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長照體系內失禁評估與處置 台北榮總高齡醫學中心 彭莉甯 Urinary Incontinence Normal urinary continence Thirugnanasothy BMJ 2010 Innervation of the Lower Urinary Tract (LUT) Brain T10–L2 T10–L2 Bladder detrusor Bladder smooth muscle detrusor smooth muscle Internalsphincter sphincter Internal smoothmuscle muscle smooth S2–S4 S2–S4 Intramural skeletal skeletal muscle muscle Intramural Extramural Extramural skeletalmuscle muscle skeletal Urethral smooth muscle muscle Urethral smooth Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83. Normal Urinary Continence Stable bladder wall Intact pelvic floor Intact neurology Manual dexterity Normal cognition Normal physical function Barrier free environment Age-Related Changes detrusor contractility urinary flow post-voiding residual urine total bladder capacity ability to postpone voiding Detrusor overactivity (20% of healthy continent) nocturia prostate size Atrophic vagintis & urethritis DuBeau CE.Urinary Incontinence.Geriatric Review Syllabus Fifth Ed.2002-2004.139-148 Definition UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. International Continence Society Symptoms of urinary tract dysfunction Hesitancy Post-voiding dribbling Urgency Urinary incontinence Leaking on strain or coughing Frequency Prevalence of Urinary Incontinence 15-30% of community dwelling persons 65 years and older. F>M until age 80 years, then M=F Up to 50% in LTCF Under-reported and delay seeking help. Clinical Impact of Urinary Incontinence Physical • Increased fall risks • Sleep deprivation • Pressure sore • Urinary tract infection Psychological • Depression • Anxiety • Social withdrawal • Interference with activities • Increase care burden Socioeconomical • Increased cost of care • Pad • Clothes • Caregiver Consequences “I don’t go out, I don’t even ask anyone round………. I’m so embarrassed about the smell. I do try and keep myself clean but it gets onto your clothes and furniture. Sometimes I wish that I hadn’t survived because it’s no life I’m leading now” Fe male stroke survivor Risk Factors for UI 1/3 have multiple conditions Stroke Diabetes Parkinson’s Disease Obesity, CHF, Constipation, TIAs, COPD, Chronic cough Impaired mobility & ADLs Depression Dementia (moderate to severe) Heterogeneous residents in LTCF Dementia and functional impairments are frequent contributors Types of Urinary Incontinence Transient UI (Acute) Established UI (Chronic) Urge UI Stress UI Overflow UI “Functional” UI Mixed UI Transient Incontinence Lower urinary tract pathology Precipitated by reversible factor Causes: Delirium, UTI, Meds, Psychiatric disorders, UO, Stool impaction Restricted mobility Causes of Transient Incontinence Mnemonics: DIAPPERS D I A P P E R S Delirium Infection Atrophic Vulvovaginitis Psychological Pharmacologic agents Endocrine, excessive UO Restricted Mobility Stool impaction Resnick NM. Med Grand Rounds. 1984;3:281-290. Classification of Chronic UI Urge UI Stress UI Overflow UI “Functional” UI Mixed UI Classification of Chronic UI Urge Incontinence Most common Detrusor overactivity with uninhibited bladder contraction Unpredictable, abrupt urgency, frequency Post-void residual usually normal (<51ml) Cause: age impaired ability of brain to send inhibitory signals (stroke, brain mass, PD) increased afferent stimulation from the bladder(UTI, uterine prolapse) Prostatic hypertrophy in men (leads to hypertrophy of detrusor muscle) Stress Incontinence most common cause in aging females Cause: child-birth, obesity (increased pressure on pelvic organs), hysterectomy, radical prostatectomy Leakage occurs with intra-abdominal pressure on coughing, sneezing, physical activity Overflow Incontinence Detrusor underactivity and/or outlet obstruction Outlet obstruction=2nd most common cause of UI in Males Dribbling, weak stream, hesitancy Prolonged urinary retention can lead to detrusor muscle failure, persisting even after obstruction relieved Functional Incontinence Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers No underlying GU dysfunction Diagnosis of exclusion Summary of Urinary Incontinence Leakage accompanied or preceded by urgency Urge Leakage or exertion, sneezing, or coughing Stress Leakage owing to bladder outflow obstruction of any cause resulting large post-void residual volume Overflow Inability to reach the toilet in time (mobility, dexterity) or lack of perceived need to (cognitive impairment) Urinary incontinence in recent 3 days Functional Transient Thirugnanasothy BMJ 2010 History Urinary symptoms Voiding: hesitancy, poor urinary stream, dribbling Precipitants of urinary leakage such cough, exertion History of haematuria and recurrent urinary tract infections Bowel symptoms : Constipation, straining, faecal incontinence Fluids Volume: caffeine, carbonated drinks, citrus drinks, sweeteners Medical / Surgical history Drug history Neurological disorders, cognitive disorders, cough Hysterectomy, prostatectomy, pregnancies, mode of delivery Sedatives and hypnotics, antimuscarinics, diuretics, alcohol Social history Access to toilets and aids; mobility. Impact on quality of life Adapted from Thirugnanasothy BMJ 2010 Examination General exam Enlarged bladder, pelvic mass, edema, orthostatic hypotension, heart failure Neurological exam Functional impairment Mobility, dexterity (undoing buttons), vision Cognition Rectal exam Prostate size and nodularity, fecal impaction Pelvic Prolapse, atrophic vaginitis Drugs and urinary incontinence DeMaagd, US Pharm. 