Download Urinary Incontinence

Incontinence
Dr. Gary Sinoff
Department of Gerontology
University of Haifa
Incontinence
Definition
2-PC-ME
Definition
INCONTINENCE:
Involuntary loss of urine or stool in sufficient amount
or frequency to constitute a social and/or health
problem.
A heterogeneous condition that ranges in severity from
dribbling to continuous incontinence.
If individuals lose only one or two drops of urine when
they don’t want to, that’s considered incontinence!
Myths:
People who are incontinent are:
• Very old
• Feeble
• Senile
• Totally dependent
• No longer in control
Brussels
How Common is Urinary Incontinence?
• Prevalence increases with age
• 25-30% of community dwelling older
women
• 10-15% of community dwelling older men
• 50% of nursing home residents
Rate of Seeking Help
70
60
50
50
41
Rate of 40
Seeking
30
Help
25
20
10
0
Asia
*
USA
**
Europe
* NIH Consensus Statement on Urinary Incontinence,1988
** Holts et al, 1988
Under-Diagnoses and Under-Treated
• Only 32% of primary care physicians routinely ask
about incontinence
• 50-75% of patients never describe symptoms to
physicians
• 80% of urinary incontinence can be cured or
improved
Why is Incontinence Important?
• Social stigmata - leads to restricted activities and
depression
• Medical complications - skin breakdown,
increased urinary tract infections
• Institutionalization - UI is the second leading
cause of nursing home placement
Anatomy of Micturition
• Detrusor muscle
• External and Internal sphincter
• CNS control
– Pons - facilitates
– Cerebral cortex – inhibits
• Hormonal effects - estrogen
Peripheral Nerves in Micturition
Peripheral Nerves in Micturition
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•
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Parasympathetic (cholinergic) - Bladder contraction
Sympathetic - Bladder Relaxation
Sympathetic - Bladder Relaxation (β adrenergic)
Sympathetic - Bladder neck and urethral contraction (α
adrenergic)
• Somatic (Pudendal nerve) - contraction pelvic floor
musculature
Bladder Pressure-Volume Relationship
Potentially Reversible Causes
D
I
A
P
P
E
R
S
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
Degree of Bother
YES : 53.7%
4 - severe
3.6%
5 - very
severe
5.2% not indicated
7%
0 - none
36.1%
3 - moderate
7.6%
2 - mild
16.5%
1- very mild
24.3%
Medications That May Cause Incontinence
• Diuretics
• Anticholinergics - antihistamines, antipsychotics,
antidepressants
• Sedatives/hypnotics
• Alcohol
• Narcotics
• Calcium channel blockers
Other factors for urinary incontinence
•
•
•
•
•
•
Sociocultural
Psychological
Muscle tone damage
Fluid intake
Diseases
Surgery
Categories of Incontinence
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•
•
•
Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence
Incontinence
• In women
49% stress incontinence
22% urge incontinence
29% mixed stress & urge
• In men
73% urge incontinence
Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder
•
•
•
•
Most common cause of UI >75 years of age
Abrupt desire to void cannot be suppressed
Usually idiopathic
Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s Disease,
dementia
Stress Incontinence
• Most common type in women < 75 years old
• Occurs with increase in abdominal pressure; cough, sneeze,
laughing, etc.
• Hypermotility of bladder neck and urethra; associated with
aging, hormonal changes, trauma of childbirth or pelvic
surgery (85% of cases)
• Intrinsic sphincter problems; due to pelvic/incontinence
surgery, pelvic radiation, trauma, neurogenic causes (15% of
cases)
Overflow Incontinence
• Over distention of bladder
• Bladder outlet obstruction; stricture, BPH,
cystocele, fecal impaction
• Non-contractile baldder (hypoactive detrusor
or atonic bladder); diabetes, MS, spinal injury,
medications
Functional Incontinence
• Does not involve lower urinary tract
• Result of psychological, cognitive or physical
impairment
Diagnostic Tests
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Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr)
Urine Culture
Simple (bedside) Cystometrics
Urodynamics - Lower urinary tract
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•
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Uroflowmetry
Cystometrography
External sphincter electromyography
Pressure flow study
Videourodynamic study
Urethral pressure profilometry
In-Hospital Use of Continence Aids and New-Onset Urinary Incontinence in
Adults Aged 70 and Older
Zisberg, A, Sinoff, G, Gur-Yaish, N, Admi, E, Shadmi, E
OBJECTIVES: To describe the types of continence aids that older adults hospitalized in acute
medical units use and to test the association between use of continence aids and
development of new urinary incontinence (UI) at discharge.
DESIGN: Prospective cohort study.
SETTING: A 900-bed teaching hospital in Israel.
PARTICIPANTS: Three hundred fifty-two acute medical patients aged 70 and older who
were continent before admission.
MEASUREMENTS: In-hospital use of continence aids was assessed according to participant
self-report on use of urinary catheters (UCs) or adult diapers o of self-toileting. The
development of new UI was defined as participant report of inability to control voiding at
discharge. Multivariate analyses mode led the association between use of continence aids
(vs self-toileting) and the development of new UI, controlling for baseline functional and
cognitive status, disease severity, age, and length of stay.
New Onset Incontinence
RESULTS: Of the 352 participants, 58 (16.5%) used adult diapers, and 27 (7.7%)
had a UC during most of the hospital stay. Sixty (17.1%) participants developed
new UI at discharge. The odds of developing new UI were 4.26 (95%
confidence interval (CI)51.53–11.83) times higher for UC users and 2.62 (95%
CI51.17–5.87) times higher for adult diaper users than for the self-toileting
group, controlling for the above risk factors.
