AGS URINARY INCONTINENCE. Tanya Cabrita, MD Emory University Department of PM&R
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1 URINARY INCONTINENCE AGS Tanya Cabrita, MD Emory University Department of PM&R THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.
2 CLINICAL VIGNETTE (1 of 4) Mr Rogers is a 78-year-old male with a history of dietcontrolled diabetes, hypertension, and ischemic stroke 2 years ago He has no residual neurological deficits from his stroke and no post-stroke bowel or bladder incontinence He comes in today complaining of a 4-month history of leaky urine, which happens any time during the day or night and usually involves only a small amount of urine Slide 2
3 CLINICAL VIGNETTE (2 of 4) He reports no issues with getting to the bathroom or mobility and is always fully aware when he has to urinate When asked to describe the symptoms, he reports strong urgency, with difficult initiation and weak stream He reports urinating up to 8 times per day and at least twice during the night. I feel like my bladder is never empty, with a constant pressure feeling. Sometimes I have to strain to get it out and get cramps in my lower stomach. Slide 3
4 CLINICAL VIGNETTE (3 of 4) He reports his previous doctor gave him antibiotics a month ago, but the symptoms and pain did not change He denies any foul-smelling or discolored urine, hematuria, fevers, previous back or pelvic surgeries, and neurologic diseases He is married and denies any extramarital relations or prior history of STDs or genital lesions He does not take any medication; however, last week he took pseudoephedrine for some nasal congestion and did not leak all day Slide 4
5 CLINICAL VIGNETTE (4 of 4) He denies inciting factors such as laughter, coughing, or sneezing He reports his wife told him to do Kegel exercises but they did not help Urinalysis is negative, PSA is 3.0, and renal ultrasound reveals hydronephrosis without stones Urodynamic and pressure-flow studies reveal high detrusor pressure and decreased urinary flow rates with high post-void residual volumes Slide 5
6 VIGNETTE QUESTIONS 1. What is the most likely etiology of Mr. Rogers urinary incontinence (UI)? 2. What type of UI does he most likely have? 3. What is the appropriate UI work-up? 4. Which medications can potentially worsen UI? 5. What are the similarities and differences between older men and women with regard to UI? 6. In general, how can the team impact the incidence of UI in the acute inpatient setting? Slide 6
7 VIGNETTE ANSWERS: QUESTIONS 1 AND 2 Benign prostatic hyperplasia is the most common etiology for UI in men Mr. Rogers has overflow incontinence Slide 7
8 VIGNETTE ANSWERS: WORK-UP OF UI Basic components of UI evaluation include history of the problem, the situations in which it occurs, medical history, bowel and bladder habits, symptoms, and lifestyle behaviors BPH screen, physical including prostate exam, CBC, BMP, LFTs, PSA, urinalysis and culture, thyroid and glucose tests Further work-up: Post-void residuals, renal ultrasound, and urodynamic studies Slide 8
9 VIGNETTE ANSWERS: MEDICATIONS THAT WORSEN OVERFLOW INCONTINENCE Alpha-adrenergic agonists strengthen muscles causing overflow Diuretics increase urine volumes Beta-blockers and calcium-channel blockers relax sphincter and detrusor muscles causing overflow Caffeine, sedatives, antidepressants, antipsychotics, and antihistamines increase the risk of incontinence Slide 9
10 VIGNETTE ANSWERS: UI IN WOMEN Urge incontinence is more common in women than in men Women are at increased risk secondary to 2 important differences: Urethras in women are shorter than in men (about 2 inches versus 10 inches) Childbirth Other risk factors in women include: postmenopausal status, urinary infections, vaginal delivery, episiotomy, and hysterectomy Slide 10
11 VIGNETTE ANSWERS: UI IN MEN In older men, prostate problems and their treatments are the most common factors affecting the urinary tract Other risk factors include diabetes, high-impact exercise, smoking, and obesity Temporary UI factors: Urinary tract infections Excess fluid intake Constipation Severe depression Restricted mobility Drugs Slide 11
12 VIGNETTE ANSWERS: REHAB TEAM Promote continence by identifying individual risk factors & designing interventions to eliminate those that are modifiable Identify risk factors: older age, immobility, cognitive limitations, DM, depression, obesity, stroke Modify: treat UTIs, caffeine intake, appropriate fluid intake, constipation, medications that worsen incontinence, and environmental changes Slide 12
13 RESOURCES (1 of 4) Emory University Geriatric Medicine Resource Module. Urinary Incontinence. ucation/edu_resources/modules/urinary_incontinence.cfm Incontinence in men. In: Schröder A, et al. Guidelines on Urinary Incontinence. Arnhem, The Netherlands: European Association of Urology; 2009: Slide 13
14 RESOURCES (2 of 4) Dowling-Castronovo A. Urinary incontinence assessment in older adults, part I: transient urinary incontinence. Try This: Best Practices in Nursing Care to Older Adults. 2007;11(1): Dowling-Castronovo A. Urinary incontinence assessment in older adults, part II: established urinary incontinence. Try This: Best Practices in Nursing Care to Older Adults. 2008;11(2): Slide 14
15 RESOURCES (3 of 4) Bradway C. Evaluation and Management of Urinary Incontinence in Older Adults [slide presentation]. Offermans MP et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn. 2009;28(4): Agency for Healthcare Research and Quality. Urinary incontinence in adults: clinical practice guideline update. March Slide 15
16 RESOURCES (4 of 4) International Continence Society aspx American Urological Association Canadian Urological Association Slide 16
17 THANK YOU FOR YOUR TIME! Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatricssociety Slide 17
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Chapter 1 Margaret Falconio-West: This video series was created to familiarize you with F315 requirements, to promote continence with your residents, and to provide treatment options for incontinence.
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