urinary incontinence - tutorial by m donaldson
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8/18/2019 Urinary Incontinence - Tutorial by m Donaldson
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URINARYURINARY
INCONTINENCEINCONTINENCE
Dr Mark DonaldsonDr Mark DonaldsonConsultant Physician inConsultant Physician in
Geriatric MedicineGeriatric Medicine
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Urinary IncontinenceUrinary Incontinence
Afects: Afects:
15%-30% elderly liin! at "o#e15%-30% elderly liin! at "o#e
30% - 35% elderly in ac$te care30% - 35% elderly in ac$te care
50% in RC& 50% in RC&
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Urinary IncontinenceUrinary Incontinence
Continence re'$iresContinence re'$ires::
Adequate mobility Adequate mobility MentationMentation
MotivationMotivation
Manual dexterityManual dexterity Intact lower urinary tract functionIntact lower urinary tract function
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Urinary IncontinenceUrinary Incontinence
(edical Co#)lications(edical Co#)lications
Ras"esRas"es *ress$re $lcers*ress$re $lcers
UTIUTI
&alls&alls
&ract$res&ract$res
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Urinary IncontinenceUrinary Incontinence
*syc"osocial co#)lications*syc"osocial co#)lications
mbarrassmentmbarrassment !ti"matisation!ti"matisation
IsolationIsolation
De#ressionDe#ression Institutionalisation risk Institutionalisation risk
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IncontinenceIncontinence
isis never never normalnormal
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Urinary IncontinenceUrinary Incontinence
A+EIN+ ,A..ER C/AN+E A+EIN+ ,A..ER C/AN+E ,ladder ca)acity decreases,ladder ca)acity decreases ,ladder co#)liance decreases,ladder co#)liance decreases Aility to )ost)one oidin! decreases Aility to )ost)one oidin! decreases Uret"ral closin! )ress$re decreases in 2o#enUret"ral closin! )ress$re decreases in 2o#en
*rostate enlar!es in #en*rostate enlar!es in #en Inol$ntary ladder contractions increaseInol$ntary ladder contractions increase *ost-oidin! resid$al ol$#e increases 50-*ost-oidin! resid$al ol$#e increases 50-
100#l4100#l4
Also: Also:
Increased $id e6cretion at ni!"tIncreased $id e6cretion at ni!"t A!e associated slee) disorders A!e associated slee) disorders .etr$sor #$scle c"an!es.etr$sor #$scle c"an!es
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Urinary IncontinenceUrinary Incontinence
Incontinence is a +eriatric syndro#e:Incontinence is a +eriatric syndro#e:
i7e7 *redis)osed y aoe 8actorsi7e7 *redis)osed y aoe 8actors
*reci)itated $s$ally y disease o$tside*reci)itated $s$ally y disease o$tside
t"e $rinary tract7 t"e $rinary tract7
&re'$ent aderse dr$! reactions t"at afect&re'$ent aderse dr$! reactions t"at afect
t"e $rinaryt"e $rinary tract tract
It is t"ese 8actorsIt is t"ese 8actors OUTSIDE OUTSIDE t"e $rinaryt"e $rinary
tract t"at are a#enale to interentiontract t"at are a#enale to interention
e7!7 art"ritis9i##oility e7!7 art"ritis9i##oility
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Urinary IncontinenceUrinary Incontinence
Transient IncontinenceTransient Incontinence
Co##on e7!7 30% co##$nity d2ellersCo##on e7!7 30% co##$nity d2ellers
50% o8 in)atients50% o8 in)atients
At ris cases: es)ecially At ris cases: es)ecially
anti-c"oliner!icsanti-c"oliner!icsdi$reticsdi$retics
2orsenin! #oility 2orsenin! #oility
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Urinary IncontinenceUrinary Incontinence
Transient IncontinenceTransient Incontinence::
.. -- ..eliri$#eliri$#
II -- IIn8ectionn8ection
A A -- A A tro)"ic Uret"ritis9a!initistro)"ic Uret"ritis9a!initis
** -- **"ar#ace$ticals"ar#ace$ticals
** -- **syc"olo!ical rare4syc"olo!ical rare4
EE -- EE6cessie $rine o$t)$t6cessie $rine o$t)$tR R -- R R estricted #oility estricted #oility
-- tool i#)actiontool i#)action
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Urinary IncontinenceUrinary Incontinence
Urinary tract ca$ses o8Urinary tract ca$ses o8incontinenceincontinence::
