Geriatric Incontinence and Geriatric Incontinence and LUTSLUTS

ObjectivesObjectives

Recognize age related lower urinary tract Recognize age related lower urinary tract changes changes

Appreciate unique aspects of geriatric Appreciate unique aspects of geriatric voiding problemsvoiding problems

Distinguish among various forms of Distinguish among various forms of incontinenceincontinence

Appreciate how non-urinary issues Appreciate how non-urinary issues contribute to continencecontribute to continence

Key PointsKey Points

LUTS are common among the elderlyLUTS are common among the elderly

Patients frequently don’t mention it & Patients frequently don’t mention it & physicians often don’t askphysicians often don’t ask

Both patient and doctor frequently Both patient and doctor frequently consider it a part of “normal aging”consider it a part of “normal aging”

LUTS are morbid, costly and lead to poor LUTS are morbid, costly and lead to poor QOLQOL

Majority of patients can be helpedMajority of patients can be helped

Case PresentationCase Presentation

84 yo male with spinal stenosis/immobility, mild 84 yo male with spinal stenosis/immobility, mild dementia and parkinsonism develops fecal dementia and parkinsonism develops fecal impaction and acute urinary retention. Prior to impaction and acute urinary retention. Prior to this he had frequent urgency, nocturia and this he had frequent urgency, nocturia and occasional incontinenceoccasional incontinence– Urinary catheterization 1.5 liters urineUrinary catheterization 1.5 liters urine– Moderate size prostateModerate size prostate– No hematuria, urine culture negativeNo hematuria, urine culture negative– PSA 4.2PSA 4.2

Acute ManagementAcute Management

What is the appropriate immediate What is the appropriate immediate management?management?– Refer for TURPRefer for TURP– Intermittent clean intermittent catheterizationIntermittent clean intermittent catheterization– Begin alpha blocker Begin alpha blocker – Place Foley and begin alpha blocker, treat Place Foley and begin alpha blocker, treat

fecal impactionfecal impaction

Long Term ManagementLong Term Management

Failed 3 voiding trials (persistent retention) Failed 3 voiding trials (persistent retention) over 4 weeks over 4 weeks

How do you manage at this point?How do you manage at this point?– Proceed with surgical options immediatelyProceed with surgical options immediately– Continue more voiding trialsContinue more voiding trials– Clean intermittent catheterizationClean intermittent catheterization– Chronic indwelling FoleyChronic indwelling Foley

Lower Urinary Tract SymptomsLower Urinary Tract Symptoms

Voiding Voiding

HesitancyHesitancy

Poor flowPoor flow

IntermittencyIntermittency

StrainingStraining

Terminal dribbleTerminal dribble

StorageStorage

UrgencyUrgency

FrequencyFrequency

NocturiaNocturia

Urge incontinenceUrge incontinence

Changing Paradigm of LUTSChanging Paradigm of LUTS

Historically men with LUTS were Historically men with LUTS were considered to have “prostatism” considered to have “prostatism” – Elderly patients show higher rates of Elderly patients show higher rates of

persistent symptoms/dissatisfaction after persistent symptoms/dissatisfaction after TURP TURP

Women frequently assumed to have stress Women frequently assumed to have stress or urge incontinenceor urge incontinence– Surgical procedures, pessaries, Kegel’s Surgical procedures, pessaries, Kegel’s

exerciseexercise

Bates 1970Bates 1970

““The Bladder Is an Unreliable The Bladder Is an Unreliable Witness”Witness”

The Unreliable WitnessThe Unreliable Witness

Many asymptomatic elderly have UD Many asymptomatic elderly have UD evidence for detrussor overactivityevidence for detrussor overactivityUD evidence of bladder outlet obstruction UD evidence of bladder outlet obstruction can be completely asymptomaticcan be completely asymptomaticElderly woman frequently have high Elderly woman frequently have high scores on IPSS and AUA symptoms scores on IPSS and AUA symptoms scalesscalesAmong elderly men with BPH, many have Among elderly men with BPH, many have residual symptoms after TURPresidual symptoms after TURP

