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What we know and what we don know about urinary incontinence

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What we know and what we don know about urinary incontinence Powered By Docstoc
					Evidence from the 4th ICI, 2008

            Ann Capewell
 With many thanks to Adrian Wagg
  This talk will
Present the highlights from the meeting
  This talk will
Present the highlights from the meeting

Aim to inspire you to 
 address continence as 
   research topic & 
   therapeutic goal
  This talk will
Present the highlights from the meeting
Aim to inspire you to 
 address continence as 
   research topic & 
   therapeutic goal

Reaffirm your central role in managing 
continence in older people
4th ICI, 2008




4th ICI, 2008
 The Consultation investigated
Urinary incontinence & faecal incontinence:
Epidemiology & economics
Prevention & Promotion
Investigation & Diagnosis
Management: Medical/ Surgical & palliative measures
Different patient groups including the frail elderly
 The Consultation investigated
Urinary incontinence & faecal incontinence:
Epidemiology & economics
Prevention & Promotion
Investigation & Diagnosis
Management: Medical/ Surgical & palliative measures
Different patient groups including the frail elderly

    (Not the ‘black box’ of how a service is put together)
Made recommendations for management& research
Evidence levels
 Level 1   meta‐analysis of RCTs or good quality RCT
 Level 2  poor RCTs, meta‐analysis of cohort studies
 Level 3   good quality case control studies 
 Level 4   expert opinion based on first principles or 
 Delphi process 
Evidence levels
   Level 1   meta‐analysis of RCTs or good quality RCT
   Level 2  poor RCTs, meta‐analysis of cohort studies
   Level 3   good quality case control studies 
   Level 4   expert opinion based on first principles or 
   Delphi process 

Lack of evidence does not mean no treatment effect
Grades of (+/_) recommendations
 Grade A  Usually  level 1 evidence, mandatory
 Grade B  Usually level 2 or 3 or majority evidence 
 from RCTs.  
 Grade C   Level 4 (non clinical) studies or a body of 
 expert opinion
 Grade D   No recommendation can be made
Grades of (+/_) recommendations
 Grade A  Usually  level 1 evidence, mandatory
 Grade B  Usually level 2 or 3 or majority evidence 
 from RCTs.  
 Grade C   Level 4 (non clinical) studies or a body of 
 expert opinion
 Grade D   No recommendation can be made

Most evidence is from many studies or
 metanalysis, so no individual references 
Population patterns
Epidemiology of urinary incontinence (UI)
Daily UI 5‐15% of women

Prevalence estimates differ because of 
Different definitions of incontinence
Epidemiology of urinary incontinence (UI)
Daily UI 5‐15% of women
Prevalence estimates differ because of 
Different definitions of incontinence

ICS definition is now: 
  ‘the complaint of any involuntary leakage of urine’
BUT
   Different severity levels and time frames
   How people respond to questionnaires
   How the sample is selected
Epidemiology of urinary incontinence (UI)
       Women > men (2:1)  
       Age  L1 (stronger  association in men  L1) 
       Frailty L1
       Diabetes   L2 

       Obesity  in women L1
       Exogenous oestrogens in women >55yrs  L1
       Infection in men  L2
       Prostatectomy  in men  L2 (especially if radical 
         surgery)

       Menopause L2 
       Mild cognitive decline  L2    (but it does increase impact)
But what about...?
Drugs
Mobility
Dementia
Etc
But what about...?
  Drugs
  Mobility
  Dementia
  Etc

Some factors associated
but are not independent risk factors 
(little or no epidemiological evidence from multivariate models)

That does not rule out their importance for individuals
The fit ...
The frail elderly are different
Frailty
Clinical phenotype of combined   level 2 evidence
impairments across:

  Physical activity
   Mobility
   Balance
   Muscle strength
   Motor processing
   Cognition
   Nutrition
   Endurance
What don’t we know?
What don’t we know?
Research evidence  
‐sparse for older people (especially the frail elderly)

 Absence of studies, 
 Lack of stratification by age or 
 Lack control for age in Multivariate  models
What don’t we know?
Research evidence is sparse for older people 
(especially the frail elderly)

