Overview of incontinence in the elderly.

1. Incontinence
Marc Evans M. Abat, MD, FPCP, FPCGM
Internal Medicine-Geriatric Medicine

2. Definition and Epidemiology
Urinary incontinence
Involuntary loss of urine in sufficient amount or
frequency to be a social and/or health problem
Increases with age
Women (30%)> men (15%)
As much as 60% among nursing home
elderly

3. Jackson, RA et al. 2004. Urinary
Incontinence in Elderly Women: Findings
From the Health, Aging, and Body
Composition Study. Obstet Gynecol 104:
301–7.

4. 21% reported incontinence at least weekly
42% reported predominantly urge
incontinence and 40% reported stress
Nearly twice as many white women as
black women (27% versus 14%, P < .001)

5. Factors associated with urge incontinence
white race (odds ratio OR 3.1, 95% confidence
interval CI 2.0–4.8)
diabetes treated with insulin (OR 3.5, 95% CI
1.6 –7.9)
depressive symptoms (OR 2.7, 95% CI 1.4 –
5.3)
current oral estrogen use (OR 1.7, 95% CI 1.1–
2.6)
arthritis (OR 1.7, 95% CI 1.1–2.6)
decreased physical performance (OR 1.6 per
point on 0–4 scale, 95% CI 1.1–2.3)

6. Factors associated with stress
incontinence
chronic obstructive pulmonary disease (OR 5.6,
95% CI 1.3–23.2)
white race (OR 4.1, 95% CI 2.5– 6.7)
current oral estrogen use (OR 2.0, 95% CI 1.3–
3.1)
Arthritis (OR 1.6, 95% CI 1.0 –2.4)
high body mass index (OR 1.3 per 5 kg/m2,
95% CI 1.1–1.6).

7. Pathophysiology and Classification
Continence requires…
Functioning lower urinary tract
Adequate cognitive and physical functioning
Motivation
Appropriate environment

8. Urination is a complex process and
incompletely understood
Influence by higher centers in the
brainstem, cerebral cortex and cerebellum
Cerebral cortex  predominantly inhibitory
Brainsterm  facilitates urination

9. Urination reflex  centered in the sacral
micturition center
Afferent pathway (somatic and autonomic)
carry bladder filling info to the spinal cord
Sympathetic tone  closes bladder neck and
inhibits parasympathetic tone (bladder dome
relaxes)
Pelvic muscle tone maintained  also inhibits
parasympathetic tone
On urination, the reverse occurs

10. Normal urination is a dynamic process
During filling, pressure remains low (<15 cm)
First urge usually at 150-250 cc
Normal bladder capacity 300-600cc
Detrussor muscle contracts and exceeds
urethral resistance  urine flow

11. Basic Causes
Urologic, neurologic, psychological and
functional factors may contribute
↓bladder capacity, ↑residual urine,
↑prevalence of involuntary bladder
contractions
In 40-75% of incontinent elderly
But also 5-30% of continent elderly

12. Involuntary bladder contractions +
impaired mobility  a substantial
proportion of incontinent elderly
Decline in bladder outlet and urethral
resistance in women
Relate to laxity of pelvic muscle due to
childbirth, obesity, deconditioned muscles, and
hysterectomy

13. In men, related to prostatic enlargement
Associated nocturia, low urine flow rate and
detrussor instability  leads to overflow and/or
urge incontinence
In both sexes, detrussor hyperactivity with
impaired contractility

14. Acute and reversible causes
Acute incontinence
Sudden onset, related to acute illness or
iatrogenesis and subsides once cause is
resolved
Persistent incontinence
Unrelated to an acute cause and persist over
time

15. Condition Management
Conditions affecting lower urinary
tract
UTI Antibiotics
Atrophic vaginitis/urethritis Topical estrogen
Postprostatectomy Behavioral, avoid more surgery
Stool impaction Disimpaction, fiber intake, etc.
Drug side effects Discontinue or change drug therapy
Increased urine production
Metabolic (hyperglycemia, Treat DM, treat cause of hypercalcemia
hypercalcemia)
Excess fluid intake Reduce intake of diuretic fluids
Volume overload Medical and supportive therapy
Impaired ability or willingness to
reach toilet
Delirium Diagnosis or treatment of cause
Chronic illness or immobility Regular toileting, environment alteration
Appropriate therapy
psychological

16. Persistent incontinence
Several types which may occur in
combination in a patient
Basic types
Stress
Urge
Overflow
Functional

17. 2 basic abnormalities in these types
Failure to store urine
Failure to fully empty the bladder

18. Definition Causes
Stress Weakness of pelvic floor muscles and
Involuntary loss of urine with urethral hypermobility
increases in abdominal pressure Bladder outlet or urethral sphincter weakness
(e.g. coughing) Postprostatectomy
Urge Detrussor hyperactivity, isolated or with the
leakage of urine due to inability to following: local genitourinary condition, CNS
delay voiding after sensation of disorders
bladder fullness is perceived
Overflow Anatomic obstruction
Urine leakage from mechanical Acontractile bladder due to DM or SCI
forces on an overdistended bladder Detrusor-sphincter dyssynergy associated
or other effects of urinary retention with MS or other suprasacral spinal lesions
on bladder and sphincter function Medication effect
Functional Severe dementia and other neurological
Associated with inability to toilet disorders
due to impaired cognition or Depression
physical functioning and hostility
environmental barriers or
psychological unwillingness

