Transcript Approach_to_Incontinence

Geriatric Incontinence and
LUTS
Objectives
Recognize age related lower urinary tract
changes
Appreciate unique aspects of geriatric
voiding problems
Distinguish among various forms of
incontinence
Appreciate how non-urinary issues
contribute to continence
Key Points
LUTS are common among the elderly
Patients frequently don’t mention it &
physicians often don’t ask
Both patient and doctor frequently
consider it a part of “normal aging”
LUTS are morbid, costly and lead to poor
QOL
Majority of patients can be helped
Case Presentation
84 yo male with spinal stenosis/immobility, mild
dementia and parkinsonism develops fecal
impaction and acute urinary retention. Prior to
this he had frequent urgency, nocturia and
occasional incontinence
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–
–
–
Urinary catheterization 1.5 liters urine
Moderate size prostate
No hematuria, urine culture negative
PSA 4.2
Acute Management
What is the appropriate immediate
management?
– Refer for TURP
– Intermittent clean intermittent catheterization
– Begin alpha blocker
– Place Foley and begin alpha blocker, treat
fecal impaction
Long Term Management
Failed 3 voiding trials (persistent retention)
over 4 weeks
How do you manage at this point?
– Proceed with surgical options immediately
– Continue more voiding trials
– Clean intermittent catheterization
– Chronic indwelling Foley
Lower Urinary Tract Symptoms
Storage
Urgency
Frequency
Nocturia
Urge incontinence
Voiding
Hesitancy
Poor flow
Intermittency
Straining
Terminal dribble
Changing Paradigm of LUTS
Historically men with LUTS were
considered to have “prostatism”
– Elderly patients show higher rates of
persistent symptoms/dissatisfaction after
TURP
Women frequently assumed to have stress
or urge incontinence
– Surgical procedures, pessaries, Kegel’s
exercise
“The Bladder Is an Unreliable
Witness”
Bates 1970
The Unreliable Witness
Many asymptomatic elderly have UD
evidence for detrussor overactivity
UD evidence of bladder outlet obstruction
can be completely asymptomatic
Elderly woman frequently have high
scores on IPSS and AUA symptoms
scales
Among elderly men with BPH, many have
residual symptoms after TURP
ICS Definitions
Urgency
– “Sudden compelling desire to pass urine which is difficult to defer”
– Differs from the “normal desire to void”
– Pathological
Frequency
– The complaint that an individual urinates too much, typical
~8x/day
Nocturia
– The complaint of awakening to void >1 time/night
Urge Incontinence
– involuntary leakage accompanied by or immediately preceded by
urgency
LUT Changes in Aging
Increased
Detrussor over activity
Nocturnal urine output
BPH
Post void residual
<100cc~90%
Bacteruria~20%
Decreased
Bladder contractility
Bladder sensation
Sphincter strength
LUTS and Aging
Almost always multifactorial
Age associated LUT changes and
comorbid disease associated
Major impact of conditions beyond the
urinary tract in LUTS
Mobility, dexterity & cognitive influence on
continence
Aging and Continence
Most elderly people remain continent in
spite of age associated LUT changes
Multiple factors interact to determine
continence status
Intervention on all the contributing factors
frequently yields good results
Looking for the one cause is wrong
paradigm
Cerebral Control of Micturition
Increasing research reveals that much of
geriatric voiding dysfunction is “beyond the
bladder”
Cortical & sub-cortical control over bladder
function
Mostly inhibitory control that requires intact
attention, working memory, executive
functions
Incontinence
Common, morbid & costly
25% of community dwelling elders are
incontinent
50% of nursing home residents
Leads to isolation, embarrassment,
depression
Associated with falls, fractures, skin
problems and institutionalization
Why is Incontinence Important?
Social Stigma – leads to restricted activities
Depression
Medical complications – skin breakdown and
Increase in urinary tract infections
Institutionalization – UI is the second leading
cause of nursing home placement
Types Incontinence
Transient vs. chronic
Stress
Urge
Overflow
Functional
Transient Incontinence
Delirium
-Infection
-Atropine vaginitis or urethritis
-Pharmaceuticals
-Psychological disorders
-Endocrine Disorders
-Restricted mobility
-Stool impaction
Stress Urinary Incontinence
Involuntary leakage on effort or exertion,
or on sneezing or coughing
The sign of stress incontinence is the
observation of urine loss from the urethra
during coughing or straining
Cough stress test may be useful
Tends to be small amounts of leakage
Overflow Incontinence
Leakage of urine associated with urinary
retention
May be due to bladder outlet obstruction or poor
bladder contractility
– BPH with BOO
– Urethral stricture, tumor
– Diabetic cystopathy, multiple sclerosis, cauda equina
etc.
Urodynamic studies to evaluate pressure/flow
Overactive Bladder
Urgency, with or without urge
incontinence, usually with frequency and
nocturia . . . if there …is no proven
infection or other etiology
Equally common among men and women
in the very elderly
2/3 of OAB patients are “dry”
Dry patients still suffer
OAB Symptom Definitions
Urgency: a sudden compelling desire to pass urine
that is difficult to defer
Urgency Urinary Inc. (UUI): involuntary leakage
accompanied by or immediately preceded by
urgency
Frequency: 8 voids / day = “normal”
Nocturia: patient wakes one or more times at night
to void (sleep “before” and “after”)
Abrams P, et al. Urology. 2003;61:37-49.
Prevalence of OAB
Age and Gender
Prevalence of OAB
• Men: 16.0%
• Women: 16.9%
40
Men
Women
35
Prevalence
(%)
30
25
20
15
10
5
0
<25
25-34
35-44
45-54
55-64
Age (years)
Stewart WF, et al. World J Urol. 2003;20:327-336.
