Transcript Geriatric Urinary incontinence

Geriatric Urinary Incontinence
Alexandra F. Suslow MD
% of Geriatric aged population
 1970
--->9.9%
 1984 -->11.5%
 1997 -- >13.1%
 2020 --> 20%
Life Expectancy
 A child
born in 1900--> <40 years
 A child of the late 60’s--> 68.5 years
 A child of the 90’s---> 72 years
 A child of the Millenium--> >75 years
Reported prevalence of UI
 15-30%
of community dwellers
(ie” independent seniors”)
 30% of elderly in acute care
 > 50% of long term care facilities (eg.
NH)
DON’T ASK
DON’T TELL
Myths and Facts
It is a normal part of
aging
 It is not a medical
issue
 “I’m not incontinent,I
just have “accidents”
 There is nothing to
do about it
 It’s just a minor
inconvenience

It is abnormal at any
age(other than infant)
 It is a medical issue,
like HTN or DM
 Any involuntary loss is
incontinence
 Alleviation and occsl.
cure are possible
 THINK AGAIN!!!

Problems due to UI
 Major
Medical Problems
 Major social issues
 Major economic issues
Medical Issues
 Pressure
ulcers leading to infections
and sepsis
 Perineal rashes
 Urosepsis
 Increased risk of falls and fractures
with subsequent increase of
morbidity/mortality
Social issues
“
Cultural conditioning leading to
stigmatization,social isolation,
depression, and increased
Psychological Morbidity”
 (Umlauff et. all)
Economical Issues, general
 Cost
of Rx of associated symptoms
(eg rashes and pressure sores)
 Routine care costs( supplies,laundry)
 Direct Medical Cost: Physician and
Diagnostics
Economical Issues, Nursing
Home
 Marked
increase in cost due to the
increase in necessary nursing care
(frequent changing of pt and linens) and
due to increase utilization of supplies
and ancilliary services
 Estimated cost $3 billion
Breakdown of costs
 Diagnostic/
medical
$6.0
0.2%
 Treatement surgical
1.2
0.04
 Treatement Pharmac.
0.7
0.02
 Routine care c catheter 104.7
3.2
 Routine care s catheter 19,061 58.4
 Sequelae (uti,falls etc) 15.71
4.8
 NH admissions due to UI 1087.7 33.3%
Total NH Cost
Us$ 3.26 Billion
(cost in 1987)
Cost in Community Dwellers
 Estimated
to be about $7 Billion,
including costs of supplies, outpatient
visits, short term hospitalizations etc.
GRAND TOTAL
• $10
billion .
•
Adjusted to 1997-->$16 billion
•
(more than cost of CABG/Dialysis combined)
Continence Determining Factors
 Intact
lower urinary tract anatomy and
function
 Adequate Mobility

Motivation

Mentation

Manual dexterity
Age Related Changes in LUT
 Women:
postmenopausal decrease in
oestrogen leading to tissue
atrophy,prolapse, changes in vaginal
flora--->incr. risk of UTI
 Men:Prostatic changes leading to
urodynamic obstruction and the
sequelae thereof
Age related changes cont’d
changes in both genders
Changes in neurotransmittor balance
and immune response.
 Anatomic changes such as
trabeculation, diverticulae, decreased
elasticity
 Involuntary detrussor contractions
 Malnutrition, dehydration leading to
fecal impaction and incr. risk of UTI

Medications
 Diuretics--.polyuria,frequency,urgency
 Anticholinergics:retention,impact.
overflow
 alpha-adrenergic blockers:urethral
relax
 alpha agonists,beta agonists, Ca
channel Blockers:urinary retention
 Ace inhibitors: cough exacerbation
Medications, cont’d
 Narcotics:
retention, impaction,
sedation, delirium
 Psychotropics: anticholinergic effect,
sedation, rigidity
 Lithium: polyuria,frequency
 ETOH: polyuiria,urgency, sedation
Classification of UI
 Transient
incontinence
 “Functional “ incontinence
 Established incontinence --LUT causes
Transient Incontinence
D
elirium
 I nfection symptomatic UTI
 A trophic urethritis
 P harmacological agents
Side effects of Specific Meds
 Anticholinergic
agents
 Frequent in prescription and OTC
meds( antihistamines)
 Causes overt and clinical retention--->
faster attainment of capacity-->
exacerbation of Detrussor overactivity
 Aggravates leakage in stress inc.
 Causes dry mouth-->polidypsia-->
increase UOP
Side Effects of Specific Meds
 Alpha
adrenergic blockers
 Found in many anti hypertensive meds
 Block receptors in the bladder neck-->
decreased tone-->agrravation of stress
incontinence
Side Effects of Specific Meds
 ACE
INHIBITORS
 Often prescribed for HTN, CHF
 Tend to exacerbate chronic cough-->
increase of stress incontinence
Transient Incontinence
D
elirium
 I nfection symptomatic UTI
 A trophic urethritis
 Pharmacological agents
 Psychiatric causes
 Excess UOP
 Restricted mobility
 Stool impaction
Established Incontinence:
LUT causes of UI
overactivity (“Urge Inc.”)
 Stress incontinence
 Overflow incontinence
 Detrussor
Goals of the Work-up
 R/o
and treat transient causes
 R/o uncommon causes : CNS,CA,stone
 Determine the type of established UI
Complaints in Detrussor
Overactivity
 Presence
or absence of “warning”
 Frequency
 Nocturia
Causes of Nocturia
 Volume
related:Excess intake, diuretic
use, metabolic/endocrine, fluid
overload, meds
 LUT Related: detrussor
instability,sensory urgency, prostatic
changes
Only 22% of incontinent patients
had pelvic/rectal exam preformed
by their Doctor
(Shame on us!!!)
Physical Exam
 Baseline
Exam (HEENT--->Extremities)
 Expanded Neurological Exam
 Stress Test
 PVR
 Urodynamic tests: cystometry

Cystoscopy
False Results of Stress test
 False
Pos: Urge during the test
 False neg:
– Stressor not strong enough
– Bladder not full
– Cystocele kinking the urethra
Management of Detrussor
Overactivity
 Bladder
Retraining
 Prompted Voiding
 “ Just Say No” to Surgery
 Pharmacological management
Drugs For DO




Others: Flavoxate, Ca chnl Blk, B-block/agonist
Imipramine
Doxepine
Anticholinergics
• Propantheline (Pro-Banthine)
• Dicyclomine (Bentyl)
• Oxybutinin (Ditropan)
• Tolterodine (Detrol)
Management of Stress
Incontinence
 Surgical
 Pharmacological
 Pelvic
mm.Strengthening
• Kegel excercises
• Vaginal Cones
• Electric Stimulation
Surgical Interventions in Stress
Incontinence
 Perurethral
injection of teflon
 Artificial Sphincter
 Colposuspension
Management of Overflow
Incontinence
Blockage:
• Conservative Rx
• alpha antagonists
• 5-alpha reductase inhibitor
• Prostatectomy
 Underactive Bladder:
• Decompression
• Catheterization
• Betanechol

Diapers and Pads
 Protect
Environment
 Maintain comfort and dignity of patient
Special Thanks
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The Lord: For everything
Pam S.: For her help (and patience) in the Library
Dr Houghton:For his help and advice for the
presentation
Stacy and Julie: The Fairy Godmothers of the
Residents
Dr Wells-Padron PharmD for the Nutrasweet
All who had to listen to the presentation over and
over and over again