ICS Definitions ICS Definitions

UrgencyUrgency– ““Sudden compelling desire to pass urine which is difficult to defer” Sudden compelling desire to pass urine which is difficult to defer” – Differs from the “normal desire to void”Differs from the “normal desire to void”– PathologicalPathological

FrequencyFrequency– The complaint that an individual urinates too much, typical The complaint that an individual urinates too much, typical

~8x/day~8x/day

NocturiaNocturia– The complaint of awakening to void >1 time/nightThe complaint of awakening to void >1 time/night

Urge IncontinenceUrge Incontinence– involuntary leakage accompanied by or immediately preceded involuntary leakage accompanied by or immediately preceded

by urgencyby urgency

LUT Changes in AgingLUT Changes in Aging

IncreasedIncreasedDetrussor over activityDetrussor over activity

Nocturnal urine outputNocturnal urine output

BPHBPH

Post void residual Post void residual <100cc~90%<100cc~90%

Bacteruria~20%Bacteruria~20%

DecreasedDecreased

Bladder contractilityBladder contractility

Bladder sensationBladder sensation

Sphincter strengthSphincter strength

LUTS and AgingLUTS and Aging

Almost always multifactorialAlmost always multifactorial

Age associated LUT changes and Age associated LUT changes and comorbid disease associated comorbid disease associated

Major impact of conditions beyond the Major impact of conditions beyond the urinary tract in LUTSurinary tract in LUTS

Mobility, dexterity & cognitive influence on Mobility, dexterity & cognitive influence on continencecontinence

Aging and ContinenceAging and Continence

Most elderly people remain continent Most elderly people remain continent in in spite of agespite of age associated LUT changes associated LUT changes

Multiple factors interact to determine Multiple factors interact to determine continence statuscontinence status

Intervention on all the contributing factors Intervention on all the contributing factors frequently yields good resultsfrequently yields good results

Looking for Looking for the onethe one cause is wrong cause is wrong paradigmparadigm

Cerebral Control of MicturitionCerebral Control of Micturition

Increasing research reveals that much of Increasing research reveals that much of geriatric voiding dysfunction is “beyond the geriatric voiding dysfunction is “beyond the bladder”bladder”

Cortical & sub-cortical control over bladder Cortical & sub-cortical control over bladder functionfunction

Mostly inhibitory control that requires intact Mostly inhibitory control that requires intact attention, working memory, executive attention, working memory, executive functionsfunctions

IncontinenceIncontinence

Common, morbid & costlyCommon, morbid & costly

25% of community dwelling elders are 25% of community dwelling elders are incontinentincontinent

50% of nursing home residents50% of nursing home residents

Leads to isolation, embarrassment, Leads to isolation, embarrassment, depressiondepression

Associated with falls, fractures, skin Associated with falls, fractures, skin problems and institutionalizationproblems and institutionalization

Why is Incontinence Why is Incontinence Important?Important?

Social Stigma – leads to restricted Social Stigma – leads to restricted activitiesactivities

DepressionDepression

Medical complications – skin breakdown Medical complications – skin breakdown andand

Increase in urinary tract infectionsIncrease in urinary tract infections

Institutionalization – UI is the second Institutionalization – UI is the second leading cause of nursing home placementleading cause of nursing home placement

Types IncontinenceTypes Incontinence

Transient vs. chronicTransient vs. chronic

Stress Stress

UrgeUrge

OverflowOverflow

FunctionalFunctional

Transient IncontinenceTransient Incontinence

DeliriumDelirium--InfectionInfection--Atropine vaginitis or urethritisAtropine vaginitis or urethritis--PharmaceuticalsPharmaceuticals--Psychological disordersPsychological disorders--Endocrine DisordersEndocrine Disorders--Restricted mobilityRestricted mobility--Stool impactionStool impaction

Stress Urinary IncontinenceStress Urinary Incontinence

Involuntary leakage on effort or exertion, Involuntary leakage on effort or exertion, or on sneezing or coughingor on sneezing or coughing