 Absence of studies, 
 Lack of stratification by age or 
 Lack control for age in Multivariate  models

 Older people should be included/excluded from 
 research only on the basis of frailty/performance 
 status not age
Bladder connections
The voiding reflex

PAG= peri‐aqeductal grey matter

PMC= pontine micturition centre



                     Afferents green
                     Efferents blue
Cerebral continence control
Evidence from 
  animal experiments
 observational studies of lesions


Frontal lesions causing frequency, urgency, 
impaired or absent awareness of bladder filling, 
either sudden or absent awareness of need to empty, 
but severe distress and embarrassment.       (1964)
but severe distress and embarrassment.       
Cerebral continence control
Evidence from 
  animal experiments
  observational studies of lesions
 Functional MRI and PET


Peaks during bladder filling,
storage & withholding 
of urine
Simple cerebral control
 Afferents
                    PAG
                           Cortex

 Efferents           PMC
We now have an increasing 
understanding of complexity
Afferents in via peri‐
aqueductal grey matter

Information modified by 
connections from cortex etc 

Efferent pathway through
pontine micturition centre
(Barringtons Nucleus)
Relation of bladder to bowel
and homeostatic emotions
We experience feelings from our bodies reflecting 
physiological condition (bladder fullness, pain etc)
Motor response mediated by the emotional motor 
system
There is (conscious) feeling
  plus a motivation & motor response
Relation of bladder to bowel
and homeostatic emotions
We experience feelings from our bodies reflecting 
physiological condition (bladder fullness, pain etc)
Motor response mediated by the emotional motor 
system
There is (conscious) feeling
  plus a motivation & motor response

Sensory pathways from bladder & bowel are similar
  produce similar problems (overactive bladder  & IBS)
What don’t we know?
The therapeutic implications 

How the bowel affects the bladder 
especially in older people 

The role of constipation in urinary 
incontinence
Bladder ultrastructure on 
electron microscopy
Dysjunction pattern
Muscle and axon degeneration

Potential effect
Bladder overactivity and urgency UI
Impaired bladder contractility, increased residual
urine, and decreased functional bladder capacity 
Bladder function
Decreased capacity
Increased detrusor overactivity
Decreased detrusor contractility
Increased residual urine



Potential effect
Increased likelihood of urinary symptoms and UI 
Urethra
Decreased closure pressure in women



Potential effect
Increased likelihood of stress and urgency UI
Prostate
Increased incidence of benign prostatic obstruction
Increased incidence of prostate cancer



Potential effect
Increased likelihood of urinary symptoms and UI
Increased night‐time urine 
production

Decreased nocturnal secretion of ADH
Decreased renal function and concentration


Potential effect
Increased likelihood of nocturia and night‐time UI
Altered central and peripheral 
 neurotransmitter
 concentrations and actions
Slower nerve conduction times
Peripheral neuropathy

Potential effect


Increased likelihood of lower urinary tract dysfunction
Frailty
Clinical phenotype of combined         level 2 evidence
impairments across:

  Physical activity         Multiple chronic medical conditions
   Mobility                 Multiple medications
   Balance                  Assistance with activities of daily living
   Muscle strength          Care requires other persons
   Motor processing         Many homebound or in institutions
   Cognition                Vulnerable to intercurrent disease
   Nutrition                High risk for hospitalization
   Endurance                Increased mortality
The frail elderly are different
Frailty can be defined (L2)



Broader concept of “disease” that is 
centered on patient‐level factors, 
rather than pathophysiology of LUT 
& its neurological control
Pathophysiology defines approach
Young people
  Simple story
  Small team

 Storage or emptying of 
   bladder?



