (gt65) with UI
  • 30 of women
  • 15-28 of men
  • Assisted living environments
  • 30-50 of women
  • 30 of men
  • Long-term care (nursing home)
  • gt 50-70 of men and women

6
Epidemiology
  • Prevalence and incidence of UI both increase with
    advancing age (both men and women)
  • However, UI should NOT be considered a normal
    part of the aging process
  • NOT an inevitable outcome of aging
  • Evaluation and treatment can help to resolve or
    at least improve symptoms

7
Epidemiology
  • Prior research has indicated that UI may be a
    significant contributing factor leading to
    nursing home placement
  • Urinary incontinence
  • Fecal incontinence
  • Behavioral issues
  • Cognitive impairment (dementia)
  • Severe physical impairments / mobility
    limitations
  • Other skilled nursing care needs

8
Epidemiology
  • Older adults with UI often do not seek evaluation
    or treatment
  • lt 50 will initiate evaluation on their own
  • Embarrassment
  • Feeling that nothing can be done to help
  • Fear that surgery is the only option
  • People with UI may not volunteer symptoms
  • Providers must ask specifically about UI
  • Often helpful to talk with an older adults
    caregivers about symptoms

9
Effects of Urinary Incontinence
  • UI has significant negative impact on both
    overall and health-related quality-of-life (QoL)
  • Social isolation
  • Depression
  • Psychological distress
  • Increased caregiver burden
  • Skin inflammation / breakdown
  • Sleep disturbance
  • ? Increased risk urinary tract infection (UTI)
  • Limitation or avoidance of sexual activity

10
Effects of Urinary Incontinence
  • Increased risk of falls and fractures
  • Urgency / frequency associated with rushing to
    reach the toilet
  • Combined with mobility impairment or visual
    changes - this leads to increased fall risk
  • Nocturia is particularly problematic
  • Getting up quickly at night
  • Orthostasis / balance impairment
  • Navigating the way to the bathroom

11
Effects of Urinary Incontinence
  • Increased risk of mortality
  • Various studies suggest an increased mortality
    risk for older adults with UI compared to
    continent
  • Persistent urinary incontinence after stroke is a
    strong predictive marker condition for subsequent
    mortality within the first year
  • Mortality risk may be associated with the results
    of UI on falls, fractures, skin breakdown, etc.

12
Costs of Urinary Incontinence
  • Estimates suggest overall costs for UI care
    exceed 20 billion / year in the US
  • More than 30 of this cost is spent on absorbent
    pads and products
  • Exceeds the overall costs for many other common
    health conditions in older adults
  • Studies of incontinent community-dwelling women
    show personal (out-of-pocket) expenses range from
    250 - 900 / year
  • More severe UI associated with higher costs

13
Costs of Urinary Incontinence
  • Costs occur in several different ways
  • Direct costs
  • Evaluation costs (provider visits, testing)
  • Treatment costs (medications, surgery)
  • Management costs (absorbent pads, products)
  • Linen and facilities costs
  • Indirect costs
  • Increased staffing in nursing home / assisted
    living
  • Caregiver costs for time away from work
  • Environmental costs (absorbent pads, products)

14
Physiology of Micturition
  • Complex series of coordinated events
  • Bladder filling and storage of urine
  • Comprehension of bladder sensations
  • Physical activity associated with normal voiding
  • Mobility to reach toilet facilities
  • Transfers on and off toilet
  • Ability to adjust clothing appropriately
  • Voiding process with adequate emptying
  • Completion of voiding, re-dressing, transfer off
    of the toilet

15
Physiology of Micturition
16
Physiology of Micturition
  • Storage of urine
  • Requires the bladder to fill at low pressures
  • No unstable bladder contractions
  • Adequate stretch of bladder detrusor muscle
    (compliance)
  • Closed external urinary sphincter
  • Normal bladder capacity 300 500 mL
  • First sensation of filling 150 200 mL
  • Sensation of need to void 200 400 mL

17
Physiology of Micturition
  • Storage of urine
  • Under sympathetic control with input from the
    cerebral cortex and frontal lobes
  • Signals transmitted via the spinothalamic tracts
    with coordination at the pontine (pons)
    micturition center
  • Increases sphincteric contraction and outlet
    resistance preventing urinary leakage
  • Pelvic floor muscular support also important to
    help with urethral and bladder neck support

18
Physiology of Micturition
  • Voiding phase
  • Coordination via the central pontine (pons)
    micturition center and sacral cord
  • Innervation via the S2 S4 sacral nerve roots
    (primarily S3)
  • Parasympathetic activity leads to relaxation of
    the external urinary sphincter, with associated
    contraction of the bladder detrusor muscle fibers
  • Somatic input to urethral sphincter via the
    pudendal nerves

