Download Geriatric Urinary Incontinence and Overactive Bladder

Geriatric Urinary Incontinence &
Overactive Bladder
Joseph G. Ouslander, M.D.
Professor of Medicine and Nursing
Director, Division of Geriatric Medicine and Gerontology
Chief Medical Officer,
Wesley Woods Center of Emory University
Director, Emory Center for Health in Aging
Research Scientist, Birmingham/Atlanta VA GRECC
Geriatric Urinary Incontinence &
Overactive Bladder (OAB)
An Update




Prevalence & impacts
Pathophysiology
Diagnostic evaluation
Management
Geriatric Urinary Incontinence
Prevalence
80%
70%
70%
Women
60%
Men
50%
40%
40%
34%
30%
22%
20%
12%
5%
10%
0%
Ever
Daily
Ever
Community (General)
Daily
Community
(Frail)/
Acute Hospital
NH
Overactive Bladder (OAB)
 Urinary Frequency
 >8

voids/24 hrs
Nocturia
 awakening

at night to void
Urgency, with or
without urge
incontinence
Overactive Bladder
Prevalence
Telephone survey of 16,776 adults age 40+
Women
17%
Men
16%
Milsom et al: BJU International, 87:760, 2001
Overactive Bladder
Prevalence
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
42%
31%
9%
3%
Age 40-44
Age 75+
Women
Age 40-44
Age 75+
Men
Top Chronic Conditions in the U.S.
40
35
Millions
30
25
20
15
10
5
0
OAB
OAB: “Dry” vs “Wet” (Urge Incontinence)
OAB
Adapted from Stewart W et al. ICI 2001
Dry
(63%)
Wet
(37%)
Spectrum of OAB and Urinary Incontinence
OAB
OAB
Stress UI z Mixed
Incontinence
Urge UI
• Urgency
• Frequency
• Nocturia
Impact of UI & OAB on Quality of Life
Physical
Discomfort,
odor
Falls and injuries
Sexual
of sexual
contact and intimacy
Psychological
Fear
and anxiety
Loss of self-esteem
Depression
Avoidance
Occupational
Decreased
productivity
Absence from work
Quality of Life
Social
Limited
travel and
activity around toilet
availability
Social isolation
Adverse Consequences of UI & OAB




87 Y.O. woman living at home,
with minimal assistance from
family
Incontinent rushing to the
toilet at 2 a.m., slipped and
fell in urine
Sustained a hip fracture
Now confined to a wheelchair
and required admission to a
nursing home
Urge Incontinence, Falls, and Fractures
• 6,049 women, mean age 78.5
• 25% reported urge UI (at least
weekly)
• Followed for 3 yrs
• 55% reported falls, 8.5%
fractures
• Odds ratios for urge UI and
Falls:
1.26
Non-spine fracture:
1.34
Brown et al: JAGS 48: 721 – 725, 2000
Geriatric Urinary Incontinence and OAB
Multi-factorial Pathophysiology
Predispose
Gender
Racial
Neurologic
Anatomic
Collagen
Muscular
Cultural
Environmental
Incite
Childbirth
Nerve damage
Muscle damage
Radiation
Tissue disruption
Radical surgery
Intervene
Behavioral
Pharmacologic
Devices
Surgical
Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.
Promote
Constipation Menstrual cycle
Occupation
Infection
Recreation
Medications
Obesity
Fluid intake
Surgery
Diet
Lung disease Toilet habits
Smoking
Menopause
Decompensate
Aging
Dementia
Debility
Disease
Environment
Medications
Geriatric Urinary Incontinence & OAB
Urinary
Tract
Functional/
Behavioral
Neurological
Drugs/Other
Conditions
Geriatric Urinary Incontinence & OAB
Pathophysiology
Lower urinary tract





Bladder pathology (infection, tumor, etc)
Detrusor overactivity
Women – atrophic urethritis, sphincter
weakness
Men – prostate enlargement
Urinary retention
•
•
Obstruction
Impaired bladder contractility
Geriatric Urinary Incontinence & OAB
Detrusor Overactivity
100
Normal
voluntary void
Bladder pressure
Involuntary
bladder contractions
0
0
100
200
300
Volume
400
Geriatric Urinary Incontinence & OAB
DHIC
% bladder emptying
100
80
60
40
20
0
Resnick, Yalla JAMA 1987;148:3076
DHIC
DH
Pathophysiology of Detrusor Overactivity
Neurogenic
 Myogenic
 Combination
 Unknown

Geriatric Urinary Incontinence & OAB
Sphincter Weakness
Geriatric Urinary Incontinence & OAB
Pathophysiology
Neurological
 Brain
•

Spinal cord
•

Stroke, dementia, Parkinson’s
Injury, compression, multiple sclerosis
Peripheral innervation
•
Diabetic neuropathy
Geriatric Urinary Incontinence & OAB
Pathophysiology
Functional/Behavioral
 Mobility impairment
 Dementia
 Fluid intake
•
•


