Geriatric Online Module 1

URINARY INCONTINENCE IN THE ELDERLY

http://www.healthcare.uiowa.edu/igec/resources-educatorsprofessionals/geriasims/viewSimulation.asp?module=urinaryincontinence&bandwidth=bb&level=gme#
Introduction
involuntary los of urine in sucient amounts or frequency to be a social or health problem
15 - 30% of people in the community and 50% of housebound or nursing home patients
nationwide cost is $10B/year
can lead to emotional disturbances, poor sleep, social isolation, decreased mobility, reduced
recreation
risk factor for institutionalization and can cause skin rashes and dermatitis, skin infections, and
pressure ulcers
Types
ACUTE UI is the sudden onset of UI
DIAPERS mnemonic
chronic UI: gradual onset of symptoms
stress: urethral sphincter failure associated with increased abdominal pressure
loss of small amounts of urine during coughing, sneezing, laughing or other physical activities
continuous urine leakage at rest or with minimal exertion
post-surgical trauma, post-radiation therapy, alpha-adrenergic blockade
may be congenital
urge
strong sensation of urinary urgency
weak urinary stream, incomplete emptying of bladder, irritative or obstructive symptoms,
frequency
most common in patients older than 75
overflow
loss of urine due to bladder overdistention, recognized from a hx of frequent or constant
dribbling
Hx of incomplete voiding
can occur acutely post-anesthesia, after instrumentation, due to medications
common in males
functional
caused by impairments of physical and/or cognitive functioning that produce incontinence
can be aggravated by urge incontinence, diuretics
mixed
combination of urge and stress
most common in elderly females
Risk factors
advancing age and physiologic changes
not a normal part of aging
factors include cognitive dysfunction, benign or malignant prostate enlargement, extirpative pelvic
surgery, COPD, neurological disease, impaired mobility, polypharmacy, obesity, parity, estrogen
deficiency, UTI, environmental conditions that limit easy access to bathroom facilities
post void residual urinary volume increases by 75 - 100 ml
more frequent nocturnal urination
increased frequency of involuntary bladder contractions
Challenges
fewer than 50% of people

 fewer than 50% of people

family member will raise the concern
be observant for odor, absorbent pad in underwear, loss of urine during the exam
Evaluation
PmHx followed by PE and testing (UA, post void residual volume, urodynamic testing, abdominal
Xrays, cystoscopy)
Hx includes lifestyle limitations or social isolation
incontinence impact questionnaire
bladder diary
incontinence patient information form
rectal exam, genital exam, neurological exam, abdominal exam,
females: genital atrophy, prolapse, pelvic masses, perivaginal mm tone, skin conditions
males: skin conditions, abnormalities of foreskin, penis, perineum
abdominal exam: diastases rectimuscle, organomegaly, masses, perineal irritations, fluid
collections, bladder distention
neuro: innervations that aect urination, edema examination, manual dexterity
Medications
diuretics, tranquilizers, narcotics, antipsychotics, CCB, B-agonists, antispasmodics,
anticholinergics, alpha agonists, alpha antagonists
diuretics and tranquilizers can increase frequency and urgency and aggravate functional
incontinence
caeine, alcohol is a diuretic
narcotics, antipsycotics, CCB, B-agonists, antispasmodics, anticholinergics> reduced
bladder wall contractility > urinary retention> overflow incontinence
alpha agonists> increase urethral sphincter pressure> retention and frequency
alpha antagonists> reduce urethral sphincter pressure> stress leakage w/high intraabdominal pressure
Causes
disease, obesity, parity, surgery, injury, infection
stress incontinence> urethral hypermobility, intrinsic urethral sphincter deficiency, failure of the
sphincter while at rest, estrogen deficient vaginal mucosa, previous childbirth
severe stress> severe uterine prolapse or urethral sphincter damage from prostate surgery
urge incontinence> most common >60 yo
detrusor instability and hyperactivity with impaired bladder contractivity (DHIC)
atrophic vaginitis, cystitis, radiation, dementia, peripheral neuropathy, involuntary sphincter
relaxation (increased stimulation from bladder)
UTI, bladder inflammation, calculi, BPH, bladder stones, fecal impaction, MS, parkinsons,
stroke
Overflow> underactive/hypotonic detrusor
males: BDH, CaP, urethral stricture, BPH
females: genital prolapse, surgical over-correction of urethral detachment, ovarian/bladder
pathology
drugs, fecal impaction, DM, lower spinal cord injury, disruption of motor innervations of the
bladder mm
Treatment
nonpharmacological
Kegel exercise
bladder training
60-80% eective
urge: prompted voiding as behavioral therapy
pharmacological