2007 Prescribing cascade… 85 years-old. Past history: Hypertension Take Norvasc(amlodipine) for BP control Leg edema, Impaired bladder empyting Urgency, Incontinence Take anti-cholingergic drug Constipation, urinary retention Take Laxatives, Insert foley Fecal Incontinence, UTI Diuretics （利尿劑） Essential investigations Urinalysis – haematuria, glucose, infection Bloods – glucose, creatinine, sodium, calcium ,+/- PSA Post-void bladder scan – <100mls ok. Post-void catheter with measure of residual if scan not available Voiding diary 3 days diary More reliable than patient recall Record type and time of intake, volumes Record time of each micturition and volume (estimate, or actual) Record number of pads used, weigh pads Ask family/carer to assist if patient unable Urinary Diary 時間 喝水量 (cc) 尿量 (cc) 廁所解尿 V 上午 5:30 250 上午 8:00 50 上午 8:50 上午 9:50 上午 10:30 上午 11:40 300 V 下午 14:00 250 V 下午 14:20 下午 16:00 50 晚上 18:00 130 少量失禁 大量失禁 失禁原因 買菜 V 100 100 V 利尿劑後1小時 300 350 250 小跑步去接孫 子 V V 炒菜炒一半突 然尿急 Further investigations Generally unnecessary unless Haematuria – micro or macroscopic Urinary retention Pelvic mass Prostate mass / significantly raised PSA New/undiagnosed renal impairment Frequent urinary infections, especially in men Renal ultrasound Urodynamic studies Cystoscopy Further investigations as per findings (e.g. MRI spinal cord or brain) Treatment options Non-pharmacological Medications Surgery Medication Review Stop all offending medications Balance against BP control, heart failure control Environmental Factors Toilet access – stairs, commode, lighting, privacy. Mobility – rehabilitation to improve function Address visual deficits Non-pharmacological: Cognitive Intact Pelvic floor exercises – for stress / urge /mixed incontinence First line treatment, 3 months trial needed RCT: improves subjective and objective cure rates (44% vs. 7% objective cure rates) Need to be cognitively intact – may not suit many older pts Bladder retraining Increase time interval between voiding Greater effectiveness Non-pharmacological: Cognitive impairment Time voiding Prompt voiding 2-3 hour time interval, for dependent residents Effective ask dependent residents regularly whether they need toileting assistance. Positive feedback Habit retraining Identification of a person’s toileting pattern; for dependent residents Cochrane review: no significant difference in the incidence and volume of incontinence Medications Urge incontinence: antimuscarinic drug Adverse effect of Antimuscarinics • Contraindicated:narrow-angle glaucoma, urinary retention and gastric retention. • Increased risk of confusion in dementia patients Antimuscarinic Drugs Medications Overflow Incontinence treat cause -antagonists： relax the muscle of prostate and bladder neck terazosin, doxazosin, tamsulosin, alfuzosin, silodosin Low blood pressure, dizziness Medications Stress incontinence α- Adrenergic agonists increasing internal sphincter tone Pseudoephedrine; weak evidence, no recommend Duloxetine(Cymbalta): Increased urethral contraction and sphincter tone Urethral catheters - indications Approx. 80% of health care-related UTI’s are catheter-related • • • • • • Acceptable reasons to catheterise Acute urinary retention Irrigation of haematuria Need to monitor urinary output Severe sacral ulcers, to protect skin Chronic urinary retention only if renal impairment Measurement of post-void volume (if bladders scan unavailable) • • • • UNACCEPTABLE reasons to catheterise Immobility Carer/staff demands Urinary incontinence Urinary tract infection Suprapubic catheters May require anaesthetic, not without complications May be associated with reduced risk of infection Reduced impact on sexual function Only if assured that a long-term catheter needed no surgical options cannot intermittently self-catheterise Treatment options - Surgery Retropubic suspension procedures Transvaginal bladder neck suspensions Less invasive Artificial urinary sphincter To support and restore the bladder neck to its retropubic location Indication: incontinence due to poor urethral sphincteric mechanism Urinary diversion Indication: as a last resort in some patients that is refractory to the above-mentioned Tx options Treatment options - Surgery Augmentation cystoplasty Using bowel segments Creation of a low-pressure system will decrease stimulation of sensory afferents Intermittent catheterization will usually be required to completely empty the bladder Sacral neuromodulation Placement of a surgical electrode permanently stimulating S3 afferent or motor nerves Conclusion High prevalence of UI in LTCF Differentiate the causes of UI Functional status, cognitive abilities, comorbidities should be considered when developing a continence in LTCF. Emphasize the importance of non-pharmacologic treatment Avoid to use urinary catheter unless under some circumstances Urethral catheters Intermittent catheterisation if at all possible Lower risk of urinary infections Dexterity needed Medical treatment has failed or surgical is not appropriate Leave catheter in for the minimum time necessary Always review need for existing catheter Catheter must provide more benefits than risks to the patient Should not be portrayed as easiest option