URINARY INCONTINENCE - E-Ageing: E
Transcript URINARY INCONTINENCE - E-Ageing: E
Dr Mark Donaldson
Consultant Physician in Geriatric
15%-30% elderly living at home
30% - 35% elderly in acute care
>50% in RCF
Intact lower urinary tract function
is never normal
AGEING BLADDER CHANGES
Bladder capacity decreases
Bladder compliance decreases
Ability to postpone voiding decreases
Urethral closing pressure decreases in women
Prostate enlarges in men
Involuntary bladder contractions increase
Post-voiding residual volume increases (50-100ml)
Increased fluid excretion at night
Age associated sleep disorders
Detrusor muscle changes
Incontinence is a Geriatric syndrome:
i.e. Predisposed by above factors
Precipitated usually by disease outside
the urinary tract.
Frequent adverse drug reactions that affect the urinary
It is these factors OUTSIDE the urinary tract that are
amenable to intervention e.g. arthritis/immobility
30% community dwellers
50% of inpatients
At risk cases: especially
Excessive urine output
Urinary tract causes of incontinence:
Genuine stress incontinence
(low urethral resistance)
(high urethral resistance)
Commonest cause of urinary incontinence
- neurologic disorders
- sudden onset
- immediate need to void
Leakage is episodic, moderate to large
Urge incontinence common
PVR low in absence of DHIC
Common in women
In men, only after sphincteric damage complicating
Clinically: Instantaneous with stress manoeuvres
Delayed - suggests stress induced detrusor
In men, ‘leaky tap’ worsened by standing or straining
Often co-exists with urge incontinence i.e. mixed
Common in men
In women, after bladder neck suspension or kinking
associated with severe prolapse
(1) Filling symptoms
(i.e. urgency, frequency, nocturia)
(2) Voiding symptoms
(i.e. poor stream, intermittency,
dribbling post void
Detrusor Underactivity (<10% of incontinence cases)
Caused by degenerative muscle and axonal changes
Frequent leakage of small amounts
PVR usually > 450ml
In men, differentiated by urodynamics rather than
cystoscopy or IVP.
Evaluation of the older incontinent patient
Investigate and treat transient and
Assess patient’s environment and support
To detect uncommon but serious
- Spinal cord lesions
- Carcinoma bladder/prostate
- Bladder stones
- Decreased bladder compliance
Exclude overflow incontinence
(e.g. PVR > 450ml)
Where appropriate, Urologist referral
Remainder - catheterise
Remaining 90%-95% depends on gender.
Females: either OAB or GSI
GSI excluded by observing for leakage with full
bladder and vigorous cough
Males: either OAB or obstruction.
If flow normal, PVR <100ml then obstruction is
If PVR > 200ml, exclude hydronephrosis.
Remainder, treat for OAB – warn about retention –
avoid bladder relaxants if PVR >150ml.
Non-Drug Treatment of OAB
Bladder Drill (re-training)
Non-Drug Treatment of GSI
Pelvic floor exercises especially if mild :
- 30-200 times per day
- Limited efficacy
- Repair procedures less invasive
Drug Treatment of OAB
Best as adjuncts to bladder drill.
Dose escalation by titration
Most NOT on PBS
Newer ones better tolerated
CI Glaucoma – Dry mouth, confusion
Voiding and Dementia
Indications for Urodynamics
Persistent diagnostic uncertainty.
Morbidity associated with potentially.
misdirected medical therapy is high.
When empiric therapy has failed.
When surgical intervention is planned.
Pharmacologic Treatment Obstruction
benefit in weeks
Finasteride 5 alpha reductase inhibitor
Side-effects esp. impotence.