.etr$sor oeractiity .etr$sor oeractiity .etr$sor $nderactiity .etr$sor $nderactiity
+en$ine stress incontinence+en$ine stress incontinence
lo2 $ret"ral resistance4lo2 $ret"ral resistance4 Ostr$ctionOstr$ction
"i!" $ret"ral resistance4"i!" $ret"ral resistance4
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Urinary IncontinenceUrinary Incontinence
.etr$sor Oeractiity .etr$sor Oeractiity
Co##onest ca$se o8 $rinaryCo##onest ca$se o8 $rinary
incontinenceincontinence;0%-
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Urinary IncontinenceUrinary Incontinence
.etr$sor Oeractiity .etr$sor Oeractiity
Clinically:Clinically: $ sudden onset$ sudden onset
$ immediate need to void$ immediate need to void %eaka"e is e#isodic& moderate to%eaka"e is e#isodic& moderate to
lar"elar"e
'octurnal frequency'octurnal frequency (r"e incontinence common(r"e incontinence common
P)* low in absence of D+ICP)* low in absence of D+IC
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Urinary IncontinenceUrinary Incontinence
tress Incontinence
Co##on in 2o#en
In #en= only a8ter s)"incteric da#a!eco#)licatin! )rostatic resection
Clinically: Instantaneo$s 2it" stress #anoe$res.elayed - s$!!ests stress ind$ced detr$soroeractiity
In #en= >leay ta)? 2orsened y standin! or
strainin! O8ten co-e6ists 2it" $r!e incontinence i7e7 #i6ed
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Urinary IncontinenceUrinary Incontinence
Uret"ral Ostr$ctionUret"ral Ostr$ction
Co##on in #enCo##on in #en In 2o#en= a8ter ladder nec s$s)ension orIn 2o#en= a8ter ladder nec s$s)ension or
inin! associated 2it" seere )rola)seinin! associated 2it" seere )rola)se *rostatic encroac"#ent*rostatic encroac"#ent Clinically:Clinically:
14 &illin! sy#)to#s14 &illin! sy#)to#s i7e7 $r!ency= 8re'$ency= noct$ria4i7e7 $r!ency= 8re'$ency= noct$ria4
@4 oidin! sy#)to#s@4 oidin! sy#)to#si7e7 )oor strea#= inter#ittency=i7e7 )oor strea#= inter#ittency=
drilin! )ost oiddrilin! )ost oid
34 Oero2 34 Oero2
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Urinary IncontinenceUrinary Incontinence
.etr$sor Underactiity .etr$sor Underactiity B10% o8 incontinenceB10% o8 incontinencecases4cases4
Us$ally idio)at"icUs$ally idio)at"ic
Ca$sed y de!eneratie #$scle and a6onalCa$sed y de!eneratie #$scle and a6onal
c"an!esc"an!es
Clinically:Clinically: Oero2 incontinenceOero2 incontinence
&re'$ency &re'$ency
Noct$riaNoct$ria
&re'$ent leaa!e o8 s#all a#o$nts&re'$ent leaa!e o8 s#all a#o$nts *R $s$ally 50#l*R $s$ally 50#l
In #en= diferentiated y $rodyna#ics rat"erIn #en= diferentiated y $rodyna#ics rat"er
t"an cystosco)y or I*7t"an cystosco)y or I*7
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Urinary IncontinenceUrinary Incontinence
Eal$ation o8 t"e older incontinent )atientEal$ation o8 t"e older incontinent )atient
+OA: Inesti!ate and treat transient andInesti!ate and treat transient andestalis"ed ca$ses7estalis"ed ca$ses7
Assess )atient?s eniron#ent and s$))ort Assess )atient?s eniron#ent and s$))ort
To detect $nco##on $t serio$sTo detect $nco##on $t serio$s$nderly"in! conditions:$nderly"in! conditions:
-- ,rain lesions,rain lesions- )inal cord lesions- )inal cord lesions- Carcino#a ladder9)rostate- Carcino#a ladder9)rostate- ,ladder stones- ,ladder stones- .ecreased ladder co#)liance- .ecreased ladder co#)liance
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Urinary IncontinenceUrinary Incontinence
Clinical (ana!e#entClinical (ana!e#ent
1717 E6cl$de oero2 incontinenceE6cl$de oero2 incontinence
e7!7 *R 50#l4e7!7 *R 50#l4
D"ere a))ro)riate= Urolo!ist D"ere a))ro)riate= Urolo!ist
re8erralre8erral
Re#ainder - cat"eteriseRe#ainder - cat"eterise
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Urinary IncontinenceUrinary Incontinence
Clinical (ana!e#entClinical (ana!e#ent@7@7 Re#ainin! 0%-5% de)ends on !ender7Re#ainin! 0%-5% de)ends on !ender7
&e#ales:&e#ales: eit"er OA, or +Ieit"er OA, or +I
+I e6cl$ded y oserin! 8or leaa!e 2it"+I e6cl$ded y oserin! 8or leaa!e 2it"8$ll8$ll ladder and i!oro$s co$!"ladder and i!oro$s co$!"