 pharmacological
stress incontinence: alpha adrenergic drugs, oral or vaginal estrogen, imipramine
urge: anticholinergics, dicyclomine hydrochloride/propantheline, TCAs, tolterodine, estrogen
cream, Abx
estrogen only when atrophic vaginitis, UTI, cystitis, or radiation treatments are contributing
causes
overflow: discontinue rug, alpha blocker for moderate BPH
surgical
anterior repair of vagina, uterine suspension, bladder suspension
vaginal hysterectomy, artificial sphincter
abdominal hysterectomy/oophorectomy, dilation of stricture, transurethral resection of prostate
Alternative Treatment
pessaries
electrical stimulation devices> pudendal nerve
periurethral bulking injections
penile compression devices
biofeedback
vagina cones
intraurethral inserts
Referrals
uncertain diagnosis or inability to develop a management plan, failure to respond to an adequate
therapeutic trial, consideration of surgical intervention beyond hymen and symptomatic pelvic
prolapse, hematuria w/o infection, or significant persistent proteinuria
comorbidities: urge incontinence, irritative bladder symptoms, previous anti-incontinence sx,
incontinence associated w/recurrent UTI, prostate nodule, suspicion of prostate cancer,
neurological abnormality suggestive of a systemic disorder or spinal cord lesion, abnormal PVR
urine test, documented overflow incontinence
Patient 1: Mrs. Hill> chronic stress UI
73 yo woman presents for return visit for urinary incontinence
1 week ago for knee pain
noticed absorbent pad for unintentional urinary discharge
bladder diary x 1 week
stress incontinence (laughing, shoveling snow, bending over, lifting, cough, hiccup, getting up,
sneeze)
incontinence impact questionnaire
greatly: ability to do household chores and physical recreation
moderately: social activities
slightly: entertainment activities, car/bus > 30 mins, emotional health, feelings of frustration
Factors contributing
urethral sphincter failure
cystocele
furosemide
atrophic vaginal mucosal change
Treatment
kegel, estrogen vaginal cream, bladder training exercises, cessation of caeine use in morning,
pseudoephedrine/imipramine, surgical repair of cystocele, replace furosemide w/ACEi

Patient 2: Mr. Jensen> acute overflow

84 yo male at Alzheimers facility for 6 months
he experiences paranoid hallucinations and has become more aggressive

 he experiences paranoid hallucinations and has become more aggressive

started on haloperidol x 1 week
improved 3-4 days
last 2 days > increasingly agitated and incontinent
Factors
UTI
enlarged prostate
haloperidol
Therapies
intermittent or short-term indwelling Foley catheter
bladder retraining protocol
antibiotic medication
Patient 3: Mrs. Walters>Chronic mixed
66 yo woman complaining of UI
Bladder Diary + incontinence impact questionnaire + incontinence patient information form
Recommendations
kegel exercise
vaginal estrogen cream
trial of imipramine or tolterodine
bladder training
limit caeine intake prior to travel
Patient 4: Mrs. Ham> chronic functional + chronic urge
78 yo woman
1 week ago daughter brought mother bc she will not leave house and there is an odor of urine in
the house
Bladder diary + incontinence impact questionnaire + incontinence patient information form
Cause
osteoarthritis
overactive bladder
Therapies
sustained release oxybutynin (muscarinic antagonist to reduce retention)
additional treatment of OA
kegel exercises