Urinary Incontinence in the Elderly

Urogenital Urinary Incontinence in the Elderly Dr. Lynn Stothers, MD, MHSc, FRCSC, Assistant Professor of Surgery/Urology, Associate Member, Department of Health Care and Epidemiology, University of British Columbia,Vancouver, BC. Dr. Howard Fenster, MD, FRCSC, Clinical Professor, Department of Surgery, Division of Urology, University of British Columbia,Vancouver, BC. Definitions and Epidemiology Urinary incontinence (UI), the involuntary loss of urine, is a common medical condition in the elderly. Over 1.5 million Canadians are currently afflicted with the condition, and the number is expected to increase significantly over the next 20 years as the baby boom population ages. 1 Chronic UI has far-reaching consequences for both the individuals affected and their caregivers. Physical complications include renal failure, urinary tract sepsis, renal calculi, hematuria, skin disease, falls and fractures and death relating to renal failure/urosepsis. Psychosocial impact can range from embarrassment and social isolation to depression and suicidal ideation. Less than 50% of those affected seek help for the condition, often due to embarrassment. lesion, multiple sclerosis or Parkinson s disease. A newly recognized condition in the elderly is detrusor hyperactivity with impaired contractility (DHIC). This condition is diagnosed with urodynamic testing and is clinically manifest as overactive bladder symptoms with increased residual urine. is leakage of urine associated with physical activities. It begins clinically as loss of urine with strenuous efforts such as coughing or sneezing. As the condition increases in severity, urine loss may occur with lesser degrees of activity, such as changing position from lying to standing, walking and other simple activities of daily living. may be caused by abnormalities of the bladder neck or urethra, and can be classified by Table 1 Clinical Classification of Urinary Incontinence Urgency incontinence Mixed incontinence Overflow incontinence Other: continuous incontinence due to fistula incontinence secondary to mobility disorders incontinence secondary to cognitive disorders the anatomic location of the abnormality or the leak point pressure the amount of abdominal pressure required on urodynamic testing to reproduce the symptom. Mixed incontinence may occur with elements of both stress and urgency incontinence in the same individual. Overflow incontinence occurs with retention of urine, and is seen in both Classification UI can be categorized according to the simple clinical classification presented in Table 1. Urgency incontinence is an involuntary loss of control associated with a desire to void. It may be experienced during activities such as opening a residence door ( key in the door syndrome ) or coming in contact with water (e.g., standing at the sink), or it may come about unexpectedly. It is often associated with urodynamic evidence of bladder overactivity, which separates the condition into motor urge (uninhibited detrusor contractions) or sensory urgency (no uninhibited detrusor contractions). The condition can be present with or without obvious neurologic disease such as a spinal cord Table 2 Physical Attributes Hormonal Status Pharmaceutical Agents Social Habits Risk Factors for Urinary Incontinence Increasing age Gender (women at greater risk than men) Post partum Obesity Race Previous pelvic surgery Immobility Decreased estrogen Diuretics (overflow or urge incontinence) Narcotics (overflow incontinence) Medications taken with large fluid intake, especially at night Smoking Alcohol Caffeine www.geriatricsandaging.ca 35

Table 3 Common Reversible Causes of Urinary Incontinence Urinary tract infection Atrophic vaginitis Pharmaceuticals Psychological factors Excessive urine production Restricted mobility Stool impaction men and women. Clinically, it may be associated with an overactive bladder, with a physical obstruction or, in the absence of physical obstruction, with an acontractile or underactive detrusor muscle. Less common forms of incontinence are seen with rare clinical conditions such as vesicovaginal fistula in women. Evaluation The evaluation of a patient with UI begins with a history, physical exam and urinalysis. A basic evaluation identifies reversible conditions and patients who require further specialist evaluation. The purpose of a specialist evaluation is to identify the cause of the leakage through reproduction of the symptom, which often involves the use of special tests such as urodynamics, cystoscopy and/or imaging studies including voiding cystourethrogram, CT scan or MRI. The specialist s mandate also includes treating conditions that require pharmaceutical or surgical interventions. Patients reluctant to discuss UI may respond to the question, How is your bladder? as part of an overall functional inquiry. Key elements in the history include the acute or chronic nature of the symptoms, identifying factors that immediately precede the loss of control, and any changes in the patient s lifestyle related temporally to the onset of symptoms. Risk factors for UI are shown in Table 2. A simple but effective component of the evaluation is the use of a voiding diary, which the patient can complete at home (Figure 1). It provides the clinician with a gauge of both the frequency of UI and the number of voidings per day relative to fluid intake. Quality of life scores, such as the SEAPI QMM Quality of Life Score, 2,3 have been validated in the elderly population. Another commonly employed score for female patients is the Urogenital Distress Inventory. 4-6 Neurologic and pelvic exams should be the focus of the general physical exam. In women, UI is commonly associated with prolapse of the pelvic organs. In men, a prostatic exam may reveal one of several conditions associated with UI. Mobility and cognitive functioning can affect awareness of the sensation of bladder filling and the ability of the patient to toilet in a timely fashion. It should be kept in mind that incontinence may not be isolated to the urinary tract, and that fecal incontinence may coexist. The history and physical assessment should aim to identify common reversible causes for UI (Table 3). Figure 1 Sample Voiding Diary Treatment The most common behavioural therapies and pharmaceutical and surgical interventions used for treating UI are summarized in Table 4. Behavioural therapies are low risk with very few side effects, but require repetition and a motivated, cooperative patient. A pelvic floor exercise program, which has been shown to be effective for adult women with stress or mixed incontinence 7 and urge incontinence, 8 usually involves five to 15 contractions with a 10-second hold, three to five times per day. Randomized controlled trials (RCTs) indicate that 56 77% of patients who follow this type of program are either cured or improved at short-term follow-up, 9-12 and there is preliminary evidence that improvement may persist for at least 10 years. 13 Bo et al. found that pelvic floor muscle exercise was superior for decreasing the volume of urine loss compared to no treatment and to conservative measures of stress incontinence, including electrical stimulation and weighted vaginal cones. 11 A recent RCT showed biofeedbackassisted behavioural treatment to be superior to oxybutynin and placebo, with a 74% cure/improved rate in the elderly with urge or mixed incontinence. 14 While patients often find information about pelvic floor exercise in the lay press, specially trained health care professionals (e.g., continence advisors or physiother- TIME Volume Voided at Volume of Fluid Episode of Toilet Intake Incontinence 06:00 200cc 07:00 250ml Yes 08:00 09:00 150cc 200ml 10:00 11:00 Yes (urgent) 12:00 250ml 13:00 250cc 14:00 etc. 36 GERIATRICS & AGING October 2002 Vol 5, Num 8