19
Physiology of Micturition
  • Bladder pharmacology
  • Detrusor (bladder walls) rich in ß-adrenergic and
    cholinergic receptors
  • Influences smooth muscle contractility
  • Stimulation leads to bladder wall contraction
  • Antagonism leads to bladder wall relaxation
  • Bladder neck and urethra rich in a-adrenergic
    receptors
  • Stimulation leads to urethral contraction
  • Antagonism leads to urethral relaxation

20
Types of Urinary Incontinence
  • Identification of the type of urinary
    incontinence is important because it will
    influence options for treatment
  • In most cases, the primary type of urinary
    incontinence can be determined by careful history
    and physical examination
  • Patients may have trouble differentiating types
    of incontinence requires detailed questioning
    when obtaining history

21
Types of Urinary Incontinence
  • Stress Incontinence
  • Leakage associated with physical activity that
    increases intra-abdominal pressure (cough, laugh,
    sneeze, lifting, etc.)
  • Mechanism due to decreased outlet resistance
    compared to intra-abdominal pressures
  • Urethral hypermobility in women
  • Intrinsic sphincter deficiency (external
    sphincter) in both men and women

22
Types of Urinary Incontinence
  • Urge Incontinence
  • Characterized by sudden onset of a sensation of
    the need to void
  • Not necessarily associated with activity
  • Most common form of UI in older adults
  • Often caused by unstable contractions of the
    detrusor muscles during bladder filling
  • Frequently associated with underlying
    neurological disorders (Parkinsons, MS, stroke)

23
Types of Urinary Incontinence
  • Overflow Incontinence
  • Characterized by incomplete bladder emptying
  • Several possible causative factors
  • Obstruction
  • BPH, urethral stricture, pelvic mass, cystocele
  • Hypocontractility of bladder detrusor
  • Diabetic neuropathy, sacral spinal injury,
    stroke, disc disease, cauda equina syndrome

24
Types of Urinary Incontinence
  • Functional Incontinence
  • Caused by chronic extrinsic functional factors
    not directly associated with the bladder
  • Bladder function may be normal
  • Often associated with ADL and IADL impairments
  • Cognitive impairment (dementia)
  • Mobility impairments
  • Ambulation
  • Transfers
  • Correction of the underlying problem may improve
    or resolve the UI symptoms

25
Types of Urinary Incontinence
  • Mixed Incontinence
  • Combination of more than one type of UI
  • Most common is Stress Urge
  • Older adults may also get Urge Overflow
  • DHIC (detrusor hyperactivity with impaired
    contractility)
  • Caused by unstable bladder contractions during
    filling but poor bladder contraction during
    voiding
  • Can be difficult to treat
  • Medications (anticholinergics) to treat urgency
  • Intermittent catheterization to treat incomplete
    emptying

26
Types of Urinary Incontinence
  • Post-Prostatectomy Incontinence
  • Most often associated with radical prostatectomy
    for treating prostate cancer
  • Usually stress UI
  • 20 have some incontinence
  • 1-2 have total incontinence
  • Urethral strictures / bladder neck contractures
    may be associated with overflow
  • Radiation therapy for prostate cancer may lead to
    urinary urgency and urge incontinence

27
Types of Urinary Incontinence
  • Dribbling Incontinence
  • If occurs only after voiding, consider Overflow
    UI
  • If occurs continuously during the day, consider
    either Stress UI or Overflow UI
  • May also be suggestive of a urethral diverticulum
    in women
  • 3-Ds dribbling, dysuria, dyspareunia
  • Soft, compressible tender mass palpable on the
    anterior portion of the urethra
  • Treated surgically with resection of diverticulum

28
Types of Urinary Incontinence
  • Vesicovaginal Fistula
  • Experiences constant urinary leakage per vagina
  • Symptoms occur both day and night
  • Often associated with other clinical factors
  • Recent hysterectomy or other pelvic surgery
  • Prior pelvic radiation therapy
  • Concern for recurrent pelvic malignancy
  • Evaluation and treatment can be challenging
  • Usually treated surgically with excision and
    closure of fistula tract

29
Transient Urinary Incontinence
  • Incontinence caused by temporary condition often
    not directly associated with the bladder
  • Consider when patient has rapid onset of new
    incontinence symptoms
  • Correction of the underlying condition often
    leads to complete resolution of the incontinence
    symptoms
  • Delirium
  • Urinary tract infection
  • Inflammation
  • Atrophic vaginitis
  • Fecal impaction
  • Pharmacologic
  • Diuretics
  • ACE inhibitors (cough)
  • Ca channel blockers
  • Psychoactive agents
  • Urinary Retention
  • Polyuria
  • Endocrine (diabetes)

