Urinary Incontinence - Tutorial by m Donaldson

8/18/2019 Urinary Incontinence - Tutorial by m Donaldson

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URINARYURINARY

INCONTINENCEINCONTINENCE

Dr Mark DonaldsonDr Mark DonaldsonConsultant Physician inConsultant Physician in

Geriatric MedicineGeriatric Medicine


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Urinary IncontinenceUrinary Incontinence

Afects: Afects:

15%-30% elderly liin! at "o#e15%-30% elderly liin! at "o#e

30% - 35% elderly in ac$te care30% - 35% elderly in ac$te care

50% in RC& 50% in RC&


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Continence re'$iresContinence re'$ires::

Adequate mobility Adequate mobility MentationMentation

MotivationMotivation

Manual dexterityManual dexterity Intact lower urinary tract functionIntact lower urinary tract function


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(edical Co#)lications(edical Co#)lications

Ras"esRas"es *ress$re $lcers*ress$re $lcers

UTIUTI

&alls&alls

&ract$res&ract$res


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*syc"osocial co#)lications*syc"osocial co#)lications

mbarrassmentmbarrassment !ti"matisation!ti"matisation

IsolationIsolation

De#ressionDe#ression Institutionalisation risk Institutionalisation risk


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IncontinenceIncontinence

isis never never normalnormal


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A+EIN+ ,A..ER C/AN+E A+EIN+ ,A..ER C/AN+E ,ladder ca)acity decreases,ladder ca)acity decreases ,ladder co#)liance decreases,ladder co#)liance decreases Aility to )ost)one oidin! decreases Aility to )ost)one oidin! decreases Uret"ral closin! )ress$re decreases in 2o#enUret"ral closin! )ress$re decreases in 2o#en

*rostate enlar!es in #en*rostate enlar!es in #en Inol$ntary ladder contractions increaseInol$ntary ladder contractions increase *ost-oidin! resid$al ol$#e increases 50-*ost-oidin! resid$al ol$#e increases 50-

100#l4100#l4

Also: Also:

Increased $id e6cretion at ni!"tIncreased $id e6cretion at ni!"t A!e associated slee) disorders A!e associated slee) disorders .etr$sor #$scle c"an!es.etr$sor #$scle c"an!es


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Incontinence is a +eriatric syndro#e:Incontinence is a +eriatric syndro#e:

i7e7 *redis)osed y aoe 8actorsi7e7 *redis)osed y aoe 8actors

*reci)itated $s$ally y disease o$tside*reci)itated $s$ally y disease o$tside

t"e $rinary tract7 t"e $rinary tract7

&re'$ent aderse dr$! reactions t"at afect&re'$ent aderse dr$! reactions t"at afect

t"e $rinaryt"e $rinary tract tract

It is t"ese 8actorsIt is t"ese 8actors OUTSIDE OUTSIDE t"e $rinaryt"e $rinary

tract t"at are a#enale to interentiontract t"at are a#enale to interention

e7!7 art"ritis9i##oility e7!7 art"ritis9i##oility


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Transient IncontinenceTransient Incontinence

Co##on e7!7 30% co##$nity d2ellersCo##on e7!7 30% co##$nity d2ellers

50% o8 in)atients50% o8 in)atients

At ris cases: es)ecially At ris cases: es)ecially

anti-c"oliner!icsanti-c"oliner!icsdi$reticsdi$retics

2orsenin! #oility 2orsenin! #oility


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Transient IncontinenceTransient Incontinence::

.. -- ..eliri$#eliri$#

II -- IIn8ectionn8ection

A A -- A A tro)"ic Uret"ritis9a!initistro)"ic Uret"ritis9a!initis

** -- **"ar#ace$ticals"ar#ace$ticals

** -- **syc"olo!ical rare4syc"olo!ical rare4

EE -- EE6cessie $rine o$t)$t6cessie $rine o$t)$tR R -- R R estricted #oility estricted #oility

-- tool i#)actiontool i#)action


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Urinary tract ca$ses o8Urinary tract ca$ses o8incontinenceincontinence::

.etr$sor oeractiity .etr$sor oeractiity .etr$sor $nderactiity .etr$sor $nderactiity