Amount and timing
Caffeine, alcohol
Bowel habits/constipation
Psychological (anxiety)
Geriatric Urinary Incontinence & OAB
Pathophysiology
Other Conditions


Diabetes (polyuria)
Volume overload (polyuria, nocturia)
•
•

Congestive heart failure
Venous insufficiency with edema
Sleep disorders (nocturia)
•
•
Sleep apnea
Periodic leg movements
Requirements for Continence
Adequate:
 Lower urinary tract function
 Mental function
 Mobility, Dexterity
 Environment
 Motivation (patients, caregivers)
Reversible Causes (“DRIP”)
D elirium
R estricted mobility, R etention
I nfection, I nflammation, I mpaction
P olyuria, P harmaceuticals
Geriatric Urinary Incontinence & OAB
Drugs






Diuretics
Narcotics
Anticholinergics
Psychotropics
Cholinesterase inhibitors
Alpha adrenergic drugs
Persistent Incontinence
Urge
Functional
Stress
Overflow
Geriatric Urinary Incontinence & OAB
Diagnostic Assessment






History (Bladder Diary in selected patients)
Physical exam
Cough test for stress incontinence
Non-invasive flow rate (helpful in men)
Measurement of voided and post-void
residual volumes
Urinalysis
History






Most bothersome symptom (s)
Treatment preferences and goals
Medical history for relevant conditions
and medications
Onset and duration of symptoms
Prior treatment and response
Characterization of symptoms






Overactive bladder
Stress incontinence
Voiding difficulty
Other (pain, hematuria)
Bowel habits
Fluid intake
Physical Exam

Cardiovascular

Abdominal

Neurological

Perineal skin condition

External genitalia

Pelvic exam


Atrophic vaginitis

Pelvic prolapse
Rectal exam

Sphincter control

Prostate
Post-Void Residual Determination
 Diabetics
 Neurological conditions
(e.g. post acute stroke,
multiple sclerosis, spinal
cord injury)
 Men (especially those who
have not had a TUR)
 Anticholinergics and narcotics
 History of urinary retention or
elevated PVR
Urinalysis
 Infection
 Sterile
hematuria
 Glucosuria
Geriatric Urinary Incontinence and OAB
Examples of criteria for further evaluation
 Recurrent UTI
 Recent pelvic surgery
 Severe pelvic prolapse
 Sterile hematuria
 Urinary retention
 Failure to respond to initial therapy,
and desire for further improvement
Management of Geriatric Incontinence and OAB
 Reversible causes
 Supportive
measures
 Education
 Environmental
 Toilet substitutes
 Catheters
 Garments/pads
 Behavioral
interventions
 Pharmacologic
therapy
 Surgical
interventions
 Devices
Management of Geriatric Incontinence and OAB
Treat Reversible Causes
 Modify
fluid intake
 Modify drug regimens (if feasible)
 Reduce volume overload (for nocturia)
 e.g.
take furosemide in late afternoon in patients
with nocturia and edema
 Treat:
 Infection
(new onset or worsening symptoms)
 Constipation
 Atrophic vaginitis (topical estrogen)
Management of Geriatric Incontinence and OAB
Supportive Measures
 Education
 Environmental
 Clear
well-lit path to toilet
 Bedside commodes, urinals
 Catheters
 For
skin problems, retention, palliative
care/patient preference
 Garments/pads
Chronic Indwelling Catheters
Appropriate indications
 Significant, irreversible retention
 Skin lesions/surgical wounds
 Patient comfort/preference
Management of Geriatric Incontinence and OAB
Undergarments and Pads
 Nonspecific
 Foster dependency
 Expensive
Management of Geriatric Incontinence and OAB
Surgical Interventions
 Stress incontinence
•
•
•
•
Periurethral injections
Bladder neck suspension
Sling procedure
Artificial sphincter
 Urge incontinence
• Implantable stimulators
• Augmentation cystoplasty
Management of Geriatric Incontinence and OAB
Behavioral Interventions
 “Bladder Training”
•
Education
•
Urge suppression techniques
•
Pelvic muscle rehabilitation
 With
and without biofeedback
 Toileting programs
•
Prompted voiding (and others)
Pelvic Muscle Exercises
Locate pelvic muscles
Squeeze muscles
tightly for up to
10 seconds
Repeat in sets
of up to 10
3-4 times/day,
and use in
everyday life
Relax completely for
at least 10 seconds
Management of Geriatric Incontinence and OAB
Behavioral vs. Drug Treatment
Behavioral
Drug
Control
Accidents per Week, No.
20
15
10
5
0
Baseline
2
4
Time, wk
Burgio et al: JAMA 280: 1995, 1998
6
8
Management of Geriatric Incontinence and OAB
Behavioral vs. Drug Treatment
Patient Perceptions
Behavior Drug Control
Much better
74
51
27
Better
26
31
39
Able to wear fewer pads
76
56
34
Completely satisfied
78
49
28
Continue treatment
97
58
43
Wants another treatment
14
76
76
Burgio et al: JAMA 280: 1995, 1998
Prompted Voiding
Protocol
•
•
•
•
Opportunity (prompt) to
toilet every 2 hours
Toileting assistance if
requested
Social interaction and
verbal feedback
Encourage fluid intake
Prompted Voiding
Efficacy in Research Studies
 Reduces severity by half
 25%-40% of frail nursing
home patients respond well
UI episodes decrease
from 3 or 4 per day to 1
or fewer
 Responsive patients can be
identified during a 3-day
trial
Ouslander JG et al. JAMA 273:1366-70
Management of Geriatric Incontinence and OAB
Drug Therapy
Lower Urinary Tract Cholinergic and
Adrenergic Receptors
Μ=muscarinic
Detrusor
muscle (M)
=1-adrenergic
Trigone ()
Bladder neck ()
Urethra ()
Motor Innervation of the Bladder
Neurotransmitter: Acetylcholine
Receptors: Muscarinic
Pelvic Nerve
Contraction
Motor Innervation of the Bladder
Ouslander J. N Engl J Med. 2004;350:786-799
Sensory Innervation of the Bladder
Ouslander J. N Engl J Med. 2004;350:786-799
Drug Therapy for Stress Incontinence
Limited efficacy
 Two basic approaches:

