Urinary incontinence in elderly

1. URINARY INCONTINENCEURINARY INCONTINENCE
Dr. Doha RasheedyDr. Doha Rasheedy
lecturer of geriatric medicinelecturer of geriatric medicine
Geriatric medicine departmentGeriatric medicine department
Ain Shams UniversityAin Shams University

2. URINARY INCONTINENCE
• Urinary incontinence (UI), defined as the involuntary
leakage of urine, is a common clinical condition that
occurs frequently in older adults
• Urinary incontinence is not a normal part of aging. It
is a loss of urine control due to a combination of:
-Age related changes.
-Genitourinary pathology.
-Comorbid conditions and medications.
-Environmental Obstacles.
•

4. Epidemiology
• Estimates suggest that at least 25% to 30% of all adults
will experience UI at some point in their lives.
• In people older than 65 years, the estimated prevalence of
UI ranges from approximately 35% for those who reside in
the community to more than 60% for those who live in
long term care facilities

5. Impact of UI
• UI is associated with a dramatic reduction in overall
and health-related quality of life for older adults.
• UI has been linked to many other important health
risks, including depression and functional disability,
which may result in social isolation and inability to
participate in desired activities.
• Elderly individuals with UI have a higher risk for falls
and fractures compared with those who do not leak
urine.
• Incontinence may have a negative effect on sexual
health in men and women.
• UI may also be a marker for increased mortality risk in
some patients.

6. Classification
Two broad categories of UI seen in older adults include:
• transient incontinence
• chronic incontinence.
Both can be subdivided into several additional categories.

7. Transient Incontinence
• Potentially Reversible Causes of incontinence ( DRIPS
Mnemonic):
1. Delirium
2. Infection (acute, symptomatic)
3. Atrophic vaginitis, urethritis
4. Pharmaceuticles for e.g: alpha-adrenergic agonists, alpha-
adrenergic blockers, anticholinergics, calcium channel
blockers, loop diuretics,NSAIDs, sedative hypnotics, narcotic
analgesics,antidepressants, antipsychotics
5. Excess urine (diabetes mellitus, caffeine intake, volume
overload).
6. Restricted mobility (illness, injury, gait disorder, restraint)
7. Stool Impaction

8. Chronic or established UI

9. Stress Incontinence
• Stress incontinence is characterized by loss of urine with
activities that increase intraabdominal pressure. Examples
include coughing, sneezing, lifting, or laughing. the pressure
inside the abdomen exceeds the closure pressure at the
urethral outlet leading to leakage of urine
• The cause is often due to inadequate closure of the external
urethral sphincter. Urethral hypermobility with loss of support
of the urethra is also seen in some women with stress
incontinence.
• In men, the most common associated risk factors include a
history of either radical prostatectomy for treatment of
prostate cancer or transurethral resection of the prostate for
treatment of benign prostatic hyperplasia.

10. URGE UI
• Urge incontinence is
typically associated
with sudden onset of a
sensation of needing
to void, with loss of
urine occurring before
the patient is able to
reach toilet facilities.

11. • Caused by uninhibited contractions of the bladder
detrusor muscle.
• The term ‘‘overactive bladder,’’ this condition due to irritation of the
reflex arc. There are two forms, including OAB-dry, which is
characterized by urinary urgency and frequency but no leakage of
urine, and OAB-wet, which includes UI (causes include UTI, Stone)
• The term bladder hyperreflexia due to activation of neuronal
regulation above level of reflex arc : Common causes, multiple
sclerosis, Parkinson disease, stroke, spinal cord injuries, and
disorders such as spinal stenosis. Dementia may also be
associated with urge incontinence

12. Overflow Incontinence
• Overflow incontinence is typically associated with either outlet
obstruction or poor detrusor contractility and incomplete
bladder emptying.
• In men, benign prostatic hyperplasia may lead to outlet
obstruction and overflow incontinence. Urethral strictures are
more common in men. in women , prior incontinence surgery
or large cystocele.
• Patients typically experience frequent loss of small volumes of
urine, in contrast to the larger volumes of urine leakage
associated with urge incontinence

13. Functional Incontinence
• urinary leakage that occurs as a result of factors not
directly associated with the bladder, which may prevent
independent toilet use. The most common examples in
older adults include limitations in either mobility or
cognition