The sign of stress incontinence is the The sign of stress incontinence is the observation of urine loss from the urethra observation of urine loss from the urethra during coughing or strainingduring coughing or straining

Cough stress test may be usefulCough stress test may be useful

Tends to be small amounts of leakageTends to be small amounts of leakage

Overflow IncontinenceOverflow Incontinence

Leakage of urine associated with urinary Leakage of urine associated with urinary retentionretention

May be due to bladder outlet obstruction or poor May be due to bladder outlet obstruction or poor bladder contractility bladder contractility – BPH with BOOBPH with BOO– Urethral stricture, tumorUrethral stricture, tumor– Diabetic cystopathy, multiple sclerosis, cauda equina Diabetic cystopathy, multiple sclerosis, cauda equina

etc.etc.

Urodynamic studies to evaluate pressure/flowUrodynamic studies to evaluate pressure/flow

Overactive BladderOveractive Bladder

Urgency, with or without urge Urgency, with or without urge incontinence, usually with frequency and incontinence, usually with frequency and nocturia . . . if there …is no proven nocturia . . . if there …is no proven infection or other etiologyinfection or other etiology

Equally common among men and women Equally common among men and women in the very elderlyin the very elderly

2/3 of OAB patients are “dry” 2/3 of OAB patients are “dry”

Dry patients still sufferDry patients still suffer

OAB Symptom DefinitionsOAB Symptom Definitions

Urgency: a sudden compelling desire to pass urine Urgency: a sudden compelling desire to pass urine

that is difficult to deferthat is difficult to defer

Urgency Urinary Inc. (UUI): involuntary leakage Urgency Urinary Inc. (UUI): involuntary leakage

accompanied by or immediately preceded by accompanied by or immediately preceded by

urgencyurgency

Frequency: 8 voids / day = “normal”Frequency: 8 voids / day = “normal”

Nocturia: patient wakes one or more times at night Nocturia: patient wakes one or more times at night

to void (sleep “before” and “after”)to void (sleep “before” and “after”)

Abrams P, et al. Urology. 2003;61:37-49.

Prevalence of OAB Prevalence of OAB Age and GenderAge and Gender

Stewart WF, et al. World J Urol. 2003;20:327-336.

0

5

10

15

20

25

30

35

40

<25 25-34 35-44 45-54 55-64 65-74 75+

Age (years)

Pre

va

len

ce

(%

)

Men

Women

Prevalence of OAB• Men: 16.0%• Women: 16.9%

OAB Treatment Rates by Age GroupOAB Treatment Rates by Age Group

9.30%

18.40%19.60%

8.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

60-64 65-74 75-84 85+Age

Source: IMS Retail Perspective

Usual EvaluationUsual Evaluation

HistoryHistory– UrgeUrge– StressStress– Symptom scalesSymptom scales

Physical examinationPhysical examination– Pelvic, rectal/prostate, abdominal, neurologic, Pelvic, rectal/prostate, abdominal, neurologic,

cognitive, cardiac/pulmonarycognitive, cardiac/pulmonary– Cough stress testCough stress test

LabsLabs– Urinalysis, culture?, ?psa, post-void residualUrinalysis, culture?, ?psa, post-void residual– Frequency volume chartFrequency volume chart

Detrussor Hyperactivity with Detrussor Hyperactivity with Impaired ContractilityImpaired Contractility

DHIC common among frail eldersDHIC common among frail elders

May predispose to acute urinary retentionMay predispose to acute urinary retention

Elevated PVRElevated PVR

Bladder is both paradoxically weak and Bladder is both paradoxically weak and overactiveoveractive

