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					       Are Your Parents All Wet?
An Update on Geriatric Urinary Incontinence &
            Overactive Bladder

        Joseph G. Ouslander, M.D.
           Professor of Clinical Biomedical Science
           Associate Dean for Geriatric Programs
                     Professor (Courtesy)
             Christine E. Lynn College of Nursing
                  Florida Atlantic University

              Professor of Medicine (Voluntary)
         University of Miami Miller School of Medicine

  Executive Editor, Journal of the American Geriatrics Society
Geriatric Urinary Incontinence &
   Overactive Bladder (OAB)
             An Update
   Definitions, prevalence, & impacts
   Pathophysiology
   Diagnostic evaluation
   Management
Basic Types of Incontinence


      Urge        Stress



   Functional   Overflow
                 (Incontinence with
                incomplete bladder
                     emptying)
           Overactive Bladder

 Urgency,   with or
      without urge
      incontinence
 Urinary Frequency
   >8 voids/24 hrs
   Nocturia
                       “My bladder is more
                        active than I am”
Case 1     Case 2

Sara         Sam
         (Sara’s husband
           of 62 years)
             Case 1 – Sara
History
  • 84 y.o. with CHF, depression
  • Meds: lisinopril, sertraline
Symptoms
  • Multiple episodes of urge
    incontinence during the day
    and night
               Case 2 – Sam
History
  • 88 y.o. Alzheimer’s, HTN, venous
    insufficiency, TURP-10 years ago
  • Meds: lisinopril, furosemide,
    tamsulosin, donepezil
Symptoms
  • Overactive bladder
  • No symptoms of voiding difficulty
      Overactive Bladder
                  Prevalence
50%
45%                                       42%
40%
35%                31%
30%
25%
20%
15%
         9%
10%
 5%                            3%
 0%
      Age 40-44   Age 75+   Age 40-44   Age 75+
           Women                    Men
  Impact of UI & OAB on Quality of Life
                          Physical
                  Discomfort,  odor
                                              Psychological
                  Falls and injuries
                                            Fearand anxiety
                                            Loss of self-esteem
      Sexual                                Depression
Avoidance of sexual
contact and intimacy
                          Quality of Life

   Occupational                                     Social
Decreased productivity                     Limited  travel and
Absence from work                           activity around toilet
                                             availability
                                            Social isolation
 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                   Incite                  Promote
           Gender                   Childbirth
                                  Nerve damage      Constipation Menstrual cycle
            Racial                                   Occupation     Infection
         Neurologic              Muscle damage
                                    Radiation        Recreation   Medications
          Anatomic                                    Obesity     Fluid intake
          Collagen              Tissue disruption
                                 Radical surgery      Surgery          Diet
          Muscular                                  Lung disease Toilet habits
           Cultural                                   Smoking      Menopause
        Environmental



                                                           Decompensate
          Intervene                                            Aging
          Behavioral                                         Dementia
        Pharmacologic                                         Debility
           Devices                                            Disease
           Surgical                                         Environment
                                                            Medications

Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.
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
Pelvic Exam in Older Women
Constipation: Effects on the LUT
Geriatric Urinary Incontinence & OAB

              Drugs
    Alcohol, caffeine
    Diuretics
    Narcotics
    Anticholinergics
    Psychotropics
    Cholinesterase inhibitors
    Alpha adrenergic drugs
    ACE Inhibitors (cough)
    Calcium channel blockers,
     gabapentin, glitazones (edema)
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
Geriatric Urinary Incontinence
     Diagnostic Assessment
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
                  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
Pelvic Exam in Older Women
Pelvic Exam in Older Women
Prostate Exam in Older Men
   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
        hematuria
 Sterile
 Glucosuria
“Urology Department. Can you hold?”
Please try to void normally.
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       Behavioral
  Supportive               interventions
   measures                Pharmacologic
    Education              therapy
    Environmental         Surgical
    Toilet substitutes
                            interventions
    Catheters
    Garments/pads         Devices
Management of Geriatric Incontinence and OAB

              Supportive Measures
          Education
          Environmental
            Clearwell-lit path to toilet
            Bedside commodes, urinals

          Garments/pads
          Catheters
            Forskin problems, retention, palliative
            care/patient preference
Chronic Indwelling Catheters
     Appropriate indications

 Significant, irreversible retention
 Skin lesions/surgical wounds
 Patient comfort/preference
Management of Geriatric Incontinence and OAB

             Treat Reversible Causes
     Modify      fluid intake (especially caffeine 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

         Behavioral Interventions
        “Bladder Training”
         •   Education
         •   Urge suppression techniques
         •   Pelvic muscle rehabilitation
               With   and without biofeedback
        Toileting programs
         •   Prompted voiding (and others)
Pelvic Muscle Exercises
           Pelvic Muscle Exercises
                 Locate pelvic muscles




Repeat in sets                           Squeeze muscles
  of up to 10                             tightly for up to
                                             10 seconds
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
                               20
     Accidents per Week, No.