30
Associated Conditions
  • Fecal Incontinence and Fecal Urgency
  • Stool symptoms are very common in older adults
  • Patients generally will not volunteer information
    on symptoms of fecal urgency or incontinence
  • Many risk factors for FI overlap with UI
  • Innervation to the lower sigmoid and rectum is
    the same as the bladder (mostly S2-S4)
  • Stool impaction may lead to problems with
    diarrhea and stool incontinence

31
Associated Conditions
  • Pelvic Organ Prolapse
  • Caused by loss of pelvic floor support
  • Can occur in ALL women (including nulliparous)
  • More common in Caucasian women with a history of
    vaginal delivery
  • Classification depends on area of vagina and
    other organs involved
  • Cystocele anterior vagina with prolapse of
    bladder
  • Rectocele posterior vagina with prolapse of
    rectum
  • Enterocele apex of vagina with prolapse of
    small bowel
  • Uterine prolapse uterus descends through
    vaginal vault

32
Associated Conditions
  • Pelvic Organ Prolapse
  • Grading depends on the extent of protrusion
  • (Baden-Walker system)
  • Grade I confined to proximal ½ vaginal vault
  • Grade II extends into distal ½ vaginal vault
    but not beyond the hymenal ring
  • Grade III extends beyond the introitus (hymenal
    ring) with straining / Valsalva
  • Grade IV extends beyond the introitus (hymenal
    ring) at rest

33
Associated Conditions
  • Prostate Disease
  • Benign prostatic hyperplasia (BPH) can cause
    obstructive voiding symptoms and may lead to
    overflow incontinence
  • Treatments for BPH and Prostate Cancer may lead
    to urinary incontinence
  • TURP / Laser treatment for BPH
  • Radical Prostatectomy for Prostate Cancer
  • 20 some incontinence / 1-2 get total
    incontinence
  • Most commonly causes stress incontinence, but
    urge or mixed incontinence also possible

34
Associated Conditions
  • Normal Pressure Hydrocephalus (NPH)
  • Classic triad of symptoms
  • Urinary incontinence
  • Cognitive changes
  • Gait impairment (ataxia)
  • Treatment of NPH may lead to improvement or
    resolution of symptoms including UI
  • Early treatment (soon after symptom onset) is
    more effective than delayed treatment

35
Associated Conditions
  • Sleep Apnea
  • Associated with sleep disturbance
  • May be difficult to differentiate from nocturia
  • Studies have shown sleep apnea leads to reduction
    in the production of anti-diuretic hormone (ADH)
  • Reduced ADH with sleep apnea leads to polyuria
  • Correction of sleep apnea (C-pap) may correct
    nocturia
  • Administration of exogenous ADH (vasopressin) in
    older adults is potentially dangerous
    (hyponatremia)
  • Limited clinical research
  • Not FDA approved at this time

36
Clinical Evaluation
  • History
  • Targeted history is extremely important
  • Onset and duration of symptoms
  • Types of UI symptoms (stress, urge, overflow,
    etc.)
  • Frequency, volume, and timing of leakage
  • Precipitating factors (activity, sounds,
    temperature)
  • Fluid intake (amount, types, times)
  • Toilet access and physical environment
  • Prior treatments

37
Clinical Evaluation
  • History
  • Obstetrical history
  • Prior pelvic surgery or radiation therapy
  • Prostate disease
  • Other urologic conditions
  • Hematuria
  • Urinary tract infections (UTIs)
  • Stone disease

38
Clinical Evaluation
  • Targeted history can be very useful to identify
    the type of UI in older adults
  • History compared to urodynamic diagnosis
  • Sensitivity
  • 90.6 for Stress UI
  • 73.5 for Urge UI
  • Specificity
  • 51.1 for Stress UI
  • 55.2 for Urge UI

39
Clinical Evaluation
  • Review of Systems
  • Other urologic conditions
  • Urinary tract infections
  • Hematuria
  • Prostate disease / treatments
  • Systemic conditions
  • Diabetes mellitus (? Duration, ? Degree of
    control)
  • Neurologic conditions
  • Dementia, Parkinsons Disease, MS, history of
    stroke
  • Mobility limitations

40
Clinical Evaluation
  • Medications
  • ALWAYS consider possibility that medications may
    be causing or exacerbating UI
  • Many different classes of drugs can lead to UI
  • Diuretics Urge UI
  • May cause nocturia if taken in late afternoon or
    evening
  • Opioids, Tricyclics, Antipsychotics Overflow UI
  • Benzodiazepines Overflow UI
  • Calcium channel blockers Mixed UI
  • Cholinesterase Inhibitors Mixed UI
  • ACE inhibitors Stress UI (cough)