CONCLUSION: The use of adult diapers and UCs during acute hospitalization is
associated with the development of new UI at discharge. The management of
continence in hospitalized older adults requires more diligence, and further
investigation is needed to devise continence promotion methods in hospital
settings. J Am Geriatr Soc 2011
Treatment Options
1
Lifestyle choices
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Reduce or eliminate caffeine
Reduce or eliminate alcohol
Drink 6 to 8 glasses of water daily
Quit smoking
Weight control
Follow a healthy diet high in fiber
Reduce physical barriers to toilet (use bedside
commode)
Timed Voiding
• Regular scheduled pattern of voiding where
the intervals between voiding are gradually
increased.
• It reduces irritability of the bladder
• Reverses bad habits
• No longer needing to camp out by the
bathroom promotes freedom and
independence once again.
Treatment Options
• Bladder training
– Patient education
– Scheduled voiding
– Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)
• Biofeedback
• Caregiver interventions
– Scheduled toileting
– Habit training
– Prompted voiding
2
Treatment for Detrusor Overactivity
Behavioral therapy
Bladder drill
Timed/prompted toileting
Medical therapy
Anticholinergic
Tricyclic antidepressants
Neurotoxins
Estrogens
Electrical therapy
Vaginal or anal electrical stimulation
Trancutaneous electrical simulation
Surgical therapy
Partial detrusor myomectomy
Augmentation cystoplasty
Urinary diversion
Pharmacological Interventions
• Urge Incontinence
– Oxybutynin (Novitropan)
– Imipramine (Tofranil)
• Stress Incontinence
– Phenylpropanolamine (Alcinal)
– Pseudo-Ephedrine (Histafed, etc.)
– Estrogen (orally, transdermally or transvaginally)
Surgical Interventions
Surgery is reported to “cure” 4 out of 5 cases, but
success rate drops to 50% after 10 years.
• Urethral Hypermotility
– Marshall-Marchetti-Kantz
procedure
– Needle neck suspension
• Intrinsic sphincter deficiency
– Sling procedure
Other Interventions
• Pessaries
• Periurethral bulking agents (periurethral injection
of collagen, fat or silicone)
• Diapers or pads
• Chronic catheterization
– Periurethral or suprapubic
– Indwelling or intermittant
Leg Bags
Designer Diapers
Pessaries
Indwelling Catheter
Fecal Incontinence
Fecal Incontinence
• “The inability to control the passage of flatus,
liquid or solid stool”
• 2% prevalence community, increases in NH
• Profoundly disabling, also on body image
• Number of different etiologies
• Variety of medical and surgical treatments
available
Normal continence mechanism
• Internal sphincter (smooth
muscle involuntary):
maintains high resting
tone
• External sphincter
(skeletal muscle
voluntary): important in
the voluntary inhibition of
the defaecatory reflex
Factors Affecting GIT Elimination
• Physiological changes with age
• Physical Activity
• Diet
• Psychological Factors
• Surgical
Classification of Incontinence
• Pseudoincontinence
– soiling, urgency, frequency
• Overflow incontinence
• Incontinence with abnormal pelvic floor
Pseudo-incontinence
• Perineal soiling
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–
–
–
hemorrhoidal prolapse
fistula en ano
incomplete defecation
perianal dermatoses
• Urgency
– non compliant rectum (radiation)
– IBD
– absent rectal reservoir
• Frequency
– diarrheal states ie IBD, autonomic neuropathy, parasites, toxins
Overflow Incontinence
• Rectal fecal impaction
– decreased rectal sensation
– obtuse anorectal angle
– chronic stimulation of rectoanal inhibitory reflex
• Neoplasm
Abnormal pelvic floor
• Neurogenic/Infiltrative
– pudendal neuropathy
– generalized neuropathy or cord lesion
– Diabetes Mellitus and Scleroderma
• Sphincter disruption
– Obstetric
– Surgical
– Trauma
Cause of Incontinence
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Sphincter degeneration (internal)
Sphincter damage (external)
Nerve damage (central or peripheral)
Rectal causes – (changes in rectal capacity,
elasticity or function)
• Faecal impaction - (chronically distended rectum
- chronically relaxed internal sphincter)
Examination
• PR examination – tone, contractile strength,
perineal descent on straining
• Impacted and overflow incontinence
• Anal Fistula
• Haemorrhoids
• Rectocele
Anorectal physiology laboratory
• Functional - Manometric studies, Dynamic Fluoroscopy
• Anatomical - Endoanal ultrasound, MRI
• Neurological - Pudendal nerve latency tests
Manometry
• Voluntary anal squeeze pressure
• Low resting pressure: internal sphincter
abnormality
• Reduced squeeze pressures: external sphincter
problem
• Fatigueability of the external sphincter: relevance
in urge incontinence
Endoanal ultrasound
• Anatomical information
• Likely be of benefit post obstetrics or surgical
trauma
• After first vaginal delivery 30% have
demonstrated sphincter defects
• 1/3 of these develops symptoms incontinence/
urgency
Normal Endo anal ultrasound
external sphincter
Internal
sphincter
Managing Bowel Incontinence:
 Note when incontinence is likely to occur
and put patient on bedpan at that time.
 Keep the skin clean and dry by using proper
hygienic measures.
 Change bed linens and clothing as necessary.
 Confer with the physician about using a
suppository or daily cleansing enema.
 Repeated rectal examinations
Next Week
Iatrogenic
Damage