Behavioral ManagementBehavioral Management

Pelvic floor exercisesPelvic floor exercises

Bladder trainingBladder training

BiofeedbackBiofeedback

Prompted voidingPrompted voiding

Fluid limitationFluid limitation

Dietary modificationsDietary modifications

Continence productsContinence products

Expectations of TreatmentExpectations of Treatment

Complete dryness may not be feasibleComplete dryness may not be feasible

Decreased urgency episodesDecreased urgency episodes

Decreased incontinent episodesDecreased incontinent episodes

More lead timeMore lead time

Tolerability of current therapiesTolerability of current therapies

Newer OAB MedicationsNewer OAB Medications

Oxybutinin Oxybutinin – Immediate, delayed release, patch formImmediate, delayed release, patch form

TolteradineTolteradine– Immediate, delayedImmediate, delayed

TrospiumTrospium

DarifenacinDarifenacin

SolafenacinSolafenacin– Immediate and long acting formImmediate and long acting form

OAB Therapy for RefractoryOAB Therapy for Refractory

Botulinum toxin injectionBotulinum toxin injection

NeurostimulatorNeurostimulator

Vanilloid bladder washingsVanilloid bladder washings

When to ReferWhen to Refer

Failure to improve with current therapyFailure to improve with current therapy

Persistently elevated PVR Persistently elevated PVR

Interest in surgical/interventional optionsInterest in surgical/interventional options

Complex neuro-urological casesComplex neuro-urological cases

Abnormal findings (hematuria, Abnormal findings (hematuria, hydronephrosis, elevated PSA, etc.)hydronephrosis, elevated PSA, etc.)

LUTS in Men Recent AdvancesLUTS in Men Recent Advances

IPSS scores not specific for BPH with IPSS scores not specific for BPH with BOOBOO

Combined BPH and OAB therapyCombined BPH and OAB therapy

PDE inhibitorsPDE inhibitors

Nocturnal polyuria therapyNocturnal polyuria therapy

Case PresentationCase Presentation

83 yo male complains of 5-6 episodes of 83 yo male complains of 5-6 episodes of nocturia for the past 6 months. nocturia for the past 6 months.

Denies dysuria, straining, or hesitancy, Denies dysuria, straining, or hesitancy, past episode of transient acute urinary past episode of transient acute urinary retention during hospitalization for knee retention during hospitalization for knee replacement 4 years ago. replacement 4 years ago.

Exam shows enlarged smooth prostate, Exam shows enlarged smooth prostate, moderate peripheral edema, and venous moderate peripheral edema, and venous stasis changesstasis changes

Which is the most likely to be Which is the most likely to be helpful?helpful?

Trial of alpha blockerTrial of alpha blocker

UrinalysisUrinalysis

Overactive bladder medicationOveractive bladder medication

Trial of 5-alpha reductase inhibitorTrial of 5-alpha reductase inhibitor

Referral for TURPReferral for TURP

Voiding diary and compression stockingsVoiding diary and compression stockings

Diagnosis?Diagnosis?

Benign prostate hypertrophyBenign prostate hypertrophy

Urinary tract infectionUrinary tract infection

Normal agingNormal aging

Overactive bladderOveractive bladder

Diabetes insipidusDiabetes insipidus

Nocturnal polyuriaNocturnal polyuria

NocturiaNocturia

DefinitionDefinition– Waking up to void one or more times during Waking up to void one or more times during

the nightthe night– Voiding during intended sleep time that is Voiding during intended sleep time that is

preceded and followed by sleeppreceded and followed by sleep

Associated with mortalityAssociated with mortalityDisruptive to sleep, contributes to fatigueDisruptive to sleep, contributes to fatigueIncreased risk for falls 10% vs. 21% with 2 Increased risk for falls 10% vs. 21% with 2 or more voidsor more voids

Prevalence of nocturia Prevalence of nocturia in menin men

05

101520253035404550

18-34 35-54 55-74 >75

1 void

2 voids2 voids

Per

cen

tag

e o

f m

en w

ith

no

ctu

ria

Age range (years)