apists) who teach the correct method of contracting and discriminating pelvic floor muscles may achieve superior results. 15 Pharmacologic therapies for stress incontinence currently focus on alpha agonist agents that promote closure of the bladder neck, thereby increasing the amount of outlet resistance to guard against stress incontinence. RCTs have demonstrated cure rates of 9 14% and cure/improvement rates of 19 60% using these medications. The most effective agent demonstrated in RCTs phenylpropanolamine (PPA) was discontinued due to increased risk of stroke. While estrogens are used by many clinicians for the treatment of incontinence, RCT evidence of their benefit is lacking. 16 Over the past decade, there have been important advances in anticholinergics for the treatment of urge incontinence. Oxybutynin (Ditropan ) has anticholinergic and direct smooth muscle relaxant properties. Longer-lasting forms of the drug are now available in Canada, allowing for once-a-day dosing (Ditropan XL ). Less costly, short-acting formulations come in 5mg tablets that can be given as 5mg or 2.5mg two to four times per day, respectively, with gradual dosage adjustments tailored to compensate for side effects and changes in symptoms. Tolterodine is a newer, competitive M3 receptor blocker that is available both in a once-a-day formulation to improve compliance (Unidet ), as well as in the shorter-acting Detrol that is typically given twice per day. RCTs showed a decrease in the frequency of urgency incontinence episodes for both oxybutynin and tolterodine compared to placebo. 17 Once-a-day formulations are associated with significantly fewer side effects, particularly dry mouth. Tricyclic agents such as imipramine are often less expensive than the newer, long-lasting anticholinergic agents. However, they have not been shown in RCTs to be as effective, and their long half-life and side effect profile may limit their use in the elderly. 18 can be treated both pharmaceutically and surgically, although there are many more surgical than pharmaceutical options. Intraurethral bulking agents are pastes or semisolid materials that can be injected through a needle into the urethra under cystoscopic or direct guidance. The most common agent, Contigen, is bovine cross-linked collagen. Patients require skin testing before urethral injection due to the rare case of allergy to the material. Bulking agents are minimally invasive and can be injected under local anesthetic in an outpatient setting, but often require multiple injections because the duration of clinical improvement may decrease over time. Synthetic agents available in Canada reduce allergy and aim to offer a greater degree of durability of improvement. The full clinical significance of migration of particulate matter placed into the urethra, which occurs rarely, is still unknown. 19 Surgical options include bladder neck suspensions and sling procedures. Advances in surgical technique and anesthetics for traditional bladder neck suspensions, such as the Burch colposuspension, have reduced the length of hospital stay to overnight in some facilities. Sling procedures aim to prevent the descent of the urethra with straining, and may increase urethral resistance. They are typically performed through a vaginal approach, minimizing length of stay. Slings can be fashioned from the existing tissues of the vagina (vaginal wall slings), autologous strips of fascia (such as the rectus fascia or the fascia lata from the thigh), cadaveric fascia or synthetic materials (such as Prolene mesh, Ethicon Inc.). The sling may be anchored in the pelvis with a variety of materials that include Prolene sutures, screws or staples. Few RCTs have directly compared different types of sling procedures, and the type of sling employed is currently dictated primarily by surgeon preference. Large scale RCTs comparing Burch colposuspension to slings for stress incontinence are currently underway in Europe. The artificial urinary sphincter (AMS Sphincter 800, American Medical Systems) is a pressurized prosthetic device that includes a ring with varying degrees of resistance designed to treat causes of UI that affect the urethra, particularly after radical prostatectomy in men. It is placed under the skin, encircling the urethra, to improve urine storage. In neurogenic bladder and incontinence augmentation, cystoplasty may be performed to increase bladder size and reduce storage pressure, which improves continence and Table 4 Treatments for Urinary Incontinence Non-pharmaceutical/Non-surgical Habit training (timed voiding) Pelvic floor muscle exercise alone or with: biofeedback electrical stimulation Pharmacologic alpha agonists Urgency incontinence oxybutynin tolterodine tricyclic agents Surgical injectable intraurethral bulking agents bladder neck suspension urethral slings artificial urinary sphincters Urgency incontinence/ Neurogenic bladder augmentation cystoplasty electrical stimulation Mechanical obstruction transurethral prostatic resection incision/reconstruction for urethral stricture urethral diverticulum removal www.geriatricsandaging.ca 37