65-74
75+
OAB Treatment Rates by Age Group
25.00%
20.00%
19.60%
15.00%
18.40%
10.00%
8.70%
9.30%
5.00%
0.00%
60-64
Source: IMS Retail Perspective
65-74
Age
75-84
85+
Usual Evaluation
History
– Urge
– Stress
– Symptom scales
Physical examination
– Pelvic, rectal/prostate, abdominal, neurologic,
cognitive, cardiac/pulmonary
– Cough stress test
Labs
– Urinalysis, culture?, ?psa, post-void residual
– Frequency volume chart
Detrussor Hyperactivity with
Impaired Contractility
DHIC common among frail elders
May predispose to acute urinary retention
Elevated PVR
Bladder is both paradoxically weak and
overactive
Behavioral Management
Pelvic floor exercises
Bladder training
Biofeedback
Prompted voiding
Fluid limitation
Dietary modifications
Continence products
Expectations of Treatment
Complete dryness may not be feasible
Decreased urgency episodes
Decreased incontinent episodes
More lead time
Tolerability of current therapies
Newer OAB Medications
Oxybutinin
– Immediate, delayed release, patch form
Tolteradine
– Immediate, delayed
Trospium
Darifenacin
Solafenacin
– Immediate and long acting form
OAB Therapy for Refractory
Botulinum toxin injection
Neurostimulator
Vanilloid bladder washings
When to Refer
Failure to improve with current therapy
Persistently elevated PVR
Interest in surgical/interventional options
Complex neuro-urological cases
Abnormal findings (hematuria,
hydronephrosis, elevated PSA, etc.)
LUTS in Men Recent Advances
IPSS scores not specific for BPH with
BOO
Combined BPH and OAB therapy
PDE inhibitors
Nocturnal polyuria therapy
Case Presentation
83 yo male complains of 5-6 episodes of
nocturia for the past 6 months.
Denies dysuria, straining, or hesitancy,
past episode of transient acute urinary
retention during hospitalization for knee
replacement 4 years ago.
Exam shows enlarged smooth prostate,
moderate peripheral edema, and venous
stasis changes
Which is the most likely to be
helpful?
Trial of alpha blocker
Urinalysis
Overactive bladder medication
Trial of 5-alpha reductase inhibitor
Referral for TURP
Voiding diary and compression stockings
Diagnosis?
Benign prostate hypertrophy
Urinary tract infection
Normal aging
Overactive bladder
Diabetes insipidus
Nocturnal polyuria
Nocturia
Definition
– Waking up to void one or more times during
the night
– Voiding during intended sleep time that is
preceded and followed by sleep
Associated with mortality
Disruptive to sleep, contributes to fatigue
Increased risk for falls 10% vs. 21% with 2
or more voids
Percentage of men with nocturia
Prevalence of nocturia
in men
50
45
40
35
30
25
20
15
10
5
0
1 void
2 voids
18-34
35-54
55-74
Age range (years)
>75
Percentage of women with nocturia
Prevalence of nocturia
in women
50
45
40
35
30
25
20
15
10
5
0
1 void
2 voids
18-34
35-54
55-74
>75
Age range (years)
van Dijk et al. 2002
Diagnostic algorithm
NOCTURIA
Bother
No Bother
No Presentation
Patient Presents
Screen
Advice
Further Evaluation
Polyuria
Nocturnal Polyuria
Apparent Bladder
Storage Problems
Other Classification
Primary Sleep Disorder
Nocturnal Polyuria
>33% of total urine volume produced while
asleep
– Changes in atrial natriuretic peptide, ADH secretion
Consider occult sleep apnea
– 30-40% will have significant OSA
CHF and venous insufficiency
Therapeutic options
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Limit evening fluids/behavioral modification
Evening loop diuretics
DDAVP therapy
Dried fruits?
Pharmacological treatment of
nocturnal polyuria
Diuretics
• Helpful in patients with lower limb venous
•
insufficiency or congestive cardiac failure
Level 1 evidence, Grade C recommendation
• Bumetanide 1 mg p.o. in afternoon
• Furosemide 40 mg p.o. in afternoon
Antidiuretics
• Helps retain water until a more appropriate
•
•
time
Reduce nocturnal voids and voided volume
Level 1 evidence, Grade A recommendation
• Desmopressin 0.1 mg p.o. titrated to 0.4 mg
• No direct bladder effect
• No direct cardiovascular actions
Bothersome Nocturia
MEDICAL HISTORY
• Other urinary tract symptoms/ Sleep history/ Drinking habits (quantity and
type)/ Medication (e.g., diuretics)
History/Clinical
Assessment
EXAMINATION
• Ankle oedema/Abdominal examination/Prostate assessment/Female pelvic
assessment/Assess post-void residual urine
INVESTIGATIONS
• Urinalysis – if infected, treat and reassess
Frequency Volume Chart
Presumed
Diagnosis
GLOBAL POLYURIA (24h
voided volume >40 ml/kg)
• Electrolytes
• Serum glucose
Lifestyle advice
NOCTURNAL POLYURIA
(nocturnal urine volume >
33% of total 24h urine
volume (age dependent)
Lifestyle advice
Non-responders
Treatment
Non-responders
• Desmopressin bed-time
• Furosemide in the afternoon
Non-responders
Specialist referral
OTHER AETIOLOGY
• Overactive bladder
• Bladder outflow obstruction
• Sleep disturbance
• Cardiac disease
• Gynaecological abnormality
• Bladder pain or bleeding
Further evaluation and
appropriate treatment
Non-responders
Summary
Incontinence is not a “normal” part of
aging
LUTS and OAB are very common
Most LUTS in the elderly are multifactorial
Don’t assume BPH is the etiology among
elderly men
Use frequency-volume charts to diagnose
nocturnal polyruria
Multiple treatment options exist for most