 Correctable  physical 
  abnormalities?
Pathophysiology defines approach
Young people               Frail older people
  Simple story               Complicated problem
  Small team                 Involve wider team
                           multifactorial problem, 
 Storage or emptying of 
   bladder?                Age related changes occur

                           Deficits in multiple domains 
                            which dominate any 
                            bladder  problem
Pathophysiology defines approach
Young people             Frail older people
 Identify correctable      Requires meticulous 
   physical abnormalities   evaluation not cystometry
   to plan intervention     to make diagnosis and 
                            treatment plan


 Intervention usually     Any treatment has high risk 
   simple                  potential for side effects
Frail Elderly  
Urinary incontinence (UI)
 Poorly correlated with age alone
 Related to accumulation of other diseases
 Prevention : as for other vascular and 
 degenerative diseases

 An independent risk factor for falls
 An early marker for frailty?
Urinary incontinence in Older 
People

Do a functional 
 assessment(A)

Identify and address 
  contributory causes
•Measuring a residual volume
•urodynamics
Measuring residual volume
Usually by ONE ultrasound
 Useful
BUT
 Volume will vary
 One measurement not representative 
 Can be helpful in deciding management: 
  Do Post Void Residual before drug or surgical 
   treatment.

 However large, Post Void Residual is not 
 significant as an isolated finding.  
Other investigations are needed prior to intervention
Post void residual volume (PVRV)
We don’t know:
 What is ‘normal’ in older people
 How much PVRV varies
 Whether test is 
  cost effective or 
  clinically beneficial
 The effect of faecal loading on 
 bladder emptying
Urodynamics: all ages
 Needed when the diagnosis is complex 
 Does not accurately reflect ‘usual LUT behaviour’
 Test/retest variability,  even in the young
 Only part of the diagnostic evaluation
 Very useful prior to surgical or invasive 
 treatment

 Little evidence of its usefulness in the elderly
Pharmacotherapy
We used to think
 Antimuscarinics block
 muscarinic (ACh) 
 receptors
 Cholinergic 
 parasympathetic nerves    
 so
    Detrusor contraction 
 in emptying phase
Pharmacotherapy
We used to think              The evidence is
 Antimuscarinics block         Antimuscarinics
 muscarinic (ACh)              reduce activity  of 
 receptors                     afferent pathway 
 Cholinergic                     Release of Ach 
 parasympathetic nerves        from urothelium
 so                            during filling
    Detrusor contraction 
                                 urgency 
 in emptying phase
                                  capacity
                               in storage phase
Anti‐muscarinics
Modern ones work for OAB (L1, gradeA)     
But
 Don’t work very well
 Not well tested in frail elderly (oxybutinin is)
 Side effects a problem (oxybutinin worst?)
  Acute delirium and cognitive impairment

No studies on cognitive impairment in 
 dementia patients
PS cholinesterase inhibitors cause diarrhoea & UI
Other medication 
 Local oestrogens
   can be helpful for local irritant symptoms
 Systemic oestrogens
   worsen incontinence in women

  Duloxetine for stress UI in younger women 
(alpha blockers can cause stress UI)
  but duloxetine has many side effects
Conservative Management in Women
 Weight loss improves continence   L1
 Moderate exercise decreases UI in middle aged 
 and older women
 Stopping smoking helps UI
 Reducing caffeine intake improves UI   L2

 Reducing ‘excess’ fluid intake has little effect
 There is no evidence for antibiotics in otherwise 
 asymptomatic patients
We don’t know
‐whether we should act on a raised post void residual
‐bladder training or medication as first line Rx?
‐cost benefit/cost effectiveness of our interventions
‐which is more important in nocturia: hormones, 
  medical conditions, LUT disorders, sleep etc
‐should we offer surgery to more frail elderly ?
‐there is a way to avoid catheter complications ?
The effect on patients & carers
‘Continence can often be cured & always 
 improved’

But what do patients & carers feel about 
  this?
‐and why don’t more people with 
   incontinence seek treatment?
      Research evidence 
   is sparse in the elderly
  Even more so in the frail elderly

Urinary Incontinence is a symptom
 -usually a manifestation of
   factors outside the bladder
     Continence is a 
 ‘core’ geriatric problem
We should know far more about 
  how to investigate & manage 
   incontinence in frail older 
            people 
     Continence is a 
 ‘core’ geriatric problem
We should know far more about 
  how to investigate & manage 
   incontinence in frail older 
             people 
              than
  any single organ specialist 
                           MANAGEMENT OF URINARY INCONTINENCE IN FRAIL OLDER PERSONS

