SPECIAL PROBLEMS IN GERIATRIC POPULATIONS(2) URINARY INCONTINENCE Objectives 1- 2- 3- 4- 5- Contents I. Definition: II. Normal urination III. PREVALENCE: IV. Causes of Stress Incontinence. V. Incontinence and Aging VI. Evaluation - Clinical History - Examination VII. Treatment: 1-Advices: 2-Devices : 3-Exercises: - Kegel exercises : - Weight Training . 4- Biofeedback. 5- Electrical Stimulation Definition: The definition of incontinence is the passing of urine in an undesirable place. Normal Urination A normal urination pattern in adults includes (1) maintenance of dry underclothes at all times; (2) urination volume of approximately 300 to 400 ml at each void; (3) urination frequency of approximately 4 to 6 times during the day and no more than once at night; and (4) urination without any discomfort, excessive effort, or false starts and stops. Several components are needed to maintain continence: The continent individual must ; a) recognize the need to urinate, b) locate the proper place to urinate, c) reach that place to urinate in an efficient time period d) retain the urine until the place is securely reached, e) be able to urinate once arriving at the proper place. In older adults, particularly those who are disabled or hospitalized, incontinence may result more from the inability to reach the desired place than from any true urological impairment. Many facilities have like beds or chairs that are hard get out of and toilets that are difficult to reach, are factors which exacerbate this problem. PREVALENCE: Women experience incontinence twice as often as men, with 15% to 30% of women in all age groups affected. Among middle-aged women, research indicates that 58% reported some urine loss, but only 25% sought treatment.? Among non-institutionalized women older than 60, it was found that 37.7% suffered from incontinence. Lack of control over urination is one of the five main reasons for admission to a nursing home, along with immobility, cognitive impairment, falls, and the consequences of stroke. Causes of Urinary Incontinence UI The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. The levator ani is usually considered in three parts: pubococcygeus, puborectalis, and iliococcygeus 1-Stress incontinence • Two main causes of stress incontinence exist. • The major cause is impaired urethral support from pelvic floor muscle weakness. • The less common cause is an intrinsic sphincter deficiency usually from pelvic surgeries. • In either case, diminished urethral sphincter function diminishes and its function is compromised with increased abdominal pressure. • Stress incontinence is characterized by urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical exertion. • 2- Urge incontinence or Hypertonic • Urge incontinence is a result of uninhibited bladder contraction from detrusor hyperactivity. • This hyperactivity can be caused by abnormalities of the CNS inhibitory pathway such as strokes and cervical stenosis. Other causes are bladder inflammation from infection, stones. • Urge incontinence is characterized by involuntary urine loss accompanied by a sudden strong desire to pass urine that is difficult to suppress. • Some individuals may have a pure sensory abnormality where they exhibit urinary frequency and urgency without urine loss. This is often referred to as overactive bladder dry. • Elderly persons frequently experience urinary loss without the sensation of urge, but the underlying mechanism of detrusor hyperactivity is still the same. 3-Mixed incontinence • Mixed incontinence is the coexistence of stress and urge incontinence. • Mixed urinary incontinence is characterized by involuntary loss of urine associated with urgency as well as exertion, cough, sneeze, or any effort that increase intra-abdominal pressure. • Mixed incontinence is the most common type of incontinence in women. 4-Overflow incontinence or Hypotonic • Overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction. • Factors involved in the development of overflow incontinence are physical obstruction, such as pelvic organ prolapse and enlarged prostate and neurological abnormalities, such as spinal cord injuries. It is also commonly associated with bladder neuropathy as occurs in diabetes mellitus. • Patients often complain of continuous small- volume leakage associated with weak urinary stream, dribbling, hesitancy, frequency, and nocturia. 5- Functional incontinence Functional incontinence occurs when a person does not recognize the need to go to the toilet, recognize where the toilet is, or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, or unwillingness to toilet because of depression, anxiety or anger. People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer's Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes 6- Other less frequent causes • Include trauma from pelvic fracture, complications of urologic procedures, and fistulas. • "Transient incontinence" is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow. • Incontinence can often occur while trying to concentrate on a task and avoiding using the toilet. Incontinence and Aging The older old (older than 75 years) are more likely as a group to suffer from incontinence. 