(ales:(ales: eit"er OA, or ostr$ction7eit"er OA, or ostr$ction7
I8 o2 nor#al= *R B100#l t"en ostr$ctionI8 o2 nor#al= *R B100#l t"en ostr$ction
isis e6cl$ded7e6cl$ded7
I8 *R @00#l= e6cl$de "ydrone)"rosis7I8 *R @00#l= e6cl$de "ydrone)"rosis7Re#ainder Re#ainder = treat 8or OA, F 2arn ao$t= treat 8or OA, F 2arn ao$t
retention Fretention F aoid ladder rela6ants i8 *Raoid ladder rela6ants i8 *R
150#l7150#l7
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Urinary IncontinenceUrinary Incontinence
Non-.r$! Treat#ent o8 OA,Non-.r$! Treat#ent o8 OA,
,ladder .rill,ladder .rill re-trainin!4re-trainin!4 Ti#ed oidin!Ti#ed oidin! .e8er#ent tec"ni'$e.e8er#ent tec"ni'$e
Co!nitiely i#)airedCo!nitiely i#)aired *ro#)ted oidin!*ro#)ted oidin!
Non-.r$! Treat#ent o8 +INon-.r$! Treat#ent o8 +I *elic oor e6ercises es)ecially i8 #ild :*elic oor e6ercises es)ecially i8 #ild :
- 30-@00 ti#es )er day - 30-@00 ti#es )er day - IndeGnitely - IndeGnitely - i#ited eficacy - i#ited eficacy - Re)air )roced$res less inasie- Re)air )roced$res less inasie
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Urinary IncontinenceUrinary Incontinence
.r$! Treat#ent o8 OA,.r$! Treat#ent o8 OA,
Anti-c"oliner!ic anti-#$scarinics4 Anti-c"oliner!ic anti-#$scarinics4
O6y$tyninO6y$tynin oli8enacinoli8enacin
.ari8enacin.ari8enacin TolterodineTolterodine
,est as adH$ncts to ladder drill7,est as adH$ncts to ladder drill7
.ose escalation y titration.ose escalation y titration (ost NOT on *,(ost NOT on *, Ne2er ones etter toleratedNe2er ones etter tolerated CI +la$co#a F .ry #o$t"= con8$sionCI +la$co#a F .ry #o$t"= con8$sion
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Urinary IncontinenceUrinary Incontinence
Alertness Alertness
Res)onsieRes)onsie (otiation(otiation
.irection.irection
(oility (oility Reco!nitionReco!nition
.ressin!.ressin!
oidin! and .e#entia
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Urinary IncontinenceUrinary Incontinence
Indications 8or Urodyna#icsIndications 8or Urodyna#ics
*ersistent dia!nostic $ncertainty7*ersistent dia!nostic $ncertainty7
(oridity associated 2it" )otentially7(oridity associated 2it" )otentially7#isdirected #edical t"era)y is "i!"7#isdirected #edical t"era)y is "i!"7
D"en e#)iric t"era)y "as 8ailed7 D"en e#)iric t"era)y "as 8ailed7
D"en s$r!ical interention is )lanned7 D"en s$r!ical interention is )lanned7 Oero2 incontinence7Oero2 incontinence7
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Urinary IncontinenceUrinary Incontinence
*"ar#acolo!ic Treat#ent Ostr$ction*"ar#acolo!ic Treat#ent Ostr$ction Al)"a locers Al)"a locers
-- delay s$r!ery delay s$r!ery -- eneGt in 2eeseneGt in 2ees
*raosin*raosin
Ta#s$losinTa#s$losinTeraosinTeraosin
&inasteride 5 al)"a red$ctase in"iitor &inasteride 5 al)"a red$ctase in"iitor
-- ess efectieess efectie-- .elayed eneGt.elayed eneGt-- ide-efects es)7 i#)otence7ide-efects es)7 i#)otence7
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