1. Dr Mark Donaldson Consultant Physician in Geriatric Medicine
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 >50% 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 % community dwellers
50% of inpatients
At risk cases: especially anti-cholinergics
diuretics
worsening mobility

10. 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

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 Overactivity Commonest 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 (<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.

17. 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

18. Urinary Incontinence
Clinical Management
1. Exclude overflow incontinence (e.g. PVR > 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 <100ml then obstruction is excluded. If PVR > 200ml, exclude hydronephrosis. Remainder, treat for OAB – warn about retention – avoid bladder relaxants if PVR >150ml.

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 : times per day - Indefinitely - Limited efficacy - Repair procedures less invasive

21. 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

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 weeks Prazosin Tamsulosin Terazosin Finasteride 5 alpha reductase inhibitor
- Less effective - Delayed benefit - Side-effects esp. impotence.