+en$ine stress incontinence+en$ine stress incontinence

lo2 $ret"ral resistance4lo2 $ret"ral resistance4 Ostr$ctionOstr$ction

"i!" $ret"ral resistance4"i!" $ret"ral resistance4


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.etr$sor Oeractiity .etr$sor Oeractiity

Co##onest ca$se o8 $rinaryCo##onest ca$se o8 $rinary

incontinenceincontinence;0%-


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.etr$sor Oeractiity .etr$sor Oeractiity

Clinically:Clinically: $ sudden onset$ sudden onset

$ immediate need to void$ immediate need to void %eaka"e is e#isodic& moderate to%eaka"e is e#isodic& moderate to

lar"elar"e

'octurnal frequency'octurnal frequency (r"e incontinence common(r"e incontinence common

P)* low in absence of D+ICP)* low in absence of D+IC


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tress Incontinence

Co##on in 2o#en

In #en= only a8ter s)"incteric da#a!eco#)licatin! )rostatic resection

Clinically: Instantaneo$s 2it" stress #anoe$res.elayed - s$!!ests stress ind$ced detr$soroeractiity

In #en= >leay ta)? 2orsened y standin! or

strainin! O8ten co-e6ists 2it" $r!e incontinence i7e7 #i6ed


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Uret"ral Ostr$ctionUret"ral Ostr$ction

Co##on in #enCo##on in #en In 2o#en= a8ter ladder nec s$s)ension orIn 2o#en= a8ter ladder nec s$s)ension or

inin! associated 2it" seere )rola)seinin! associated 2it" seere )rola)se *rostatic encroac"#ent*rostatic encroac"#ent Clinically:Clinically:

14 &illin! sy#)to#s14 &illin! sy#)to#s i7e7 $r!ency= 8re'$ency= noct$ria4i7e7 $r!ency= 8re'$ency= noct$ria4

@4 oidin! sy#)to#s@4 oidin! sy#)to#si7e7 )oor strea#= inter#ittency=i7e7 )oor strea#= inter#ittency=

drilin! )ost oiddrilin! )ost oid

34 Oero2 34 Oero2


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.etr$sor Underactiity .etr$sor Underactiity B10% o8 incontinenceB10% o8 incontinencecases4cases4

Us$ally idio)at"icUs$ally idio)at"ic

Ca$sed y de!eneratie #$scle and a6onalCa$sed y de!eneratie #$scle and a6onal

c"an!esc"an!es

Clinically:Clinically: Oero2 incontinenceOero2 incontinence

&re'$ency &re'$ency

Noct$riaNoct$ria

&re'$ent leaa!e o8 s#all a#o$nts&re'$ent leaa!e o8 s#all a#o$nts *R $s$ally 50#l*R $s$ally 50#l

In #en= diferentiated y $rodyna#ics rat"erIn #en= diferentiated y $rodyna#ics rat"er

t"an cystosco)y or I*7t"an cystosco)y or I*7


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Eal$ation o8 t"e older incontinent )atientEal$ation o8 t"e older incontinent )atient

+OA: Inesti!ate and treat transient andInesti!ate and treat transient andestalis"ed ca$ses7estalis"ed ca$ses7

Assess )atient?s eniron#ent and s$))ort Assess )atient?s eniron#ent and s$))ort

To detect $nco##on $t serio$sTo detect $nco##on $t serio$s$nderly"in! conditions:$nderly"in! conditions:

-- ,rain lesions,rain lesions- )inal cord lesions- )inal cord lesions- Carcino#a ladder9)rostate- Carcino#a ladder9)rostate- ,ladder stones- ,ladder stones- .ecreased ladder co#)liance- .ecreased ladder co#)liance


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Clinical (ana!e#entClinical (ana!e#ent

1717 E6cl$de oero2 incontinenceE6cl$de oero2 incontinence

e7!7 *R 50#l4e7!7 *R 50#l4

D"ere a))ro)riate= Urolo!ist D"ere a))ro)riate= Urolo!ist

re8erralre8erral

Re#ainder - cat"eteriseRe#ainder - cat"eterise


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Clinical (ana!e#entClinical (ana!e#ent@7@7 Re#ainin! 0%-5% de)ends on !ender7Re#ainin! 0%-5% de)ends on !ender7

&e#ales:&e#ales: eit"er OA, or +Ieit"er OA, or +I

+I e6cl$ded y oserin! 8or leaa!e 2it"+I e6cl$ded y oserin! 8or leaa!e 2it"8$ll8$ll ladder and i!oro$s co$!"ladder and i!oro$s co$!"