41
Clinical Evaluation
  • Physical Examination All Adults
  • General physical examination
  • Focused neurological examination
  • Gait and balance
  • Mobility ambulation and transfers
  • Cognitive status and affect
  • Abdominal examination mass, hernia
  • Peripheral edema
  • Skin integrity

42
Clinical Evaluation
  • Physical Examination Women
  • Pelvic examination
  • External genitalia lesions?
  • Perineal sensation (lower lumbar sacral
    dermatomes)
  • Mucosa adequate estrogenization or atrophy?
  • Pelvic floor support well supported or
    prolapse?
  • Urine leakage
  • Examine with moderately full bladder
  • Cough, Valsalva
  • Rectovaginal examination sphincter tone, mass,
    stool

43
Clinical Evaluation
  • Physical Examination Men
  • Genital / Rectal examination
  • Phallus anatomic development
  • Uncircumcised foreskin retractable?
  • Urethral meatus at tip of glans?
  • Masses?
  • Scrotum testes descended? masses? consistency?
  • Hernia examination
  • Rectal examination
  • Sphincter tone, mass, stool
  • Prostate size, consistency, symmetry, nodules?

44
Clinical Evaluation
  • Laboratory Assessment
  • Urinalysis (dipstick and microscopic)
  • Hematuria
  • Proteinuria
  • Dilutional problems (specific gravity)
  • Urine Culture
  • Very important if UTI suspected
  • Identifies bacterial organism(s)
  • Helps guide therapy

45
Clinical Evaluation
  • Uroflow and Basic Urodynamics
  • Measures speed of urine flow
  • May help to indicate possible obstruction or poor
    bladder contractility
  • However, uroflow alone cannot differentiate
    between these conditions
  • Measurement of bladder volume
  • Cystometrogram measures bladder pressure with
    filling
  • Should stay low pressure (normal compliance)
  • If pressure increases with filling, suggests
    possible detrusor instability

46
Clinical Evaluation
  • Post-Void Residual (PVR) Measurement
  • Normally empty the bladder with no residual urine
  • Acceptable PVR is controversial
  • Most would consider 100 200 mL the maximum PVR
    in older adults
  • PVR gt 200 mL may be associated with development
    of renal insufficiency or renal failure
  • Measured immediately after voiding
  • Straight catheterization
  • Bladder ultrasound (avoids instrumentation of
    urethra)

47
Clinical Evaluation
  • Complex Urodynamics
  • Multichannel studies assess both filling and
    storage and the voiding phase of micturition
  • Leak-point pressure (LPP) measurements
  • Help to identify Stress UI
  • Intrinsic sphincter deficiency (ISD) if LPP lt 90
    cm H2O
  • Insurance may require for surgical
    pre-authorization
  • Pressure-flow urodynamics
  • Simultaneous measure of urine flow and bladder
    contraction
  • Very useful to differentiate obstruction from
    hypocontractility

48
Clinical Evaluation
  • Other Testing
  • Cystoscopy
  • Required in evaluation of hematuria
  • Useful to evaluate for stones, bladder tumors,
    strictures
  • Imaging
  • Videourodynamics can help compare anatomy and
    physiology of voiding dysfunction
  • Renal imaging used to evaluate for hydronephrosis
    and hematuria
  • Renal ultrasound good for hydronephrosis /
    stones
  • Contrast based imaging (CT or IVP) important
    for hematuria

49
Clinical Evaluation
  • Voiding Diaries
  • Provide valuable information that can help
    classify incontinence type and degree of bother
  • May help diagnose other conditions (Diabetes
    insipidus, sleep apnea, or polyuria)
  • Minimal data includes time of void and leakage
  • Additional information on precipitating factors
  • If possible, measurements of each void and fluid
    intake can also be useful (more work to collect
    data)
  • Usually 2-3 days data is sufficient

50
Treatments Non-Surgical
  • Behavioral Interventions
  • Timed voiding
  • May prevent urgency or stress episodes that occur
    when bladder is full
  • Timing specific for each patient
  • Some patients will plan to get up once nightly
  • Diet
  • Avoidance of foods / beverages that irritate
    bladder
  • Caffeine, carbonation, alcohol, acidic or spicy
    foods
  • Decreasing evening fluid intake may help nocturia
  • Avoid dehydration which can make urgency worse

51
Treatments Non-Surgical
  • Clean Intermittent Catheterization
  • Used to treat chronic urinary retention and
    overflow incontinence
  • Strongly preferred over indwelling catheters
  • Lower risk of infection
  • Fewer associated complications (stones, trauma)
  • Clean (not sterile) technique
  • Catheters can be cleaned and reused
  • Requires adequate cognitive skill and hand
    dexterity (patient or caregiver(s))

