Dr Mark Donaldson Consultant Physician in Geriatric Medicine 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 (50-100ml) 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

Transient Incontinence: 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

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 (<10% of incontinence cases) 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 patient’s 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.