Department of Geriatric Medicine John A Burns School of Medicine July 12 2017 Case Mrs Kim is a 65 year old lady who works at the perfume shop at the mall She reports slight leakage of urine for more than 10 years that has now become much worse in the last 3 months She has to change her u ID: 647638
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Slide1
Urinary Incontinence
Project ECHO
Department of Geriatric Medicine
John A. Burns School of Medicine
July 12, 2017Slide2
Case
Mrs. Kim is a 65 year old lady who works at the perfume shop at the mall. She reports slight leakage of urine for more than 10 years that has now become much worse in the last 3 months. She has to change her underwear every 2-3 hours when she is up and around.
Her friends have told her that this is a “normal” part of aging, but she comes to your office because she is worried she might lose her job, She is hoping you can do something about it.Slide3
CASE
She denies dysuria, states it is more of a problem during the day than the night. She does say she is afraid to cough, laugh or sneeze as these sometimes may cause “accidents”. She is also afraid of drinking too much water because it might worsen the leakage.
She denies any history of UTI in the last year. She has 5 children, all vaginal deliveries.Slide4
Prevalence
Affects 15%–30% of community-dwelling older adults
Affects 60%–70% of residents of long-term-care institutions
Prevalence increases with age
Affects more women than men (2:1) until age 80 (then 1:1)Slide5
Impact
5
Morbidity
Cellulitis, pressure ulcers, UTIs
Sleep deprivation, falls with fractures, sexual dysfunction
Depression, social withdrawal, impaired quality of life
Costs: >$26 billion annuallySlide6
Comorbidities that can cause or worsen UI
6
Affective and anxiety disorders
Alcoholism
Arteriovascular disease
Chronic cough
Congestive heart failure
Constipation
Degenerative joint disease
Delirium
Dementia
Depression
Diabetes
Hypercalcemia
Mobility impairment
Multiple sclerosis
Normal-pressure hydrocephalus
Parkinson disease
Peripheral venous insufficiency
Psychosis
Sleep apnea
Spinal cord injury
Spinal stenosis
Stroke
Vitamin B
12
deficiencySlide7
Age Related Urinary Tract Changes
Decreased bladder contractility
Increased inhibited bladder contractions
Diurnal urine output shifted later in the day
Sphincteric striated muscle attenuated
Decreased bladder capacity
(Modest) Increased postvoid residual (PVR)
Decreased urethral closure pressure and vaginal mucosal atrophy (women)
Benign prostatic hyperplasia and prostate hypertrophy (men)Slide8
Workup for Reversible CAUSES
D
ementia, Delirium, Diabetes
I
nfection
A
trophy
P
harmacology
E
xcessive Output
R
estricted Mobility
Stool Impaction30-50% of incontinence are transient Slide9
Types of UI
Urge UI
detrusor overactivity (DO) (uninhibited bladder contractions)
Stress UI
impaired urethral sphincter support and/or closure
Mixed UI
both DO and impaired sphincter support/function
Overflow
impaired bladder emptying due to bladder obstruction and/or detrusor underactivitySlide10Slide11
Assessment: Overview
Screening
History: including quality of life
Physical examination: include cardiovascular, abdominal, musculoskeletal, neurologic, & genitourinary exams
Testing: bladder diary, stress test, urinalysis, renal function
Optional: PVR, urodynamics, cytology, other lab testsSlide12
screening
All older patients, especially women, should be asked at least every 2 years about UI:
Do you have any problems with bladder control?
Do you have problems making it to the bathroom on time?
Do you ever leak urine?
If positive, screen for UI, then ask classification questions
(see next slide)Slide13
Screening
Do you leak urine most often
:
When you are performing some physical activity, such as coughing, sneezing, lifting, or exercising?
(stress UI)
When you have the urge or feeling that you need to empty your bladder but cannot get to the toilet fast enough? (urge UI)
With both physical activity and a sense of urgency? (mixed UI)
Without physical activity and without sense of urgency? (other)Slide14
History
Ask about specific symptoms
: onset, frequency, volume, timing, amount/types of fluid
Identify associated factors
: bowel & sexual function, medical conditions, medications, access to toilets
Establish goals of care and impact on quality of life
: patient’s, caregiver’s, complete continence, fewer pad changes
Red flag symptoms
: abrupt onset, pelvic pain, hematuria (neurologic disease or cancer)Slide15
Assessment
General
: cognitive and functional status, focus on signs of associated comorbidities, depression screening, sleep apnea screening if nocturia
Cardiovascular
: volume overload, peripheral edema, CHF
Abdominal
: masses, tenderness, palpation (insensitive and nonspecific for bladder distention)
Musculoskeletal
: mobility, manual dexterity
Neurologic
: cervical disease suggested by limited lateral rotation & lateral flexion, interossei wasting, Hoffmann's or Babinski’s sign; lower-extremity motor or sensory deficitsSlide16
Assessment
Genitourinary
:
Men: prostate consistency, masses (cannot tell size by DRE); if uncircumcised, check for phimosis, paraphimosis, balanitis
Women: vaginal mucosa for atrophy, pelvic support, prolapse
Sacral reflexes
Anal wink
Bulbocavernosus reflexSlide17
Assessment
Bladder Diary
Clinical Stress Test
Post Void Residuals
not routinely done
Hx prior urinary retention, longstanding DM, recurrent UTI, severe constipations, suspect medications, prolapse, prior surgery
Urinalysis