52
Treatments Non-Surgical
  • Indwelling Catheters
  • Avoided if possible due to risks and potential
    complications (stones, infection, bladder cancer)
  • If required, suprapubic tubes preferred over
    urethral catheters
  • Risk of infection / colonization is the same
  • Lower risk for urethral trauma or erosion
  • Catheter changed monthly
  • Do not treat bacterial colonization
  • Impossible to fully eradicate
  • Only treat symptomatic infections
  • Avoid prophylactic antibiotics

53
Treatments Non-Surgical
  • Pelvic Floor Muscle Exercises (PFME)
  • Kegel Exercises
  • Target is the bulbocavernosus muscles
  • Effective for both men and women
  • Useful for both stress urge UI
  • Also used to treat fecal urgency and FI
  • Appropriate technique is critical for success
  • Avoid straining or Valsalva
  • Avoid fatiguing the muscles several sets of a
    few reps is best
  • If effective, must continue to do exercise or
    effect lost

54
Treatments Non-Surgical
  • Pelvic Floor Muscle Exercises (PFME)
  • Requires motivated patient
  • Need adequate cognitive function in order to
    perform exercises correctly
  • Research ongoing regarding role of PFME in
    prevention of UI
  • Men undergoing radical prostatectomy
  • Women undergoing hysterectomy
  • Important to also focus on pelvic floor
    relaxation
  • Helpful with dyspareunia

55
Treatments Non-Surgical
  • Biofeedback Therapy
  • Pressure sensor placed in the urethra, vagina or
    rectum (catheter and transducer)
  • Computer provides information back about the
    strength and duration of contractions
  • Used in conjunction with coaching from nursing
    staff or physiotherapist
  • Helps to reinforce good techniques and teach
    specific skills (fast vs. slow contractions,
    etc.)
  • Up to 6 sessions usually covered by insurance
    including Medicare

56
Treatments Non-Surgical
  • Weight Loss
  • Several studies have shown that weight loss can
    help to reduce stress UI symptoms in moderately
    or severely obese women
  • Role of weight loss on UI in men is less well
    understood
  • Effects on urge UI or other forms of incontinence
    have not been specifically examined
  • Weight loss encouraged for other associated
    health benefits (hypertension, diabetes, etc.)

57
Treatments Non-Surgical
  • Treatment of Underlying Comorbidities
  • Associated medical / neurological conditions
  • Parkinsons disease
  • Multiple sclerosis
  • Diabetes
  • Benign Prostatic Hyperplasia (BPH)
  • Sleep Apnea

58
Treatments Non-Surgical
  • Prompted Voiding
  • Patient voids on a set schedule rather than
    waiting for bladder signals which may occur to
    late to prevent leakage (like Timed Voiding) with
    prompting cues
  • Particularly useful for urgency and urge UI
  • May also improve stress UI if this occurs with
    full bladder
  • Prompting options another person, watch alarm,
    etc.
  • Requires satisfactory level of cognitive and
    physical function to toilet independently
  • Studies have shown this to be useful in the
    long-term care setting

59
Treatments Non-Surgical
  • Assisted Toileting
  • Similar to Prompted Toileting, but may used in
    cases of cognitive or functional limitations
  • Requires that caregiver(s) or staff members
    physically assist patient onto toilet, help with
    clothes, etc.
  • Most research has been in the long-term care and
    assisted living settings
  • Labor intensive process, but can be quite
    effective with appropriate patients

60
Treatments Non-Surgical
  • Medications
  • Most commonly used class of medications are the
    anti-cholinergic, anti-muscarinic drugs
  • Treat OAB and urinary urgency / urge incontinence
  • Overall these drugs have good efficacy
  • Limitations due to side effects
  • Dry mouth, constipation most common
  • Urinary retention, blurred vision
  • May worsen confusion or increase symptom
    progression in dementia
  • Contraindicated with narrow-angle glaucoma

61
Treatments Non-Surgical
  • Oxybutynin
  • 5 mg PO BID-TID
  • Extended release
  • 5, 10, 15 mg PO daily
  • Transdermal
  • Patch changed q 3 days
  • Gel applied once daily
  • Tolterodine
  • 1 or 2 mg PO BID
  • Extended release
  • 4 mg PO daily
  • 2 mg PO daily by special order
  • Darifenacin
  • Extended release
  • 7.5 or 15 mg PO daily
  • Solifenacin
  • Extended release
  • 5 or 10 mg PO daily
  • Trospium
  • 20 mg PO BID
  • Extended release
  • 60 mg PO daily
  • Fesoterodine
  • Extended release
  • 4 or 8 mg PO daily