14. Mixed UI
• more than one type of UI occurs at a time, the
combination of stress and urge UI is extremely
common. Some patients can describe the
predominant symptom and this may be amenable to
initial therapy.
• Another unique form of mixed incontinence that is
more common in older adults is termed ‘‘detrusor
hyperactivity with impaired contractility (DHIC)’’. In
this condition, patients experience urinary urgency
and frequency caused by uninhibited contractions of
the detrusor. However, when they try to void
voluntarily, the bladder does not contract adequately,
and therefore does not empty completely. This may
lead to associated overflow incontinence

15. Asking The Right Questions
“Do you leak with you cough, laugh, or sneeze?”
“Do you ever get the feelings of gotta go,
gotta go, gotta go!?!”
“Do you not always make it when you are racing for the
bathroom?”
“How many times do you get up during the night?”
“Do you feel a bulge?”
“Do you have to shift your upper body to urinate?”

16. Evaluation
• History:
1.onset, frequency, volume, timing, precipitants ( eg, caffeine,
diuretics, alcohol, cough, medications).
2.Character:
• Sudden, compelling urgency suggests urge UI.
• Loss with cough, laugh, or bend suggests stress UI.
• Continuous leakage suggests intrinsic sphincter insufficiency or
overflow.

17. Physical Examination
• Functinal status ( e.g, mobility)
• Mental status
• Findings as: bladder distension, cord compression, rectal
mass or impaction, anal sphincter tone, perineal sensation,
volume overload, edema.
• Male Genitourinary system: prostate consistency, symmetry ,
check phimosis, paraphimosis, balanitis.
• Female Genitourinary system: atrophic vaginitis, pelvic
support, cystocele, rectocele, prolapse.

18. Laboratory
• UA and urine C&S, glucose and calcium if polyuric : renal
function tests and B12 if urinary retention ; urine cytology if
hematuria or pain.

19. Testing include:
• bladder diary which record time and volume of
incontinent and continent voids, activities and time of
sleep, knowing oral intake is sometimes helpuful
• standing full bladder stress Test ( for patients with
symptoms of stress UI ) relax perineum and cough once
immediate loss suggests stress, several seconds delay
suggests detrusor overactivity.

23. Postvoid residual
•bladder ultrasound after voiding is preferred to catheterization.
If > 100 ml repeat if still > 100 suggests detrusor weakness ,
neuropathy, medications, fecal impaction, outlet obstruction, or
DHIC.

24. Urodynamic Studies
• not routinely indicated ; indicated before corrective
surgery, when diagnosis is unclear, when empric
therapy is ineffective or if postvoid residual volume >
200-300 ml ( possibly lower in men ).
• This may range from simple urodynamics, with
measurement of bladder capacity or noninvasive
uroflowmetry, to more complex multichannel studies
that examine storage and emptying capabilities.
• Simultaneous measurement of detrusor pressure and
urinary flow may be particularly helpful to differentiate
between outlet obstruction and detrusor insufficiency
in patients with symptoms of overflow incontinence

26. uroflowmetery

27. • Male <40 years max flow rate 25 ml/s
• Male > 60 years max flow rate 15 ml/s
• Female is higher by 5-10 ml/s and increased in stress
incontinence when outlet resistance is minimal.

31. Characteristic flow pattern
• Fast bladder= stress UI, DO
• Prolonged flow= BOO, DU
• Intermittent flow= BOO, DU compensated with abdominal
straining.
• Flat plateau= urethral structure
• NB: error occur with total volume <150 ml or >400ml
• NB: free flow vs. non free flow

32. • a normal flow rate can be present in the early stages of
obstruction as a consequence of a compensatory
increase in voiding pressure by hypertrophied detrusor
which will maintain of an apparently normal flow rate.
Ultrasound scan of the bladder will show a thickened
bladder wall and cystoscopy will confirm the bladder out
flow obstruction due to BPH or stricture urethra despite of
a normal flow rate

33. Ultrasound cystodyanamogram
• Ultrasound scan of urinary tract is combined with a flow
rate to provide more practical information of bladder
function. This investigation is performed routinely to all
patients with lower urinary tract symptoms

35. Urethral pressure measurement
• Research tool
• Urethral pressure measurement and the Urethral Pressure Profile are techniques used to
provide information about the ability of the urethra to prevent leakage.
• Urethral pressure can be measured with balloon catheters, membrane catheters, perfusion
techniques, or micro-transducers

37. • The urethral pressure profile (UPP) is another procedure
commonly used to measure the competency of the
urethral sphincter (outflow resistance).
• Urethral pressure profile (UPP) -- indicates the
intraluminal pressure along the length of the urethra with
the bladder at rest.
• Pressure transmission ratio (PTR) -- is the increment in
urethral pressure on stress as a percentage of the
simultaneously reported increment in vesical pressure.