1-Aging in general has an impact on UI partially because of obstruction of the bladder outlet (urethra) in older adults, which is probably due to diminished or absent urethral compliance or lack of detrusor contractility. 2- Older people may be more susceptible urinary incontinence due to side effects of pharmaceuticals, lack of necessary social and or medical support, or an interaction of various pathologies that can lead to functional disability. 3- As the urinary system ages, the kidneys have diminished urine concentration, which leads to increased volume of urine passing through the bladder. 4- In conjunction with other effects of aging such as hypotrophic changes in collagen, elastic tissue, and smooth muscle of the bladder, this change in urine volume results in more frequent micturition. 5- Decreased muscle tone in bladder, internal and external sphincters, bladder outlet, and pelvic muscles also contributes to an elderly women's tendency toward UI. 6- Other age-related changes in women are reduced urethral closure pressure that is possibly due to lower estrogen levels, which leads to decreased submucosal blood supply and decreased EVALUATION Clinical History: All patients (especially those >65 y) should be asked specific questions about voiding problems. - Onset (pregnancy, postpartum, surgery, trauma) - Duration of complaint - Patterns (nocturnal vs diurnal) - Precipitants (cough, sneeze, and position change, sound of running water). - Frequency/severity/quantity - Voiding diary. Examination Proper examination of the pelvic floor muscles lays the foundation for a plan of intervention. 1- One of the most commonly used methods for evaluation of pelvic floor action is the modified Oxford scale, which uses a number to represent a certain grade of muscle power. The scale measures contractions from a low of 0 for no contraction (nil) to a high of 5 for a strong contraction. Intermediate scores of 1, 2, 3, and 4 correspond to muscle ratings of flicker, weak, moderate, and good. This scoring system can be adapted to measure muscle endurance by determining the duration and repetition of quick contractions. 2- Visual inspection of proper contracting and lifting activity of the pelvic floor also can be used to assess impairment. 3- Self-assessment can be performed by the stop test. A stop test simply tests the ability to stop the flow of urine. It is recommended as an occasional-use test only. Performing this measure of urine control on a regular basis is contraindicated because it may trigger bladder instability or infection. 4- Urodynamic testing and other examination procedures to assess the extent of leakage in response to increased abdominal pressure, such as the pad test, may be performed by the therapist or other health care professionals. During a pad test the subject is asked to wear a pre- weighed pad and to drink 500 ml of fluid in a set period of time, such as 15 minutes. Next, the subject performs a variety of set functions for 30 minutes, including sit to stand, walking, jumping, reaching for an object on the floor, and running water over the hands. The pad is then re-weighed to collect data on urine loss during activity. Treatment I. Advices: There are several things patients can do to help improve continence. 1-Avoid overconsumption of diuretics, antidepressants, antihistamines, and cough-cold preparations. 2- Perform Kegel exercises daily. 3- Practice double voiding (urinate, wait a few seconds, urinate again). 4- Eat fruits, vegetables, and whole grains daily to prevent constipation. 5- Retrain the bladder (urinate only every 3 to 6 hours). 6- Stop smoking (nicotine irritates the bladder). II. Devices : A number of protective devices are available to help manage accidental urination, including the following: 1-Bed pads 2- Combination pad-pant systems 3- Disposable or reusable adult diapers 4-Full-length absorbent undergarments 5-Male incontinence drip collectors 6-Underwear liners (pads, guards, shields, inserts) Early reliance on absorbent pads may cause the wearer to accept incontinence rather than seek diagnosis and treatment. These products should be applied correctly and changed often to prevent skin irritation and urinary tract infection III. Exercises 1- Kegel exercises : The muscle group strengthened through Kegel exercises is the pubococcygeous muscle group. These muscles relax under your command, to control the opening and closing of your urethral sphincter: in other words, they are the muscles that give you urinary control. When they are weak, leakage occurs. Through regular exercise, however, you can build up their strength and endurance and, in many cases, regain control. When instructing a