19. Evaluation
Includes thorough history, PE, urinalysis
and postvoid residual determination
Objectives
Identify potentially reversible conditions
Identify conditions that require further
diagnostic test or urologic/gynecologic
evaluation
Develop a management plan

20.  All patients
 History, PE, urinalysis, postvoid residual determination
 Selected patients
 Lab studies
Urine culture, urine cytology, serum glucose and calcium, renal
function tests, renal ultrasound
 Gynecologic evaluation
 Urologic evaluation
 Cystourethroscopy
 Urodynamic tests
Simple
• Observation of voiding
• Cough test for stress incontinence
• Simple cystometry
• Urine flowmetry (for men)
Complex
• Multichannel cystometrogram
• Pressure-flow study
• Leak point pressure
• Urethral pressure profilometry
• Sphincter electromyography
• videourodynamics

21. Patient history should also include
Characteristic of incontinence: timing,
frequency, amount
symptoms of voiding difficulty: hesitancy,
intermittent voiding, straining to void
Symptoms of stress vs urge incontinence

22. PE should include
 Abdominal, rectal, genital exam
 Exam of lumbosacral innervation
 In women, examine for POP, inflammation suggestive of
atrophic vaginitis
 Cough test
Leakage with coughing documents stress incontinence
Delayed leakage (>3 seconds after) indicates cough-
induced bladder contraction
 Mobility and mental status
 In patients with nocturia, examine for CHF or venous
insufficiency

23. Urinalysis
Clear relationship between incontinence and
UTI
Controversial for asymptomatic bacteriuria
No benefit in treating nursing home elderly with
stable bacteriuria
May be reasonable to treat initially in non-
institutionalized patients

24. Postvoid determination
May be done using UTZ
Done within a few minutes of a spontaneous
(continent or incontinent) void
<100 cc in the absence of straining generally
reflect adequate bladder emptying
>200 cc is abnormal

25. Criteria Definition Rationale
History
Recent lower urinary tract or Surgery or irradiation within Structural abnormality related
pelvic surgery/iiradiation the past 6 months to the procedure
Recurrent symptomatic UTI 3 or more symptomatic Structural abnormality
episodes in 12 months predisposing to UTI
Physical Examination
Marked POP Prominent cystocele Abnormality may underlie the
descending entire height of pathophysiology of
vaginal vault with coughing incontinence; may benefit
on speculum exam from surgery
Gross enlargement on DRE; Evaluation to exclude cancer
Prostatic enlargement or induration or assymetry of
possible cancer lobes
Postvoid residual
Diffuculty inserting 14F Unable to pass through, Anatomick block of the
straight catheter requiring more force or urethra or bladder
larger, stiffer catheter
Residual >200cc Anatomic or neurogenic
obstruction

26. Criteria Definition Rationale
Urinalysis
Hematuria >5 RBCS per HPF in the Pathology of urinary tract
absence of UTI should be excluded
Therapeutic Trial
Failure to respond Persistence of symptoms Urodynamic evaluation
after adequate trial

27. Management
Acute incontinence in elderly in acute care
 Catheterization
 Toilet accessibility or substitutes
 Bed pads or diapers
 Causes or contributing factors should be treated
Supportive measures
 Education
 Environment manipulation
 Avoidance of iatrogenesis
 Modification of fluids and diuretics
 Skin care

28. Behavioral interventions
May be patient-dependent or caregiver-
dependent
Goal of the former is to restore normal voiding
and continence
The latter is to keep patient and environment
dry

29. Patient-dependent interventions
Require a functional and motivated patient and
a skill trainer
Relies on education, counselling and frequent
patient contact
Kegel exercises are effective for stress, urge or
mixed incontinence
3-5 sets of 10 contractions throughout the day, each
contraction 3-10 seconds in duration

30. Biofeedback
Use recordings of bladder, rectal or vaginal pressure
or electrical activity to train patients to contract pelvic
floor muscles with the abdominal muscles relaxed
Limited by requirement for equipment and trained
personel; may also be invasive and unacceptable
Bladdder training
Uses the pelvic muscle exercises and strategies to
manage urgency
Persistence of voiding difficulties despite the
protocol should prompt urologic referral

31. Hay-Smith EJC, and C. Dumoulin. Pelvic
floor muscle training versus no treatment,
or inactive control treatments, for urinary
incontinence in women. Cochrane
Database of Systematic Reviews 2006,
Issue 1. Art. No.: CD005654. DOI:
10.1002/14651858.CD005654

32. To determine the effects of pelvic floor muscle
training for women with urinary incontinence in
comparison to no treatment, placebo or sham
treatments, or other inactive control treatments.
403 women in six trials of varying age and types
of incontinence
Use of PFMT lead to more reports of cure
Greater benefit in younger populations
Studies heterogenous and needs further
investigation