62
Treatments Non-Surgical
  • a-agonist medications
  • Theoretically act to increase smooth muscle tone
    of the external sphincter
  • Limited clinical improvement except for very mild
    stress UI
  • Side effects limit overall clinical utility
  • a-antagonist medications
  • Useful in the management of BPH with obstructive
    voiding symptoms and nocturia
  • Tamsulosin 0.4 mg PO daily
  • Alfuzosin 0.4 mg PO daily
  • Older medications associated with more
    orthostasis
  • prazosin, terazosin, doxazosin

63
Treatments Non-Surgical
  • ß-adrenergic agonists
  • Theoretically, would lead to enhanced bladder
    contractility and better emptying
  • bethanechol
  • urecholine
  • However, in clinical practice, these medications
    do not work well, and can have significant
    systemic side effects in older adults
  • Essentially no clinical studies support the
    routine use of these medications

64
Treatments Non-Surgical
  • Estrogen
  • Systemic estrogen administration has been
    associated with INCREASED rates of stress UI in
    older women
  • Topical (vaginal) estrogen may be useful to treat
    atrophic vaginitis or help prevent UT
  • Acts to re-acidify vaginal fluid which becomes
    more alkaline after menopause
  • Enhances growth of Lactobacillus sp. which is a
    natural host-defense mechanism
  • Improves vaginal lubrication and dyspareunia
  • Fingertip application vaginally 3x/week at HS or
    estrogen ring (Estring) vaginally changed q 3
    months
  • Contraindicated if personal past history of
    breast and /or uterine cancer

65
Treatments Non-Surgical
  • Pessaries
  • Intravaginal devices designed to support the
    bladder and bladder neck
  • Useful for treatment of stress UI in some women
  • Mild incontinence
  • Non-surgical candidates
  • Also helpful for treatment of pelvic organ
    prolapse
  • Cystocele
  • Rectocele
  • Uterine prolapse

66
Pessaries
67
Treatments Non-Surgical
  • Pessaries
  • Come in a variety of shapes and sizes
  • Must be fit to the patient
  • Should not feel the device if fit correctly
  • Does involve some work for the patient or
    caregivers
  • Removed periodically (daily/weekly) for cleaning
  • Examine vaginal tissues for signs of erosion
  • Often prescribe vaginal estrogens to help keep
    tissue healthy

68
Pessary Fitting
69
Treatments Non-Surgical
  • Modifications to Physical Environment
  • May be very useful to help with mobility or
    transfer limitations, or difficulty with dressing
  • Grab bars in bathroom
  • Raised toilet seats
  • Bedside commodes
  • Hand-held urinals
  • Consider on what level of the home the toilets
    are located (main living level or need for
    stairs)
  • Can help to maintain independence for toileting

70
Treatments Non-Surgical
  • Absorbent Pad and Products
  • Should not considered a cure for UI
  • However, they may be quite useful in management
  • Help increase social interaction
  • Improve or maintain level of independence
  • Assist caregivers with routine continence cares
  • Useful for odor control
  • Advances in technology have continued to improve
    product features
  • Expensive both direct financial costs and
    environmental costs for disposal

71
Treatments - Surgical
  • Patients and providers often have a bias against
    surgery for UI in older adults
  • However, some patients may be good candidates for
    surgery if other comorbidity can be managed and
    UI is potentially treatable surgically
  • Development of minimally invasive surgeries has
    increased the use of surgery in older adults with
    UI

72
Treatments - Surgical
  • Injection Therapy
  • Used to treat Stress incontinence
  • Minimally invasive (no incision), performed with
    cystoscopy
  • Local anesthesia/sedation or general anesthesia
  • Outpatient with minimal recovery
  • Collagen vs. other agents (coated microbeads)
  • Overall success 80 in women, 15 in men
  • Need to repeat procedure in 70 patients

73
Treatments - Surgical
  • Bladder Neck Suspension
  • Used to treat Stress incontinence in women
  • Functions to correct urethral hypermobility and
    support bladder neck
  • Not as effective for treatment of intrinsic
    sphincter deficiency (ISD)
  • Marshall-Marchetti-Krantz (MMK) Stamey Raz and
    Peyrera procedures
  • Used less commonly than slings now

74
Treatments - Surgical
  • Pubovaginal Slings
  • Designed to treat Stress incontinence in women
  • Effective for treatment of both urethral
    hypermobility and intrinsic sphincter deficiency
  • Involves placement of a graft underneath the
    bladder neck or mid-urethra
  • Natural materials vs. synthetic mesh grafts
  • Vaginal incision and small lower abdominal
    incision