 Estrogen
to strengthen periurethral
tissues (not effective by itself)
 Alpha adrenergic drugs to increase
urethral smooth muscle tone (no drugs
are FDA approved for this indication)
 Pseudoephedrine (“Sudafed”)
 Duloxitene (“Cymbalta”)
Drug Therapy for Urge UI and OAB
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
Antimuscarinic/Anticholinergics
-Blockers
•

Men with concomitant benign prostatic
enlargement
Estrogen (topical)
May be a helpful adjunct for women with
severe vaginal atrophy and atrophic vaginitis
 DDAVP (Off label in the U.S.)
• Carefully selected patients with primary
complaint of nocturia
•
Drug Therapy for Urge UI and OAB
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


Darifenacin (“Enablex”)
Oxybutynin (“Ditropan”)
• IR
• ER (“ XL”)
• Patch (“Oxytrol”)
Solifenacin (“Vesicare”)
Tolterodine (“Detrol”)
• IR
• Long-acting (“LA”)
Trospium (“Sanctura”)
Drug Therapy for UI and OAB

Several factors influence the decision to use
pharmacologic therapy:
 Degree
and bother of symptoms
 Patient/family
 Risk
preference
for side effects/co-morbidity
 Responsiveness
 Cost
to behavioral interventions
Drug Therapy for Urge UI and OAB

Anticholinergics: meta-analysis
•
•
32 trials; most double-blind; 6,800 subjects
Significant effects on:
 Incontinence
and voiding frequency
 Cure/improvement
 Bladder capacity
•
•
Modest clinical efficacy vs. placebo
Measured over short time periods
Herbison P, et al. BMJ. 2003;326:841-844
Drug Therapy for Urge UI and OAB

Efficacy




~ 60 - 70% reduction in urge UI
~ 30 - 50% placebo effect
Efficacy is similar in elderly vs. younger
Adverse events


Dry mouth ~ 20-25% (~ 5% “severe”)
Others – less common
Potential Side Effects of Antimuscarinic Drugs
CNS
Somnolence
Impaired Cognition
Iris/Ciliary Body = Blurred Vision
Lacrimal Gland = Dry Eyes
Salivary Glands = Dry Mouth
Heart = Tachycardia
Stomach = GERD
Colon = Constipation
Bladder = Retention
Antimuscarinics and Cognition
•
•
•
•
Antimuscarinic drugs used for the
bladder can theoretically cause
cognitive impairment
ACh is a pivotal mediator of shortterm memory and cognition
Cholinergic system involvement
in Alzheimer’s disease has been
clearly established
Of the 5 muscarinic receptors M1
appears most involved in memory
and learning
Antimuscarinic Drugs and Cognition
Vasculature
Tolterodine
+
Darifenacin
+
+ +
+
+ + +
+ +
• High lipophilicity,
• Neutral
• Relatively “small”
Oxybutynin,
Solifenacin
Trospium
• Low lipophilicity
• Charged
• Relatively “bulky”
BBB
++
• Relatively “bulky”
• Highly polar
• Lipophilic, small
• “M3 selective”
++ ++ ++
++ ++
++
++
++
CNS
Summary
1. UI and OAB are common conditions in the geriatric
population, and are associated with considerable
morbidity and cost
2. The pathophysiology is multifactorial, and many
potentially reversible factors can contribute
3. All patients should have a basic diagnostic
assessment, and selected patients should be referred
for further evaluation
4. A variety of treatment options are available; behavioral
interventions and drug therapy for urge UI and OAB
are most commonly prescribed
5. Treatment should be guided by patient preference,
their most bothersome symptoms, and the
pathophysiology felt to underlie these symptoms