34. Caregiver-dependent interventions
Prevent incontinence episodes
Motivated caregivers are essential
Includes scheduled toileting, habit training and
prompted voiding
Scheduled toileting
Putting the patient to toiletting at scheduled intervals
regardless of expressed desire to void
Habit training
A schedule of toileting based on patient’s pattern of
continent voids and incontinent episodes

35. Prompted voiding
Involves focusing the patient’s attention on their
bladders and prompting the patient to attempt
voiding and giving feedback by personal interaction

36. JAMA, February 25, 2004—Vol 291, No. 8 989

37. Drug Treatment
Prescribed in conjunction with one or
more behavioral interventions
For urge incontinenceanticholinergic
and bladder smooth muscle relaxants
60-70% reduction in incontinence episodes
Systemic anticholinergic side effects
(constipation, dry mouth, urinary retention);
drug-induced delirium in patients with dementia

38. Stress incontinencecombination of α-agonist
and estrogen
 Pseudoephedrine most commonly used
 Appropriate for patients
With mild to moderate stress incontinence
No major anatomic abnormality like cystocele
No contraindication to these drugs, e.g. poorly controlled
hypertension
 Estrogen (topical or oral) combined with α-agonists also
effective in women with atrophic vaginitis and urethritis
0.5-1.0 g vaginal cream@HS x 1-2 months

39. May combine several drug classes for
mixed incontinence
Drug therapy for chronic overflow
incontinence not usually effective

42. Surgery and periurethral injection
Elderly women with stress incontinence
who are
Unresponsive to nonsurgical treatment
With significant degree of pelvic organ prolapse
(POP)
Range from periurethral collagen injections and
neck suspension to sling procedures
Periurethral injection for those with intrinsic
urethral weakness

43. Indicated in men whose incontinence is
associated with outflow obstruction
Complete retention
Those with significant residuals causing recurrent
UTI and hydronephrosis
Decision should be based on degree of
symptomatology, benefits and risks

44. Catheters and Catheter Care
3 basic types
External catheters
Intermittent straight catheterization
Chronic indwelling catheterization

45. External catheters
In males, consists of a form of condom
Increased risk of developing symptomatic
infections
For intractable incontinence in males without
retention and are physically dependent
Safety and effectiveness in females is not well
document in the elderly population

46. Intermittent catheterization
Can be done 2-4x daily
Goal is to keep residual urine to <300 cc
Straight catheter should be kept clean (not
necessarily sterile)
Practical and reduces risk of symptomatic
infection compared to chronic catheterization
Presence of anatomic abnormalities increase
risk of infection in the elderly
Risk of nosocomial infection also high in
institutional settings

47. Chronic indwelling catheterization
Indications
Urinary retention causing persistent overflow
incontinence, cannot be corrected surgically or
medically and cannot be managed practically by
intermittent catheterization
Wounds or ulcers contaminated by urine
Patient preference
Care of terminally ill or severely impaired patients in
whom bed and clothing changes are disruptive or
uncomfortable

48. Increased complications like
Chronic bacteriuria
Bladder stones
Periurethral abscess

49. Fecal Incontinence
Less common
Unusual in elderly patients who are
continent of urine
30-50% of institutionalized patients with
urinary incontinence also have fecal
incontinence

50. Causes
Fecal impaction
Constipation
Laxative abuse or overuse
Hyperosmotic enteral feedings
Neurologic disorders (e.g. dementia, stroke,
spinal cord disease)
Colorectal disorders (e.g. diarrheal diseases,
diabetic autonomic neuropathy, rectal sphincter
damage)

52. Evaluation
Detailed history
PE should include perineal examination and
DRE
Done on left lateral or decubitus position
Examine for hemorrhoids, patulous anus (indicates
denervation), anal deformities or anal dermatitis
Test for excessive perineal descent or rectal
prolapse by asking patient to strain
Test for anocutaneous reflex
Examination of the rectal vault

53. Diagnostic Testing
Anorectal manometry-assess sphincter tone
and strength
Anorectal ultrasound-assess structural integrity
EMG-rules out denervation
Barium proctography
Dynamic pelvic MRI

54. General Measures
Incontinence pads
Barrier preparations like zinc oxide
Topical antifungals for perineal fungal infections

56. Biofeedback
To improve perception of rectal sensation and
responsiveness of the rectal sphincter
However most studies have imprecise
endpoints and lacked sham controls
No superiority over conservative measures
No difference between instrumental and non-
instrumental biofeedback

57. Surgical methods
Anal sphincteroplasty
Effective for acute fecal incontinence; uncertain
effectivity and durability in chronic incontinence
May have failure rates as high as 50% after 5 years
Antegrade colonic irrigation by a
cecostomy/appendicostomy
Optimal for those with neurogenic fecal incontinence
and anorectal deformities
Can be complicated by stenosis and infection

58. Surgical replacement using surrounding
muscles and implantation of a stimulator
(dynamic graciloplasty)
Pelvic floor muscle repair
Diverting colostomy
Sacral nerve stimulation