75
Treatments - Surgical
  • Pubovaginal Slings
  • Overall success rates
  • 85-90 initially
  • 80 overall at 5 years
  • Success rates and complications similar in older
    and younger women
  • Potential risks and complications
  • Bleeding / infection at time of surgery
  • Prolonged urinary retention
  • Possible need for surgical revision
  • Decision for surgery should not be based on age
    only

76
Treatments - Surgical
  • Artificial Urinary Sphincters
  • Prosthetic device consisting of a cuff that
    fits around the urethra at the bladder neck, a
    fluid reservoir placed in the abdomen, and a pump
    placed in the scrotum
  • Used mostly in men with post-prostatectomy
    incontinence
  • Overall success 90
  • Requires cognitive skill and hand dexterity to
    use device (must open cuff each time to urinate)

77
Treatments - Surgical
  • Sacral Neuromodulation
  • Surgically implanted in the lower back
    interactive device
  • Stimulates the S3 nerve root
  • FDA approved for treatment of
  • Urinary urgency and frequency
  • Urge urinary incontinence
  • Idiopathic urinary retention
  • Patient tests the leads with external generator
    prior to programmable battery placement
  • Overall success 85-90
  • Requires good cognition and manual dexterity to
    program

78
Treatments - Surgical
  • Urinary Diversions
  • Usually considered a last treatment option
  • Requires use of bowel segments to create
    diversion
  • Various options available depending on patient
  • Continent (dry) diversions (may require
    catheterization)
  • Indiana Pouch
  • Orthotopic neobladder
  • Non-continent (wet) diversions (uses ostomy
    appliance)
  • Ileal conduit
  • Colon conduit

79
Prevention and Continence Promotion
  • Research ongoing to look at the role of
    prevention programs for UI
  • Prophylactic use of pelvic floor muscle exercises
  • Behavioral interventions
  • Timed voiding to prevent detrusor dysfunction
  • Dietary management to avoid potential triggers
  • Prevention of UI by treating underlying
    comorbidity
  • Improved diabetes control may prevent development
    of diabetic uropathy

80
Prevention and Continence Promotion
  • Continence Promotion
  • Increased efforts for public awareness of the
    causes and treatments available for UI
  • Public service announcements
  • Celebrity spokesperson
  • More information in lay press
  • Enhanced professional education to improve
    understanding of UI for health care providers
  • US is looking at models in other countries
  • UK Continence nursing specialists (by county)
  • Australia Continence care advisors

81
Prevention and Continence Promotion
  • Quality Measures
  • Pay-for-Reporting
  • ICD codes for screening and documenting UI in
    women gt 65 years old already in place
  • Currently reporting is voluntary, but practice
    receives bonus if documentation present in gt
    85 of patients
  • Pay-for-Performance
  • Standards in development
  • Likely required implementation in near future

82
ACOVE Indicators
  • Assessing Care of Vulnerable Elders
  • 348 peer-reviewed articles considered for the
    evidence base to develop measures
  • Expert panel review of proposed indicators
  • If Then Because statements
  • 14 Quality Indicators for UI were selected
  • 1 additional Quality Indicator for Post-Void
    Residual Urine measurement also included

83
ACOVE Indicators
  • Initial Evaluation Annual Assessment
  • (1) All VEs have documentation of UI at initial
    assessment
  • (2) All VEs have documentation of UI at least
    every 2 years
  • UI is common but underdiagnosed
  • Clinical conditions may change and new onset UI
    may develop over time
  • (3) If UI present, then documentation if it is
    bothersome for the patient and/or caregiver(s)
  • Effects of UI may change with time, new or
    different treatments may be required, assess
    caregiver burden

84
ACOVE Indicators
  • Targeted History / Physical Exam / Labs
  • (4) If VE has UI w/bothersome symptoms, get
    targeted history
  • Targeted history can often identify underlying
    causes
  • Can help to guide appropriate therapy
  • (5) If VE has new UI, do targeted physical exam
  • Targeted exam can identify contributory factors
  • Can help to guide appropriate therapy
  • (6) If VE has bothersome UI, get
    urinalysis/culture
  • UA can identify hematuria and pyuria which may
    need additional investigation

85
ACOVE Indicators
  • Post-Void Residual (PVR) Measurement
  • (7) If VE has PVR gt 300 mL, get a serum
    creatinine level within 72 hours, and if no
    underlying cause found, refer to urologic
    specialist within 2 months
  • (8) If VE has PVR of 200 300 mL, then assess
    renal function within 3 months
  • Elevated PVR can be associated with deterioration
    of renal function and development of renal
    failure
  • Underlying conditions such as BPH or other outlet
    obstruction may require additional evaluation and
    treatment