- the only recommended test! hematuria, glycosuria
Urodynamic testing
not routinely done in older adults (usually multifactorial)
when to consider: empiric therapy failure, specific dx unclear, before surgical interventionSlide18
Management
Goal: relieve the most bothersome aspect(s)
Stepped management strategy:
1 - Lifestyle changes
2 - Behavioral Therapy
3 - Medications
4 - SurgerySlide19
Lifestyle
Correct/address underlying medical illnesses, functional impairments, and medications that may contribute to UI
Weight loss for moderately obese
Manage fluid intake: avoid caffeine, alcohol; minimize evening intake
In smokers with stress UI: tobacco cessationSlide20
Behavioral: Cognitively Intact
Urgency suppression
Be still, don’t run to the bathroom
Do pelvic muscle contractions
When urgency decreases, then go to the bathroom
Scheduled voiding while awake
Initial toileting frequency: About 2 hr, or use the shortest interval between voids from bladder diary if possible
After 2 days without leakage: ↑ time between scheduled voids by 30–60 min until can go 4 hours without leakage
Success may take several weeks; reassure patientSlide21
Behavioral: Cognitively Impaired
21
Only prompted voiding is proven effective
Patient is prompted to void, placed on toilet, and given positive feedback after voiding
Schedule optimally based on frequency of UI
Requires caregiver training, motivation, continued effortSlide22
Pelvic muscle Exercises
Requires motivated patient & careful instruction and monitoring by health professionals
Exercise prescription:
Focus on isolation of pelvic muscles; avoid buttock, abdomen, thigh muscle contraction
Repeat strongest possible contraction: 3 sets of 8–10 contractions; aim for 6–8 sec (usually 1–2 sec to start)
Start doing PME 3–4 times per week; increase duration and frequency, and continue for at least 15–20 weeksSlide23
Medications:
Stress incontinence
No medication has been FDA approved for the treatment of stress incontinence.
Off-label medications:
Pseudoephedrine 60mg Q4-6H; max 240mg/day
Phenylephrine 10-20mg Q4H up to 7 days
Duloxetine 20-40 mg twice dailySlide24
Medications:
Urge incontinence
Anticholinergic agents:
Darifenacin
,
fesoterodine
,
oxybutinin
,
solifenacin
,
tolterodine
,
trospiumBeta 3 agonist: mirabegronNeuromuscular blocking agent: onabotulinumtoxinASlide25
Medications:
Urge incontinence
Tolterodine
: 2 mg BID (IR), or 4 mg QD (ER); may cause QT prolongation
Transdermal
oxybutinin
: one patch (3.9 mg/day) applied twice weekly (every 3 to 4 days); can be applied to abdomen, hip, or buttock; should not be exposed to sunlight
Mirabegron
: 25 mg once daily; may give 50 mg once
daily
OnabotulinumtoxinA
: 20 injections of 0.5 mL for a total dose of 100 units/10 mL; may consider retreatment after a MINIMUM of 12 weeks; prophylactic antimicrobial therapy should be administered prior to and following
onabotulinumtoxinA
treatmentSlide26
Medications:
Mixed incontinence
Mixed incontinence displays symptoms of both stress and urge incontinence.
Treatment options are the same as for stress and urge incontinence.Slide27
Medications causing incontinence
Alpha-antagonists: may relax urethral sphincter
ACE
inhibitors: may cause chronic cough
Diuretics:
may cause rapid accumulation of urine
Alpha-agonists, TCAs, CCBs, narcotic analgesics, and antipsychotics may cause overflow incontinence by increasing urethral resistance or closure pressureSlide28
Requirements for Continence
Mobility
Manual dexterity
Cognitive ability to recognize and react to bladder sensation; motivation to stay dry
Absence of medical conditions and factors affecting bladder and general function
Balance and coordination of bladder contraction & urethral closure mechanisms, and their central & peripheral controlSlide29
Minimally invasive procedures
Sacral nerve neuromodulation has some effect for urge UI refractory to drug treatment and urinary retention (idiopathic and neurogenic)
Peroneal nerve stimulation ― less invasive procedure under investigation for the same indications
Intravesical injection of botulinum toxin for refractory urge UI; FDA-approved for this indication in people with neurologic conditions
Pessaries for women with stress or urge UI exacerbated by bladder or uterine prolapseSlide30
surgery
Highest cure rates
Approach depends on underlying defect, whether there is coexistent prolapse
Most common:
Colposuspension
Slings
Periurethral injection of collagen for short term (≤1 year)
Artificial sphincters (for refractory stress incontinence from sphincter damage (eg, after radical prostatectomy)Slide31
Back to the Case…
Mrs. Kim is a 65 year old lady who works at the perfume shop at the mall. She reports slight leakage of urine for more than 10 years that has now become much worse in the last 3 months. She has to change her underwear every 2-3 hours when she is up and around.
Her friends have told her that this is a “normal” part of aging, but she comes to your office because she is worried she might lose her job, She is hoping you can do something about it.Slide32
Back to the Case…
She denies dysuria, states it is more of a problem during the day than the night. She does say she is afraid to cough, laugh or sneeze as these sometimes may cause “accidents”. She is also afraid of drinking too much water because it might worsen the leakage.
She denies any history of UTI in the last year. She has 5 children, all vaginal deliveries.Slide33
Back to the Case…
What kind of incontinence does the patient have?
What can we advise her?