Prevalence of nocturia Prevalence of nocturia in womenin women

05

101520253035404550

18-34 35-54 55-74 >75Per

cen

tag

e o

f w

om

en w

ith

no

ctu

ria

Age range (years)van Dijk et al. 2002

1 void

2 voids2 voids

Diagnostic algorithmDiagnostic algorithm NOCTURIA NOCTURIA

BotherBother No Bother No Bother

Patient Presents Patient Presents

Screen Screen

No Presentation No Presentation

Advice Advice

Polyuria Polyuria Nocturnal Polyuria Nocturnal Polyuria Apparent Bladder Apparent Bladder Storage Problems Storage Problems

Other Classification Other Classification Primary Sleep DisorderPrimary Sleep Disorder

Further Evaluation Further Evaluation

Nocturnal PolyuriaNocturnal Polyuria

>33% of total urine volume produced while >33% of total urine volume produced while asleepasleep– Changes in atrial natriuretic peptide, ADH secretionChanges in atrial natriuretic peptide, ADH secretion

Consider occult sleep apneaConsider occult sleep apnea– 30-40% will have significant OSA30-40% will have significant OSA

CHF and venous insufficiencyCHF and venous insufficiencyTherapeutic optionsTherapeutic options– Limit evening fluids/behavioral modificationLimit evening fluids/behavioral modification– Evening loop diureticsEvening loop diuretics– DDAVP therapyDDAVP therapy– Dried fruits?Dried fruits?

Pharmacological treatment of Pharmacological treatment of nocturnal polyurianocturnal polyuria

DiureticsDiuretics• Helpful in patients with lower limb venous Helpful in patients with lower limb venous

insufficiency or congestive cardiac failure insufficiency or congestive cardiac failure • Level 1 evidence, Grade C recommendation Level 1 evidence, Grade C recommendation

• Bumetanide 1 mg p.o. in afternoon Bumetanide 1 mg p.o. in afternoon • Furosemide 40 mg p.o. in afternoonFurosemide 40 mg p.o. in afternoon

AntidiureticsAntidiuretics• Helps retain water until a more appropriate Helps retain water until a more appropriate

timetime• Reduce nocturnal voids and voided volumeReduce nocturnal voids and voided volume• Level 1 evidence, Grade A recommendationLevel 1 evidence, Grade A recommendation

• Desmopressin 0.1 mg p.o. titrated to 0.4 mg Desmopressin 0.1 mg p.o. titrated to 0.4 mg • No direct bladder effectNo direct bladder effect• No direct cardiovascular actionsNo direct cardiovascular actions

PresumedDiagnosis

Treatment

History/Clinical

Assessment

Bothersome Nocturia

MEDICAL HISTORY• Other urinary tract symptoms/ Sleep history/ Drinking habits (quantity and type)/ Medication (e.g., diuretics)EXAMINATION• Ankle oedema/Abdominal examination/Prostate assessment/Female pelvic assessment/Assess post-void residual urine

INVESTIGATIONS• Urinalysis – if infected, treat and reassess

OTHER AETIOLOGY• Overactive bladder• Bladder outflow obstruction• Sleep disturbance• Cardiac disease• Gynaecological abnormality• Bladder pain or bleeding

NOCTURNAL POLYURIA (nocturnal urine volume > 33% of total 24h urine volume (age dependent)

Lifestyle advice

• Desmopressin bed-time• Furosemide in the afternoon

GLOBAL POLYURIA (24h voided volume >40 ml/kg)• Electrolytes• Serum glucose

Lifestyle advice

Non-responders

Non-responders

Non-responders

Frequency Volume Chart

Specialist referral

Further evaluation and appropriate treatment

Non-responders

SummarySummary

Incontinence is not a “normal” part of Incontinence is not a “normal” part of agingagingLUTS and OAB are very commonLUTS and OAB are very commonMost LUTS in the elderly are multifactorialMost LUTS in the elderly are multifactorialDon’t assume BPH is the etiology among Don’t assume BPH is the etiology among elderly menelderly menUse frequency-volume charts to diagnose Use frequency-volume charts to diagnose nocturnal polyrurianocturnal polyruriaMultiple treatment options exist for mostMultiple treatment options exist for most