Urinary Incontinence: Pharmacologic and Surgical Interventions Alpha agonist Intraurethral bulking agents Vaginal sling Pharmacologic therapies for urinary stress incontinence currently focus on alpha agonist agents that promote closure of the bladder neck. However, there are more surgical options for urinary incontinence available, including the injection of paste-like bulking agents into the urethra under cystoscopic guidance. Sling procedures aim to prevent the descent of the urethra with straining, and can be fashioned from existing tissues of the vagina (seen in patient laying down). 38 GERIATRICS & AGING October 2002 Vol 5, Num 8

decreases the risk of renal impairment from high-pressure storage. Select patients with overactive bladder symptoms and/or urgency incontinence may be helped by less invasive implantation of an electrical stimulator to enhance bladder storage. Supportive Measures Supportive measures are an important adjunct or alternative to more direct treatments. Moderation of fluids and access to toilet facilities are important. Improved access to toileting includes nighttime toilet facilities located close to where the patient sleeps, a well-lit environment, adequate hand rails and elevated toilet seats for those with restricted lower limb mobility. Absorbent garments specifically designed for UI may keep the skin dryer than menstrual pads. Beyond clinical support, there are patient support groups and foundations, such as the Canadian Continence Foundation (www.ccf.ca) and the National Association for Continence (www.nafc.org), that offer information to patients on how to deal with UI. No competing financial interests declared. References 1. Canadian Continence Foundation. Urinary incontinence. Retrieved August 28, 2002 from http://www.continencefdn.ca 2. Raz S, Erickson DR. SEAPI QMM incontinence classification system. Neurourol Urodyn 1992;11:187-99. 3. Stothers L. The reliability, validity, and gender differences in the SEAPI-QMM Quality of Life Score for urinary incontinence. Neurol Urodynamics, 2002. In press. 4. Hanley J, Capewell A, Hagen S. Validity study of the severity index a simple measure of urinary incontinence in women. BMJ 2001;322:1096-7. 5. Sandvik H, Hunskaar S, Seim A, et al. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993;47:497-9. 6. Sandvik H, Seim A, Vanvik AH, et al. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48 hours pad-weighing tests. Neurourol Urodyn 2000;19:137-45. 7. Hay-Smith EJ, Bo Berghmans LC, Hendriks HJ, et al. Pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev 2001;1:CD001407. 8. Berghmans LC, Hendriks HJ, de Bie RA, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int 2000;85:254-63. 9. Gunnarsson M, Teleman P, Mattiasson A, et al. Effects of pelvic floor exercises in middle aged women with a history of naive urinary incontinence: a population based study. Eur Urol 2002;41:556-61. 10. Janssen CC, Lagro-Janssen AL, Felling AJ. The effects of physiotherapy for female urinary incontinence: individual compared with group treatment. BJU Int 2001;87:201-6. 11. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;318:487-93. 12. Wells TJ, Brink CA, Diokno AC, et al. Pelvic muscle exercise for stress urinary incontinence in elderly women. J Am Geriatr Soc 1991;39:785-91. 13. Datillo J. A long-term study of patient outcomes with pelvic muscle re-education for urinary incontinence. J Wound Ostomy Continence Nurs 2001;28:199-205. 14. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998;280:1995-2000. 15. Dougherty, MC. Current status of research on pelvic muscle strengthening techniques. J Wound Ostomy Continence Nurs 1998;25:75-83. 16. Fantl JA, Bump RC, Robinson D, et al. Efficacy of estrogen supplementation in the treatment of urinary incontinence. The Continence Program for Women Research Group. Obstet Gynecol 1996;88:745-9. 17. Harvey MA, Baker K, Well GA. Tolterodine versus oxybutynin in the treatment of urge urinary incontinence: a meta-analysis. Am J Obstet Gynecol 2001;185:56-61. 18. Owens RG, Karram MM. Comparative tolerability of drug therapies used to treat incontinence and enuresis. Drug Saf 1998;19:123-39. 19. Dmochowski RR, Appell RA. Injectable agents in the treatment of stress urinary incontinence in women: where are we now? Urology 2000;56:32-40. www.geriatricsandaging.ca 39