1. Department of Gerontology
Incontinence
Dr. Gary Sinoff
Department of Gerontology
University of Haifa

2. Incontinence

3. Definition
2 - P C - M E

4. Definition
INCONTINENCE:
Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem.
A heterogeneous condition that ranges in severity from dribbling to continuous incontinence.
If individuals lose only one or two drops of urine when they don’t want to, that’s considered incontinence!

5. Myths: People who are incontinent are: Very old Feeble Senile
Totally dependent
No longer in control

6. Brussels

7. How Common is Urinary Incontinence?
Prevalence increases with age
25-30% of community dwelling older women
10-15% of community dwelling older men
50% of nursing home residents

9. Rate of Seeking Help * **
* NIH Consensus Statement on Urinary Incontinence,1988
** Holts et al, 1988

10. Under-Diagnoses and Under-Treated
Only 32% of primary care physicians routinely ask about incontinence
50-75% of patients never describe symptoms to physicians
80% of urinary incontinence can be cured or improved

11. Why is Incontinence Important?
Social stigmata - leads to restricted activities and depression
Medical complications - skin breakdown, increased urinary tract infections
Institutionalization - UI is the second leading cause of nursing home placement

12. Anatomy of Micturition
Detrusor muscle
External and Internal sphincter
CNS control
Pons - facilitates
Cerebral cortex – inhibits
Hormonal effects - estrogen

13. Peripheral Nerves in Micturition

14. Peripheral Nerves in Micturition
Parasympathetic (cholinergic) - Bladder contraction
Sympathetic - Bladder Relaxation
Sympathetic - Bladder Relaxation (β adrenergic)
Sympathetic - Bladder neck and urethral contraction (α adrenergic)
Somatic (Pudendal nerve) - contraction pelvic floor musculature

15. Bladder Pressure-Volume Relationship

16. Potentially Reversible Causes
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction

17. Degree of Bother
YES : 53.7%

18. Medications That May Cause Incontinence
Diuretics
Anticholinergics - antihistamines, antipsychotics, antidepressants
Sedatives/hypnotics
Alcohol
Narcotics
Calcium channel blockers

19. Other factors for urinary incontinence
Sociocultural
Psychological
Muscle tone damage
Fluid intake
Diseases
Surgery

20. Categories of Incontinence
Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence

22. Incontinence In women 49% stress incontinence 22% urge incontinence
29% mixed stress & urge
In men % urge incontinence

23. Urge Incontinence Most common cause of UI >75 years of age
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder
Most common cause of UI >75 years of age
Abrupt desire to void cannot be suppressed
Usually idiopathic
Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s Disease, dementia

24. Stress Incontinence Most common type in women < 75 years old
Occurs with increase in abdominal pressure; cough, sneeze, laughing, etc.
Hypermotility of bladder neck and urethra; associated with aging, hormonal changes, trauma of childbirth or pelvic surgery (85% of cases)
Intrinsic sphincter problems; due to pelvic/incontinence surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)

25. Overflow Incontinence
Over distention of bladder
Bladder outlet obstruction; stricture, BPH, cystocele, fecal impaction
Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, MS, spinal injury, medications

26. Functional Incontinence
Does not involve lower urinary tract
Result of psychological, cognitive or physical impairment

27. Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr)
Urine Culture
Simple (bedside) Cystometrics

28. Urodynamics - Lower urinary tract
Uroflowmetry
Cystometrography
External sphincter electromyography
Pressure flow study
Videourodynamic study
Urethral pressure profilometry

29. In-Hospital Use of Continence Aids and New-Onset Urinary Incontinence in Adults Aged 70 and Older Zisberg, A, Sinoff, G, Gur-Yaish, N, Admi, E, Shadmi, E
OBJECTIVES: To describe the types of continence aids that older adults hospitalized in acute medical units use and to test the association between use of continence aids and development of new urinary incontinence (UI) at discharge. DESIGN: Prospective cohort study. SETTING: A 900-bed teaching hospital in Israel. PARTICIPANTS: Three hundred fifty-two acute medical patients aged 70 and older who were continent before admission. MEASUREMENTS: In-hospital use of continence aids was assessed according to participant self-report on use of urinary catheters (UCs) or adult diapers o of self-toileting. The development of new UI was defined as participant report of inability to control voiding at discharge. Multivariate analyses mode led the association between use of continence aids (vs self-toileting) and the development of new UI, controlling for baseline functional and cognitive status, disease severity, age, and length of stay.

30. New Onset Incontinence
RESULTS: Of the 352 participants, 58 (16.5%) used adult diapers, and 27 (7.7%) had a UC during most of the hospital stay. Sixty (17.1%) participants developed new UI at discharge. The odds of developing new UI were 4.26 (95% confidence interval (CI)51.53–11.83) times higher for UC users and 2.62 (95% CI51.17–5.87) times higher for adult diaper users than for the self-toileting group, controlling for the above risk factors.
CONCLUSION: The use of adult diapers and UCs during acute hospitalization is associated with the development of new UI at discharge. The management of continence in hospitalized older adults requires more diligence, and further investigation is needed to devise continence promotion methods in hospital settings. J Am Geriatr Soc 2011

31. Treatment Options 1

32. Lifestyle choices Reduce or eliminate caffeine
Reduce or eliminate alcohol
Drink 6 to 8 glasses of water daily
Quit smoking
Weight control
Follow a healthy diet high in fiber
Reduce physical barriers to toilet (use bedside commode)

33. Timed Voiding
Regular scheduled pattern of voiding where the intervals between voiding are gradually increased.
It reduces irritability of the bladder
Reverses bad habits
No longer needing to camp out by the bathroom promotes freedom and independence once again.

