1. Geriatric Incontinence and LUTS

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. “The Bladder Is an Unreliable Witness”
Bates 1970

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Types Incontinence Transient vs. chronic Stress Urge Overflow
Functional

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

20. 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

21. 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

22. 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

23. 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.

24. 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:
Stewart WF, et al. World J Urol. 2003;20:

25. OAB Treatment Rates by Age Group
Source: IMS Retail Perspective

26. 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

27. 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

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

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

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

31. OAB Therapy for Refractory
Botulinum toxin injection
Neurostimulator
Vanilloid bladder washings

32. 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.)

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

34. 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

35. 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

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

37. 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

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

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

40. 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

41. 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?

42. 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

43. 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

44. 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

45. 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

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