86
ACOVE Indicators
  • Classification of UI Before Treatment
  • (9) If VE has new UI or chronic UI with
    bothersome symptoms and treatment is planned,
    then the type of suspected causes of UI should be
    documented
  • Classification of the type of UI or possible
    causes improves the likelihood that the
    underlying causes of UI are addressed by treatment

87
ACOVE Indicators
  • Discussion of Treatment Options
  • (10) If VE has new UI or chronic bothersome UI,
    then treatment options should be discussed within
    3 months
  • Explicit discussion of treatment options
  • Include patient, family, caregivers
  • Improves likelihood that treatment plan
    consistent with goals is formulated
  • Improves adherence to treatment plan

88
ACOVE Indicators
  • Response to Treatment
  • (11) If a VE is treated for UI, then response to
    therapy should be documented within 3 months
  • Undertreatment may occur which can adversely
    impact quality-of-life (QoL)
  • Other types of treatment may be available and may
    be more effective
  • Combination of therapies may be required to
    improve efficacy
  • Adverse events from UI treatment may occur and
    need to be identified and addressed

89
ACOVE Indicators
  • Behavioral and Lifestyle Treatments
  • (12) If a cognitively intact VE has stress, urge,
    or mixed UI, then behavioral or lifestyle
    treatment options should be offered
  • May decrease incontinence episodes without
    significant adverse side effects
  • Some behavioral therapies have been proven
    equally effective to pharmacological or surgical
    therapy
  • Older adults may prefer to try behavioral therapy
    before other interventions

90
ACOVE Indicators
  • Preoperative Urodynamic Testing
  • (13) If a female VE undergoes surgery for stress
    UI, then urodynamic investigations should be
    performed prior to surgery
  • Needed to identify the indications for the
    surgical procedure(s)
  • Helps to define the appropriate surgical approach
  • Helps to estimate the risks of surgery

91
ACOVE Indicators
  • Surgery for Stress Urinary Incontinence
  • (14) If a female VE has stress UI and undergoes a
    procedure or surgery for UI, then surgical
    correction with an open retropubic suspension,
    sling, or periurethral bulking agent should be
    offered
  • These procedures may improve stress UI
  • These procedures have an acceptable risk of
    complications

92
ACOVE Indicators
  • Catheter Use
  • (15) If a VE has clinically significant urinary
    retention, and a long-term (gt 1 month) urethral
    catheter is placed, then there should be
    documentation about justification for use
  • Use of chronic catheters is associated with risks
  • Urinary tract infection, colonization, stones,
    bladder cancer
  • Treatment of underlying causes of urinary
    retention may have less risk than catheter use
  • Constipation, fecal impaction, bladder outlet
    obstruction (BPH), diabetes, medications, etc.

93
Conclusions
  • Urinary Incontinence is a common clinical problem
    in older adults
  • UI is associated with significant negative
    outcomes on overall and health-related QoL
  • The financial costs associated with UI among
    older adults are quite high
  • Older adults and caregivers may not readily
    discuss UI with health care providers

94
Conclusions
  • Targeted history, physical examination, and
    laboratory studies may help to identify the
    underlying cause(s) and type(s) of UI
  • A wide variety of treatment options are available
    for UI in both men and women
  • Non-surgical therapies
  • Surgical therapies
  • Treatment needs to be tailored for the patient
    within the context of their goals for therapy

95
Conclusions
  • Treatment may lead to complete resolution of UI,
    or at least an improvement in symptoms which can
    make the condition more manageable
  • Improvement in UI can lead to significant
    positive health benefits for older adults and can
    help to reduce health care costs

96
Resources
  • American Urological Association (AUA)
  • www.auanet.org
  • International Continence Society (ICS)
  • www.icsoffice.org
  • Society for Urodynamics Female Urology (SUFU)
  • www.sufuorg.com
  • American Urogynecological Society (AUGS)
  • www.augs.org

97
Resources
  • The Simon Foundation for Continence
  • www.simonfoundation.org
  • National Association for Continence (NAFC)
  • www.nafc.org
  • The Continence Foundation (UK)
  • www.continence-foundation.org.uk
  • Continence Foundation of Australia
  • www.continence.org.au

98
References
  • Société Internationale dUrologie (SIU)
  • www.siu-urology.org
  • American Geriatrics Society
  • www.americangeriatrics.org
  • Gerontological Society of America
  • www.geron.org

99
Resources
  • National Institutes of Health
  • National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK)
  • www2.niddk.nih.gov
  • National Institute on Aging (NIA)
  • www.nia.nih.gov
  • Agency for Healthcare Research and Quality
  • www.ahrg.org

100
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