Geriatric Incontinence and LUTS

Objectives Recognize age related lower urinary tract changes Appreciate unique aspects of geriatric voiding problems Distinguish among various forms of incontinence Appreciate how non-urinary issues contribute to continence

Key Points LUTS are common among the elderly Patients frequently don’t mention it & physicians often don’t ask Both patient and doctor frequently consider it a part of “normal aging” LUTS are morbid, costly and lead to poor QOL Majority of patients can be helped

Case Presentation 84 yo male with spinal stenosis/immobility, mild dementia and parkinsonism develops fecal impaction and acute urinary retention. Prior to this he had frequent urgency, nocturia and occasional incontinence Urinary catheterization 1.5 liters urine Moderate size prostate No hematuria, urine culture negative PSA 4.2

Acute Management What is the appropriate immediate management? Refer for TURP Intermittent clean intermittent catheterization Begin alpha blocker Place Foley and begin alpha blocker, treat fecal impaction

Long Term Management Failed 3 voiding trials (persistent retention) over 4 weeks How do you manage at this point? Proceed with surgical options immediately Continue more voiding trials Clean intermittent catheterization Chronic indwelling Foley

Lower Urinary Tract Symptoms Storage Urgency Frequency Nocturia Urge incontinence Voiding Hesitancy Poor flow Intermittency Straining Terminal dribble

Changing Paradigm of LUTS Historically men with LUTS were considered to have “prostatism” Elderly patients show higher rates of persistent symptoms/dissatisfaction after TURP Women frequently assumed to have stress or urge incontinence Surgical procedures, pessaries, Kegel’s exercise

“The Bladder Is an Unreliable Witness” Bates 1970

The Unreliable Witness Many asymptomatic elderly have UD evidence for detrussor overactivity UD evidence of bladder outlet obstruction can be completely asymptomatic Elderly woman frequently have high scores on IPSS and AUA symptoms scales Among elderly men with BPH, many have residual symptoms after TURP

ICS Definitions Urgency Frequency Nocturia Urge Incontinence “Sudden compelling desire to pass urine which is difficult to defer” Differs from the “normal desire to void” Pathological Frequency The complaint that an individual urinates too much, typical ~8x/day Nocturia The complaint of awakening to void >1 time/night Urge Incontinence involuntary leakage accompanied by or immediately preceded by urgency

LUT Changes in Aging Increased Decreased Bladder contractility Detrussor over activity Nocturnal urine output BPH Post void residual <100cc~90% Bacteruria~20% Decreased Bladder contractility Bladder sensation Sphincter strength

LUTS and Aging Almost always multifactorial Age associated LUT changes and comorbid disease associated Major impact of conditions beyond the urinary tract in LUTS Mobility, dexterity & cognitive influence on continence

Aging and Continence Most elderly people remain continent in spite of age associated LUT changes Multiple factors interact to determine continence status Intervention on all the contributing factors frequently yields good results Looking for the one cause is wrong paradigm

Cerebral Control of Micturition Increasing research reveals that much of geriatric voiding dysfunction is “beyond the bladder” Cortical & sub-cortical control over bladder function Mostly inhibitory control that requires intact attention, working memory, executive functions

Incontinence Common, morbid & costly 25% of community dwelling elders are incontinent 50% of nursing home residents Leads to isolation, embarrassment, depression Associated with falls, fractures, skin problems and institutionalization

Why is Incontinence Important? Social Stigma – leads to restricted activities Depression Medical complications – skin breakdown and Increase in urinary tract infections Institutionalization – UI is the second leading cause of nursing home placement

Types Incontinence Transient vs. chronic Stress Urge Overflow Functional

Transient Incontinence Delirium -Infection -Atropine vaginitis or urethritis -Pharmaceuticals -Psychological disorders -Endocrine Disorders -Restricted mobility -Stool impaction