patient on how to contract the pelvic muscles, the therapist should first have him/her assume a comfortable supine position with the legs well-supported and apart. The first step is to properly identify the muscle group to be exercised. - The patient should be instructed to tighten or draw up the muscles around the openings of the vagina, urethra, and rectum as if he/she were trying to prevent the flow of urine ( lift and squiz). -As you begin urinating, try to stop the flow of urine without tensing the muscles of your legs. - It is very important not to use these other muscles, because only the pelvic floor muscles help with bladder control. -When you are able to slow or stop the stream of urine you have located the correct muscles. -Feel the sensation of the muscles pulling inward and upward. -The therapist then encourages the patient to notice the muscle tension and hold the contraction as long as possible (striving for a goal of a lO-second contraction). - The patient should then allow the muscle to relax or rest for twice as long as it contracted, i.e., if contraction is held for 3 seconds, the patient should rest for at least 6 seconds. -The therapist should then have the patient repeat the cycle of contraction and relaxation and increase his/her awareness of the muscle action. - At this point the patient should be able to feel the pelvic muscles working. - The baseline muscle performance should be measured by recording how long a contraction can be held and how many times it is repeated. After noting this baseline assessment of performance, the patient should be encouraged to increase the repetitions, duration, and frequency of the exercises. Various recommendations range from a high of 300 to 400 repetitions per day to as few as three to four maximal contractions performed three times a week. Other exercise regimens can be performed in a group exercise setting using several positions with the legs abducted, in which 8 to 12 contractions are performed by the patient in each position followed by relaxation. This exercise prescription is recommended for use as a home program of 8 to 12 repetitions in a set performed 3 times per day. 2-Weight Training Resistive exercise for the pelvic muscles can be perfonned using weighted vaginal cones. Cones are usually packaged in sets of five that gradually increase in weight, ranging from 20 to 70 grams. For this exercise, the patient simply places the small plastic cone within her vagina, where it is held in by a mild reflex contraction of the pelvic floor muscles. Because it is a reflex contraction, little effort is required on the part of the patient. A woman inserts the heaviest cone that can be retained for at least 1 minute and then progresses to heavier cones and increased duration and difficulty of retention during activity as her strength improves. One treatment regimen recommends that the patient insert a cone twice a day and walk around for 15 minutes. If the cone slips, the patient should reinsert the cone. When the cone can be retained, the cone with the next highest weight can be used, or the patient can try to use the same cone with more challenging activities, such as jumping. 3-Biofeedback Visual and auditory feedback can be provided using a perineometer or electronic biofeedback (BF) modalities. The perineometer transmits pressure changes relating to pelvic muscle contractile forces. Electronic devices during examination can pick up a very sensitive range of signal from the musculature using external or internal electrodes. The success rate of visual and/or auditory feedback in muscle re-education resulting in diminished episodes of urine leakage has been estimated as ranging from 54% to 90%.8 There are four conditions contribute the successful use of this modality: - an easily measurable and detectable response; - an ability to detect change in that response; - a cue to control need; - and motivation of the patient to be actively involved in the treatment 4-Electricnl Stimulation Electrical stimulation uses faradic or interferential current delivered via internal or external electrodes to recruit muscles fibers, beginning with large-diameter fibers and eventually engaging the small-diameter fibers. Electrical stimulation can be used to achieve the following anticipated goals: 1-enhance storage of urine by altering bladder sensation via afferent fiber stimulation, 2- stimulate detrusor muscle activity to contract the bladder via efferent stimulation, 3- improve circulation to the muscles and capillary nerwork, 4- and promote muscle hypertrophy. Treatment protocols vary, and intensity is determined according to patient tolerance. A stimulation frequency of 35 Hz provides muscle feedback and can elicit a cortical response. A frequency that is too high may unduly fatigue a muscle. Pulse width is generally set at 200 to 400 microseconds with adequate rest period, usual at least equal to or longer than the stimulation phase.