34. Treatment Options Bladder training
Patient education
Scheduled voiding
Positive reinforcement
Pelvic floor exercises (Kegel Exercises)
Biofeedback
Caregiver interventions
Scheduled toileting
Habit training
Prompted voiding 2

35. Treatment for Detrusor Overactivity
Behavioral therapy
Bladder drill
Timed/prompted toileting
Medical therapy
Anticholinergic
Tricyclic antidepressants
Neurotoxins
Estrogens
Electrical therapy
Vaginal or anal electrical stimulation
Trancutaneous electrical simulation
Surgical therapy
Partial detrusor myomectomy
Augmentation cystoplasty
Urinary diversion

36. Pharmacological Interventions
Urge Incontinence
Oxybutynin (Novitropan)
Imipramine (Tofranil)
Stress Incontinence
Phenylpropanolamine (Alcinal)
Pseudo-Ephedrine (Histafed, etc.)
Estrogen (orally, transdermally or transvaginally)

37. Surgical Interventions
Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years.
Urethral Hypermotility
Marshall-Marchetti-Kantz procedure
Needle neck suspension
Intrinsic sphincter deficiency
Sling procedure

38. Other Interventions Pessaries
Periurethral bulking agents (periurethral injection of collagen, fat or silicone)
Diapers or pads
Chronic catheterization
Periurethral or suprapubic
Indwelling or intermittant

39. Leg Bags

40. Designer Diapers

41. Pessaries

42. Indwelling Catheter

43. Fecal Incontinence

44. Fecal Incontinence
“The inability to control the passage of flatus, liquid or solid stool”
2% prevalence community, increases in NH
Profoundly disabling, also on body image
Number of different etiologies
Variety of medical and surgical treatments available

45. Normal continence mechanism
Internal sphincter (smooth muscle involuntary): maintains high resting tone
External sphincter (skeletal muscle voluntary): important in the voluntary inhibition of the defaecatory reflex

46. Factors Affecting GIT Elimination
Physiological changes with age
Physical Activity
Diet
Psychological Factors
Surgical

47. Classification of Incontinence
Pseudoincontinence
soiling, urgency, frequency
Overflow incontinence
Incontinence with abnormal pelvic floor

48. Pseudo-incontinence Perineal soiling Urgency Frequency
hemorrhoidal prolapse
fistula en ano
incomplete defecation
perianal dermatoses
Urgency
non compliant rectum (radiation)
IBD
absent rectal reservoir
Frequency
diarrheal states ie IBD, autonomic neuropathy, parasites, toxins

49. Overflow Incontinence
Rectal fecal impaction
decreased rectal sensation
obtuse anorectal angle
chronic stimulation of rectoanal inhibitory reflex
Neoplasm

50. Abnormal pelvic floor Neurogenic/Infiltrative Sphincter disruption
pudendal neuropathy
generalized neuropathy or cord lesion
Diabetes Mellitus and Scleroderma
Sphincter disruption
Obstetric
Surgical
Trauma

51. Cause of Incontinence Sphincter degeneration (internal)
Sphincter damage (external)
Nerve damage (central or peripheral)
Rectal causes – (changes in rectal capacity, elasticity or function)
Faecal impaction - (chronically distended rectum - chronically relaxed internal sphincter)

52. Examination
PR examination – tone, contractile strength, perineal descent on straining
Impacted and overflow incontinence
Anal Fistula
Haemorrhoids
Rectocele

53. Anorectal physiology laboratory
Functional - Manometric studies, Dynamic Fluoroscopy
Anatomical - Endoanal ultrasound, MRI
Neurological - Pudendal nerve latency tests

54. Manometry Voluntary anal squeeze pressure
Low resting pressure: internal sphincter abnormality
Reduced squeeze pressures: external sphincter problem
Fatigueability of the external sphincter: relevance in urge incontinence

55. Endoanal ultrasound Anatomical information
Likely be of benefit post obstetrics or surgical trauma
After first vaginal delivery 30% have demonstrated sphincter defects
1/3 of these develops symptoms incontinence/ urgency

56. Normal Endo anal ultrasound
Internal sphincter
external sphincter
Figure 12. Transverse endoanal US image obtained with a 10-MHz transducer shows normal sphincter anatomy in a 37-year-old asymptomatic male volunteer. Subepithelial tissues (SE), the internal sphincter (IS), the intersphincteric space and longitudinal muscle (IL), and the external sphincter (ES) are visible.

57. Managing Bowel Incontinence:
Note when incontinence is likely to occur and put patient on bedpan at that time.
Keep the skin clean and dry by using proper hygienic measures.
Change bed linens and clothing as necessary.
Confer with the physician about using a suppository or daily cleansing enema.
Repeated rectal examinations

58. Next Week
Iatrogenic Damage