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Urinary Incontinence Project ECHO Urinary Incontinence Project ECHO

Urinary Incontinence Project ECHO - PowerPoint Presentation

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Urinary Incontinence Project ECHO - PPT Presentation

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

incontinence bladder urge stress bladder incontinence stress urge medications amp leakage urine day women year impaired pelvic urethral disease

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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 underactivitySlide10
Slide11

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?