APRN Assistant Professor UT Medical School Geriatric and Palliative Medicine Prevalence Increases with age and affects women more than men 21 until age 80 1530 in community dwellers age 65 and older ID: 700224
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Slide1
Urinary Incontinence
Kathleen Pace Murphy, PhD, MS,
APRN
Assistant Professor, UT Medical School
Geriatric and Palliative MedicineSlide2
Prevalence
Increases with age and affects women more than men (2:1) until age 80
15-30% in community dwellers age 65 and older
60-70% in older adults age 65 and older in long term careSignificantly impairs quality of lifeSlide3
Risk Factors
Obesity
Functional impairment
DementiaMedicationsEnvironmental barriers to toilet accessSlide4
Age related LUT changes
Bladder contractility decreases
Uninhibited bladder contractions increase
Diurnal urine output occurse later in dayBladder capacity decreases
Sphincteric
striated muscle attenuates
PVR increasesSlide5
Age related LUT changes- Women
In addition to the physiologic changes already discussed:
Urethral closure pressure decreases
Vaginal mucosal atrophySlide6
Age related LUT changes- Men
In addition to the physiologic changes already discussed:
Benign prostatic hyperplasia
Prostate hypertrophySlide7
LUT Pathophysiology in UI
Urge UI
Urge UI with detrusor
overactivity (uninhibited bladder contractions)
40% on urodynamic testing
Suggest detrusor
overactivity
PLUS impaired compensatory mechanisms.
Idiopathic, age-related, secondary to lesions in cerebral and spinal pathways.
Due to bladder outlet obstruction or bladder irritation (infection, stones, tumor)Slide8
LUT Pathophysiology in UI
Stress UI
Etiology
Damage to the pelvic floor supports
Sphincter failure
Leakage associated with coughing, sneezing, laughing, physical activity
Second most common form in women
Seen in men after
prostectomySlide9
LUT Pathophysiology in UI
Mixed UI with both detrusor
overactivity
and impaired sphincter support
Leakage occurs with both urgency and activity
Seen in womenSlide10
LUT Pathophysiology in UI
UI
with impaired bladder emptying
Increase PVR (200mL)Intermittent small dribbling
Frail elderly: coexistence of urge UI and PVR (in the absence of bladder outlet obstruction)= detrusor hyperactivity with impaired contractility (DHIC)
Men
prostate hypertrophy
Women
urethral surgical scarring
Large
cytocele
/prolapseSlide11
UI Screening and Evaluation
Multifactorial evaluation
Comorbidity
FuncitonMedicationQuestions to ask
Do you have any problems with bladder control?
Do you have any problems making it to the bathroom on time?
Do you ever leak urine?Slide12
Medications Associated with UI
Alcohol
Alpha-adrenergic agonists
Alpha-adrenergic blockers
ACE Inhibitors
Anticholinergic
Antipsychotics
CCB
Cholinesterase inhibitors
Estrogen
Gabapentin
Loop diuretics
Narcotics
NSAIDs
Sedative hypnotics
Thiazolidinediones
TCASlide13
UI Red Flags
Abrupt onset
Pelvic pain (constant,
w
orsened, or improve with voiding)
HematuriaSlide14
Physical Examination
Rectal Exam
Masses, fecal loading, prostate nodules or firmness
Neuro ExamSacral cord integrity (sensory)
Perianal wink (motor)
Pelvic Exam
Labial and vaginal lesions
Pelvic organ prolapse
Psychological Exam
Association between depression and UI
Sleep apnea-
nocturia
associationSlide15
Diagnostic Testing
Urinalysis
Hematuria, glycosuria
Bladder diaries (time, volume & UI episode x 48 hr)Urodynamics
Only in uncertain diagnosisSlide16
UI Treatment and Management
Lifestyle Management
Weight loss (SOE=A)
Extreme fluid intakeLimit caffinated beverages
Limit ETOH
Limit evening fluid intake
Quit smoking (stress UI)Slide17
UI Treatment and Management
Behavioral Therapies
A. Bladder training and pelvic muscle exercises
1. Effective urge, mixed, and stress UI (SOE=A)B. Prompt timed voiding in cognitively impaired
C. Biofeedback for PME
1. Medicare covers (SOE=
Unkown
)Slide18
MedicationsAnti
Muscarinics
MOA
Increase bladder capacity by decreasing basal excretion of Ach from
urothelium
Contraindicated
Narrow angle glaucoma
Impaired gastric emptying
Known urinary retention
Patient taking cholinesterase inhibitor
Drugs
Oxybutynin
Tolterodine
Fesoterodine
Trospium
Darifenacin
SolifenacinSlide19
Medications
Rx UI and OAB
MOA
Stimulation of beta 3 receptors in the detruor mediates bladder relaxation:
Myrbetriq
25-50mg QD
ADE
Increase blood pressure
Prescribe carefully in patient with renal and hepatic impairment
Many drug-drug AE like
muscarinsSlide20
Other Treatments
Intravesical
injection of botulinum toxin
Sacral nerve neuromodulationSurgery (stress UI)
Colpsuspension
(Burch Operation)
Slings (synthetic mesh, or
autologus
or cadaveric fascia)Slide21
References
Flaherty E &
Resnick
B Geriatric Nursing Review Syllabus (4th Ed). New York: American Geriatric Society; 2014.
Gulur
DM,
Mevcha
AM, Drake MJ.
Nocturia
as a manifestation of systemic disease. BJU Int. 2011; 107 (50): 702-13.
Ham, RJ, Sloan, PD,
Warshaw
, GA, Potter, JE & Flaherty E. Primary Care Geriatrics: A case-based approach (6
th
Ed.). 2014. Philadelphia: Elsevier Saunders.
Holroyd-Leduc JM,
Tannenbaum
C, Thorpe KE, Strauss SE. What type of
urinariy
incontinence does this woman have? JAMA, 2008 : 299: 1446-56.
Landefeld
CS, Bowers BJ, Feld AD et al. NIH state-of-the-science-conference statement: Prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008:148: 449-58.
Shamliyan
T, Wyman J, Kane RL. Benefits and harms of pharmacologic treatment for UI in women: A systematic review. Ann Intern Med 2012: 156(12): 861-74.