38. • Maximum urethral pressure (MUP) -- is the maximum pressure of the
measured profile.
Maximum urethral closure pressure (MUCP) -- is the difference
between the maximum urethral pressure and the intravesical
pressure.
• Functional urethral length -- is the length of the urethra along which
the urethral pressure exceeds the intravesical pressure
• the anatomic urethral length is the total length of the urethra.
•

39. Valsalva Leak Point Pressure
VLPP
• Measures the lowest
abdominal pressure
required during a stress
activity (such as
coughing) that would
cause the urethra to
open and, therefore,
leak.

40. Cystometry
• continuous measurement of the pressure/volume
relationship of the bladder to assess sensations, detrusor
activity, bladder capacity and bladder compliance.
• All three pressure,1)Bladder pressure, 2)Abdominal
pressure and3) detrusor pressure is recorded
simultaneously during the test.
• Video Cystometry : the bladder can be filled with contrast
media, thus allowing the simultaneous screening of the ,
bladder and outflow tract during filling and voiding

41. • Bladder sensation is assessed by recording the volume at
which the patient experiences: the first sensation of
bladder fullness the first desire to void, and a strong
desire to void and urgency.

44. MANAGEMENT

45. stepped approach
1- Conservative Treatments:
•Dietary Modification and Weight Loss:
• restriction or elimination of
dietary caffeine
acidic foods and beverages, including citrus fruits and juices
Alcohol
fluid intake
• Decreasing late-afternoon or evening fluid intake is often advocated for
elderly patients with nocturia.
• Weight loss may also be helpful for some patients, particularly women
with stress UI.

46. Nonpharmacologic Behavioral
Therapy• Bladder retraining:
• Timed voiding.
• urgency control when urgency occurs, sit or stand quietly, focus on
letting urge pass, do muscle contraction when no longer urgent walk
slowly to the bathroom and void.
• When no incontinence for 2 d, increase voiding interval by 30-60 min
until voiding every 3-4 h.
• prompted toileting for cognitively impaired individuals: ( ask if patient
needs to void, take them to toilet) starting at 2 to 3 hour intervals
during day; encourge patients to report continence status; praise
patients when continent and responds to toileting.
• Pelvic Floor Muscle Exercises (+ Biofeedback training)
(Kegel‘s) exercises-isolate pelvic muscles (avoid thigh, rectal ,
buttocks contractions, 3-4 times/wk for at least 15-20 wk. vaginal
weights are an alternative for strengthening pelvic muscles

48. Pessaries
may benefit women with vaginal or uterine prolapse who
experience retention or stress UI.
DHIC:
Treat urge first with behavioral methods; may add detrusor
muscle relaxing medications but follow postvoid residual;
clean intermittent self-catheterization if needed

49. Nocturnal Frequency :
Two voidings per night is probably normal for older adults.
If between bedtime and awaking, the patient voids more than
one third of his or her total 24-hr output , this is excessive fluid
excretion.
All patients should restrict fluid intake 4 h before bedtime.
If stasis edema is present , patient should wear pressure graded
stockings.
a potent , short acting loop diuretic can be used in the afternoon
or early evening to induce a diuresis before bedtime, eg,
bumetanide 0.5-1.5 mg titrated to achieve a brisk diuresis.
Evaluate for other factors contributing to volume overload or
diuresis (eg, HF, poorly controlled diabetes).

50. Pharmacologic Therapy
• Eliminate medications causing UI if possible.
• Benefit of topical postmenopausal estrogen therapy in
urge and possibly stress UI are limited.
• Medications as Oxybutynin, Tolterodine, Trospium can be
used but with common adverse effects as constipation,
dry mouth, delirium , dyspepsia and headache, also
should be used with caution in patients with liver
dysfunction.

52. Surgical Therapy:
Sling Procedures.
Bulking Agent Injection Therapy.
Neuromodulation.

53. Catheter
• Catheter should be used only for chronic urinary retention,
to protect pressure ulcers and when requested by patients
or families to promote comfort ( eg, at end of life).

54. Pads and Absorbent Products
• they do not cure incontinence and are generally not
regarded as an ideal form of therapy.

55. Thank you