Stress Urinary Incontinence Involuntary leakage on effort or exertion, or on sneezing or coughing The sign of stress incontinence is the observation of urine loss from the urethra during coughing or straining Cough stress test may be useful Tends to be small amounts of leakage

Overflow Incontinence Leakage of urine associated with urinary retention May be due to bladder outlet obstruction or poor bladder contractility BPH with BOO Urethral stricture, tumor Diabetic cystopathy, multiple sclerosis, cauda equina etc. Urodynamic studies to evaluate pressure/flow

Overactive Bladder Urgency, with or without urge incontinence, usually with frequency and nocturia . . . if there …is no proven infection or other etiology Equally common among men and women in the very elderly 2/3 of OAB patients are “dry” Dry patients still suffer

OAB Symptom Definitions Urgency: a sudden compelling desire to pass urine that is difficult to defer Urgency Urinary Inc. (UUI): involuntary leakage accompanied by or immediately preceded by urgency Frequency: 8 voids / day = “normal” Nocturia: patient wakes one or more times at night to void (sleep “before” and “after”) Slide 23: Symptoms of OAB as Defined by ICS The symptoms of OAB as defined by the International Continence Society are as follows: Urgency: a sudden compelling desire to pass urine that is difficult to defer Urge urinary incontinence (UUI): involuntary leakage of urine accompanied by or immediately preceded by urgency Frequency (increased daytime): patient considers that he/she voids too often during the day Nocturia: patient wakes one or more times at night to void Reference Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the Standardisation Sub-Committee of the International Continence Society. Urology. 2003;61:37-49. Abrams P, et al. Urology. 2003;61:37-49.

Prevalence of OAB Age and Gender Men: 16.0% Women: 16.9% Slide 24: Prevalence of OAB by Age and Gender in the US The overall prevalence of OAB was 16.5% in adults ≥18 years of age as determined in the National Overactive Bladder Evaluation (NOBLE) program, which was designed to gain a better understanding of the prevalence and burden of OAB in the US. As part of NOBLE, a national telephone survey using a clinically validated, computer-assisted telephone interview questionnaire was administered to a sample of 5,204 adults who were representative of the US population. The overall prevalence of OAB was 16.0% in men and 16.9% in women. The age-specific prevalence of OAB was similar for men and women, as shown in this slide. However, the age patterns differed by sex and by type of OAB, as shown in the next 2 slides. Reference Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327-336. Stewart WF, et al. World J Urol. 2003;20:327-336.

OAB Treatment Rates by Age Group Source: IMS Retail Perspective

Usual Evaluation History Physical examination Labs Urge Stress Symptom scales Physical examination Pelvic, rectal/prostate, abdominal, neurologic, cognitive, cardiac/pulmonary Cough stress test Labs Urinalysis, culture?, ?psa, post-void residual Frequency volume chart

Detrussor Hyperactivity with Impaired Contractility DHIC common among frail elders May predispose to acute urinary retention Elevated PVR Bladder is both paradoxically weak and overactive

Behavioral Management Pelvic floor exercises Bladder training Biofeedback Prompted voiding Fluid limitation Dietary modifications Continence products

Expectations of Treatment Complete dryness may not be feasible Decreased urgency episodes Decreased incontinent episodes More lead time Tolerability of current therapies

Newer OAB Medications Oxybutinin Tolteradine Trospium Darifenacin Immediate, delayed release, patch form Tolteradine Immediate, delayed Trospium Darifenacin Solafenacin Immediate and long acting form

OAB Therapy for Refractory Botulinum toxin injection Neurostimulator Vanilloid bladder washings

When to Refer Failure to improve with current therapy Persistently elevated PVR Interest in surgical/interventional options Complex neuro-urological cases Abnormal findings (hematuria, hydronephrosis, elevated PSA, etc.)