HX/ SX ASSESSMENT                                 Active Case Finding in All Frail Elderly
                                                                                                                      UI associated with:
                                                                                                                          • Pain
                                                                                                                          • Haematuria
CLINICAL ASSESSMENT                     Assess, treat and reassess potentially treatable conditions, including            • Recurrent symptomatic UTI
    Delirium
                                        relevant comorbidities and ADLs (see text)                                        • Pelvic mass
    Infection
                                        Assess QoL, desire for Rx, goals of Rx, pt & caregiver preferences                • Pelvic irradiation
    Pharmaceuticals                     Targeted physical exam including cognition, mobility, neurological                • Pelvic/LUT surgery
    Psychological                       and rectal exams                                                                  • Prolapse beyond hymen
    Excess urine output                 Urinalysis                                                                           (women)
    Reduced Mobility                    Bladder diary or wet checks                                                       • Suspected fistula
    Stool impaction
        and other factors                                                                                                 • Post prostatectomy (men)
    Avoid overtreatment of
    asymptomatic bacteriuria


CLINICAL DIAGNOSIS                      Urgency UI *                      Significant PVR*                              Stress UI*           Other*

* These diagnoses may overlap
 in various combinations, eg, Mixed
 UI, DHIC (see text)


INITIAL MANAGEMENT                                                         Treat constipation                             Lifestyle interventions
                                  Lifestyle interventions                  Review medications                             Behavioral therapies
(If Mixed UI, initially treat     Behavioral therapies                     Consider trial of alpha-blocker
                                  Consider addition and trial of           (men)
most bothersome symptoms)         antimuscarinic drugs                     Catheter drainage if PVR 200-500
                                                                           ml, then reassess (see text)

ONGOING
MANAGEMENT and                         If insufficient improvement, reassess for and treat contributing comorbidity +/- functional impairment
REASSESSMENT


                                       If fails, consider specialist referral as appropriate per patient preferences and comorbidity (see text)
                              MANAGEMENT OF URINARY INCONTINENCE IN FRAIL OLDER PERSONS
HX/ SX ASSESSMENT                                    Active Case Finding in All Frail Elderly
                                                                                                                         UI associated with:
                                                                                                                             • Pain
                                                                                                                             • Haematuria
CLINICAL ASSESSMENT                        Assess, treat and reassess potentially treatable conditions, including            • Recurrent symptomatic UTI
       Delirium
                                           relevant comorbidities and ADLs (see text)                                        • Pelvic mass
       Infection                           Assess QoL, desire for Rx, goals of Rx, pt & caregiver preferences                • Pelvic irradiation
       Pharmaceuticals                     Targeted physical exam including cognition, mobility, neurological                • Pelvic/LUT surgery
       Psychological                       and rectal exams                                                                  • Prolapse beyond hymen
       Excess urine output                 Urinalysis                                                                           (women)
       Reduced Mobility                    Bladder diary or wet checks                                                       • Suspected fistula
       Stool impaction
           and other factors                                                                                                 • Post prostatectomy (men)
       Avoid overtreatment of
       asymptomatic bacteriuria


CLINICAL DIAGNOSIS                         Urgency UI *                      Significant PVR*                              Stress UI*           Other*

*   These diagnoses may overlap
    in various combinations, eg, Mixed
    UI, DHIC (see text)


INITIAL MANAGEMENT                                                            Treat constipation                             Lifestyle interventions
                                     Lifestyle interventions                  Review medications                             Behavioral therapies
(If Mixed UI, initially treat        Behavioral therapies                     Consider trial of alpha-blocker
                                     Consider addition and trial of           (men)
most bothersome symptoms)            antimuscarinic drugs                     Catheter drainage if PVR 200-500
                                                                              ml, then reassess (see text)

ONGOING
MANAGEMENT and                            If insufficient improvement, reassess for and treat contributing comorbidity +/- functional impairment
REASSESSMENT

                                          If fails, consider specialist referral as appropriate per patient preferences and comorbidity (see text)

				
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