                               15

                               10

                               5

                               0
                                    Baseline         2         4            6    8
                                                            Time, wk
Burgio et al: JAMA 280: 1995, 1998
Management of Geriatric Incontinence and OAB




             Drug Therapy
    Lower Urinary Tract Cholinergic and
          Adrenergic Receptors
         Μ=muscarinic   α=α1-adrenergic




Detrusor                               Trigone (α)
muscle (M)
                               Bladder neck (α)




                              Urethra (α)
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

      Antimuscarinic/Anticholinergics
      α-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
Antimuscarinic Therapy
 for Urge UI and OAB
   Darifenacin (Enablex®)
   Fesoterodine (Toviaz®)
   Oxybutynin (Ditropan®)
     •   Immediate release
     •   Extended release (Ditropan XL®)
     •   Transdermal patch (Oxytrol®)
   Solifenacin (Vesicare®)
   Tolterodine (Detrol 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   preference

     Risk   for side effects/co-morbidity

     Responsiveness     to behavioral interventions

     Cost
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
        Drug Therapy for Urge UI and OAB
           Combined Alpha Blocker and Antimuscarinic
               for OAB Symptoms in Older Men
   Randomized, double-blind,
    controlled trial of tamsulosin          Group         Benefit
    (n=215), tolterodine ER (n=217),
    a combination (n=225), vs.              Placebo         62%
    placebo (n=222) for 12 weeks
                                         Tolterodine ER     65%
   ~ 60% over age 60
   Main outcome = Perception of          Tamsulosin        71%
    Treatment Benefit
       “Have you had any benefit from   Combination
        your treatment?”                                    80%

    Kaplan et al, JAMA. 2006; 2319-28      Very low rate (<0.5%) of
                                              urinary retention
 Potential Side Effects of Antimuscarinic Drugs

                          Iris/Ciliary Body = Blurred Vision
      CNS                 Lacrimal Gland = Dry Eyes

   Somnolence
                          Salivary Glands = Dry Mouth
Impaired Cognition
                          Heart = Tachycardia


                          Stomach = GERD


                           Colon = Constipation

                           Bladder = Retention
                 Case 1 – Sara

History
  • 84 y.o. with CHF, depression
  • Meds: lisinopril, sertraline
Symptoms
  • Multiple episodes of urge incontinence
    during the day and night
Physical Findings
  •   2+ edema bilaterally to above ankles
  •   Moderate cystocele
  •   Signs of atrophic vaginitis
  •   Negative cough test
  •   Void 275 ml; PVR 40 ml,
  •   UA negative by dipstick
                  Case 1 – Sara
Management
  • Decrease caffeine intake
  • Prescribe furosemide in the late afternoon
    to reduce edema and nocturia
  • Topical estrogen cream or estradiol
    vaginal ring for atrophic vaginitis
  • Ignore the cysotcele
  • Bladder training with pelvic muscle
    exercises (taught by biofeedback)
  • Consider:
     • Antimuscarinic drug therapy
                 Case 2 – Sam
History
  • 88 y.o. Alzheimer’s, HTN, venous
    insufficiency, TURP-10 years ago
  • Meds: lisinopril, furosemide,
    tamsulosin, donepezil
Symptoms
  • Overactive bladder
  • No symptoms of voiding difficulty
Findings
  •   Trace ankle edema bilaterally
  •   Prostate not enlarged on rectal exam
  •   Large amount of soft stool in rectum
  •   Voided volume 180 ml
  •   PVR 90 ml; UA negative
                Case 2 – Sam

Management
 • Bowel regimen – regular use of
   suppositories
 • Consider a trial off furosemide and
   donepezil
 • Bladder training with pelvic muscle
   exercises (with reminders by Sara)
 • Consider:
    • Careful trial of antimuscarinic
      drug therapy