LUTS in Men Recent Advances IPSS scores not specific for BPH with BOO Combined BPH and OAB therapy PDE inhibitors Nocturnal polyuria therapy

Case Presentation 83 yo male complains of 5-6 episodes of nocturia for the past 6 months. Denies dysuria, straining, or hesitancy, past episode of transient acute urinary retention during hospitalization for knee replacement 4 years ago. Exam shows enlarged smooth prostate, moderate peripheral edema, and venous stasis changes

Which is the most likely to be helpful? Trial of alpha blocker Urinalysis Overactive bladder medication Trial of 5-alpha reductase inhibitor Referral for TURP Voiding diary and compression stockings

Diagnosis? Benign prostate hypertrophy Urinary tract infection Normal aging Overactive bladder Diabetes insipidus Nocturnal polyuria

Nocturia Definition Associated with mortality Waking up to void one or more times during the night Voiding during intended sleep time that is preceded and followed by sleep Associated with mortality Disruptive to sleep, contributes to fatigue Increased risk for falls 10% vs. 21% with 2 or more voids

Prevalence of nocturia in men 1 void 2 voids Percentage of men with nocturia Age range (years)

Prevalence of nocturia in women 1 void 2 voids Percentage of women with nocturia Age range (years) van Dijk et al. 2002

Diagnostic algorithm NOCTURIA Bother No Bother Patient Presents Screen No Presentation Advice Polyuria Nocturnal Polyuria Apparent Bladder Storage Problems Other Classification Primary Sleep Disorder Further Evaluation

Nocturnal Polyuria >33% of total urine volume produced while asleep Changes in atrial natriuretic peptide, ADH secretion Consider occult sleep apnea 30-40% will have significant OSA CHF and venous insufficiency Therapeutic options Limit evening fluids/behavioral modification Evening loop diuretics DDAVP therapy Dried fruits?

Pharmacological treatment of nocturnal polyuria Diuretics Helpful in patients with lower limb venous insufficiency or congestive cardiac failure Level 1 evidence, Grade C recommendation Bumetanide 1 mg p.o. in afternoon Furosemide 40 mg p.o. in afternoon Antidiuretics Helps retain water until a more appropriate time Reduce nocturnal voids and voided volume Level 1 evidence, Grade A recommendation Desmopressin 0.1 mg p.o. titrated to 0.4 mg No direct bladder effect No direct cardiovascular actions

Frequency Volume Chart Bothersome Nocturia MEDICAL HISTORY Other urinary tract symptoms/ Sleep history/ Drinking habits (quantity and type)/ Medication (e.g., diuretics) EXAMINATION Ankle oedema/Abdominal examination/Prostate assessment/Female pelvic assessment/Assess post-void residual urine INVESTIGATIONS Urinalysis – if infected, treat and reassess History/Clinical Assessment Frequency Volume Chart GLOBAL POLYURIA (24h voided volume >40 ml/kg) Electrolytes Serum glucose NOCTURNAL POLYURIA (nocturnal urine volume > 33% of total 24h urine volume (age dependent) OTHER AETIOLOGY Overactive bladder Bladder outflow obstruction Sleep disturbance Cardiac disease Gynaecological abnormality Bladder pain or bleeding Presumed Diagnosis Lifestyle advice Lifestyle advice Non-responders Treatment Further evaluation and appropriate treatment Desmopressin bed-time Furosemide in the afternoon Non-responders Non-responders Non-responders Specialist referral

Summary Incontinence is not a “normal” part of aging LUTS and OAB are very common Most LUTS in the elderly are multifactorial Don’t assume BPH is the etiology among elderly men Use frequency-volume charts to diagnose nocturnal polyruria Multiple treatment options exist for most

Urodynamic Studies Bladder unreliable witness Confirm UD BOO Mutliple UD abnormalities in “normal” continent elderly person Confirm UD BOO Rule out detrussor underactivity Useful prior to surgical interventions for BPH Helpful in complex neurologic illnesses

Special Circumstances Incontinence and dementia Incontinence and asymptomatic bacteruria Dual cholinesterase inhibitors and OAB meds Dual fecal & urine incontinence Delirium and incontinence/asymptomatic bacteruria