(ales:(ales: eit"er OA, or ostr$ction7eit"er OA, or ostr$ction7

I8 o2 nor#al= *R B100#l t"en ostr$ctionI8 o2 nor#al= *R B100#l t"en ostr$ction

isis e6cl$ded7e6cl$ded7

I8 *R @00#l= e6cl$de "ydrone)"rosis7I8 *R @00#l= e6cl$de "ydrone)"rosis7Re#ainder Re#ainder = treat 8or OA, F 2arn ao$t= treat 8or OA, F 2arn ao$t

retention Fretention F aoid ladder rela6ants i8 *Raoid ladder rela6ants i8 *R

150#l7150#l7


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Non-.r$! Treat#ent o8 OA,Non-.r$! Treat#ent o8 OA,

,ladder .rill,ladder .rill re-trainin!4re-trainin!4 Ti#ed oidin!Ti#ed oidin! .e8er#ent tec"ni'$e.e8er#ent tec"ni'$e

Co!nitiely i#)airedCo!nitiely i#)aired *ro#)ted oidin!*ro#)ted oidin!

Non-.r$! Treat#ent o8 +INon-.r$! Treat#ent o8 +I *elic oor e6ercises es)ecially i8 #ild :*elic oor e6ercises es)ecially i8 #ild :

- 30-@00 ti#es )er day - 30-@00 ti#es )er day - IndeGnitely - IndeGnitely - i#ited eficacy - i#ited eficacy - Re)air )roced$res less inasie- Re)air )roced$res less inasie


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.r$! Treat#ent o8 OA,.r$! Treat#ent o8 OA,

Anti-c"oliner!ic anti-#$scarinics4 Anti-c"oliner!ic anti-#$scarinics4

O6y$tyninO6y$tynin oli8enacinoli8enacin

.ari8enacin.ari8enacin TolterodineTolterodine

,est as adH$ncts to ladder drill7,est as adH$ncts to ladder drill7

.ose escalation y titration.ose escalation y titration (ost NOT on *,(ost NOT on *, Ne2er ones etter toleratedNe2er ones etter tolerated CI +la$co#a F .ry #o$t"= con8$sionCI +la$co#a F .ry #o$t"= con8$sion


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Alertness Alertness

Res)onsieRes)onsie (otiation(otiation

.irection.irection

(oility (oility Reco!nitionReco!nition

.ressin!.ressin!

oidin! and .e#entia


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Indications 8or Urodyna#icsIndications 8or Urodyna#ics

*ersistent dia!nostic $ncertainty7*ersistent dia!nostic $ncertainty7

(oridity associated 2it" )otentially7(oridity associated 2it" )otentially7#isdirected #edical t"era)y is "i!"7#isdirected #edical t"era)y is "i!"7

D"en e#)iric t"era)y "as 8ailed7 D"en e#)iric t"era)y "as 8ailed7

D"en s$r!ical interention is )lanned7 D"en s$r!ical interention is )lanned7 Oero2 incontinence7Oero2 incontinence7


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*"ar#acolo!ic Treat#ent Ostr$ction*"ar#acolo!ic Treat#ent Ostr$ction Al)"a locers Al)"a locers

-- delay s$r!ery delay s$r!ery -- eneGt in 2eeseneGt in 2ees

*raosin*raosin

Ta#s$losinTa#s$losinTeraosinTeraosin

&inasteride 5 al)"a red$ctase in"iitor &inasteride 5 al)"a red$ctase in"iitor

-- ess efectieess efectie-- .elayed eneGt.elayed eneGt-- ide-efects es)7 i#)otence7ide-efects es)7 i#)otence7

Urinary Incontinence - Tutorial by m Donaldson

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