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Geriatric Urinary Incontinence &Overactive Bladder
Joseph G. Ouslander, M.D.Professor of Medicine and Nursing
Director, Division of Geriatric Medicine and GerontologyChief Medical Officer,
Wesley Woods Center of Emory UniversityDirector, Emory Center for Health in Aging
Research Scientist, Birmingham/Atlanta VA GRECC
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Geriatric Urinary Incontinence &Overactive Bladder (OAB)
Prevalence & impacts Pathophysiology Diagnostic evaluation Management
An Update
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Geriatric Urinary IncontinencePrevalence
34%
12%22%
5%
70%
40%
0%10%20%30%40%
50%60%70%80%
Ever Daily Ever Daily
Community (General)Community
(Frail)/Acute Hospital
N H
Women Men
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Overactive Bladder Overactive Bladder (OAB)(OAB)
Urinary Frequency >8 voids/24 hrs
Nocturia awakening at night to void
Urgency, with or without urge incontinence
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Overactive BladderPrevalence
17%16%
WomenMen
Milsom et al: BJU International, 87:760, 2001
Telephone survey of 16,776 adults age 40+
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Overactive BladderPrevalence
9%
31%
3%
42%
0%5%
10%15%20%25%30%35%40%45%50%
Age 40-44 Age 75+ Age 40-44 Age 75+
Women Men
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05
10152025303540
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iseas
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Top Chronic Conditions in the U.S.M
illio
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OAB
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OAB: “Dry” vs “Wet” (Urge Incontinence)
Wet(37%)Dry
(63%)OAB
Adapted from Stewart W et al. ICI 2001
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Spectrum of OAB and Urinary Incontinence
z• Urgency• Frequency• Nocturia
Stress UI Mixed Urge UI
OABOAB
Incontinence
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Impact of UI & OAB on Quality of Life
Quality of Life
OccupationalDecreased productivityAbsence from work
SocialLimited travel and activity around toilet availability
Social isolation
Psychological Fear and anxietyLoss of self-esteemDepressionSexual
Avoidance of sexual contact and intimacy
PhysicalDiscomfort, odorFalls and injuries
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Adverse Consequences of UI & OAB
87 Y.O. woman living at home, with minimal assistance from family
Incontinent rushing to the toilet at 2 a.m., slipped and fell in urine
Sustained a hip fracture Now confined to a wheelchair
and required admission to a nursing home
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Urge Incontinence, Falls, and Fractures
• 6,049 women, mean age 78.5• 25% reported urge UI (at least weekly)• Followed for 3 yrs• 55% reported falls, 8.5% fractures• Odds ratios for urge UI and
Falls: 1.26 Non-spine fracture: 1.34
Brown et al: JAGS 48: 721 – 725, 2000
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PredisposeGenderRacial
NeurologicAnatomicCollagenMuscularCultural
Environmental
InciteChildbirth
Nerve damageMuscle damage
RadiationTissue disruptionRadical surgery
InterveneBehavioral
PharmacologicDevicesSurgical
DecompensateAging
DementiaDebilityDisease
EnvironmentMedications
ConstipationOccupationRecreation
ObesitySurgery
Lung diseaseSmoking
Menstrual cycleInfection
MedicationsFluid intake
DietToilet habitsMenopause
Promote
Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.
Geriatric Urinary Incontinence and OABMulti-factorial
Pathophysiology
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Drugs/Other Conditions
Urinary
Tract Neurological
Functional/Behavioral
Geriatric Urinary Incontinence & OAB
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Geriatric Urinary Incontinence & OAB
Lower urinary tract Bladder pathology (infection, tumor, etc) Detrusor overactivity Women – atrophic urethritis, sphincter
weakness Men – prostate enlargement Urinary retention
• Obstruction• Impaired bladder contractility
Pathophysiology
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100Volume
Blad
der p
ress
ure
200 40030000
100 Involuntarybladder contractions
Normal voluntary void
Geriatric Urinary Incontinence & OABDetrusor Overactivity
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DHIC
% b
ladd
er e
mpt
ying
DH0
20
40
60
80
100
Resnick, Yalla JAMA 1987;148:3076
Geriatric Urinary Incontinence & OABDHIC
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Pathophysiology of Detrusor Overactivity
Neurogenic Myogenic Combination Unknown
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Sphincter Weakness
Geriatric Urinary Incontinence & OAB
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Neurological Brain
• Stroke, dementia, Parkinson’s Spinal cord
• Injury, compression, multiple sclerosis Peripheral innervation
• Diabetic neuropathy
PathophysiologyGeriatric Urinary Incontinence & OAB
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Functional/Behavioral Mobility impairment Dementia Fluid intake
• Amount and timing• Caffeine, alcohol
Bowel habits/constipation Psychological (anxiety)
Pathophysiology
Geriatric Urinary Incontinence & OAB
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Other Conditions Diabetes (polyuria) Volume overload (polyuria, nocturia)
• Congestive heart failure• Venous insufficiency with edema
Sleep disorders (nocturia)• Sleep apnea• Periodic leg movements
PathophysiologyGeriatric Urinary Incontinence & OAB
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Requirements for Continence
Adequate: Lower urinary tract function Mental function Mobility, Dexterity Environment Motivation (patients, caregivers)
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Reversible Causes (“DRIP”)
D elirium
R estricted mobility, R etention
I nfection, I nflammation, I mpaction
P olyuria, P harmaceuticals
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Geriatric Urinary Incontinence & OAB
Drugs
Diuretics Narcotics Anticholinergics Psychotropics Cholinesterase inhibitors Alpha adrenergic drugs
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Overflow
Urge Stress
Functional
Persistent Incontinence
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History (Bladder Diary in selected patients) Physical exam Cough test for stress incontinence Non-invasive flow rate (helpful in men) Measurement of voided and post-void
residual volumes Urinalysis
Diagnostic Assessment
Geriatric Urinary Incontinence & OAB
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History Most bothersome symptom (s) Treatment preferences and goals Medical history for relevant conditions and
medications Onset and duration of symptoms Prior treatment and response Characterization of symptoms
Overactive bladder Stress incontinence Voiding difficulty Other (pain, hematuria)
Bowel habits Fluid intake
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Physical Exam Cardiovascular Abdominal Neurological Perineal skin condition External genitalia Pelvic exam
Atrophic vaginitis Pelvic prolapse
Rectal exam Sphincter control Prostate
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Post-Void Residual Determination
Diabetics Neurological conditions (e.g. post acute stroke, multiple sclerosis, spinal cord injury) Men (especially those who have not had a TUR) Anticholinergics and narcotics History of urinary retention or
elevated PVR
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Urinalysis
Infection Sterile hematuria Glucosuria
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Examples of criteria for further evaluation Recurrent UTI Recent pelvic surgery Severe pelvic prolapse Sterile hematuria Urinary retention Failure to respond to initial therapy,
and desire for further improvement
Geriatric Urinary Incontinence and OAB
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Management of Geriatric Incontinence and OAB
Reversible causes Supportive
measures Education Environmental Toilet substitutes Catheters Garments/pads
Behavioral interventions
Pharmacologic therapy
Surgical interventions
Devices
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Modify fluid intakeModify drug regimens (if feasible)Reduce volume overload (for nocturia)
e.g. take furosemide in late afternoon in patients with nocturia and edema
Treat: Infection (new onset or worsening symptoms)ConstipationAtrophic vaginitis (topical estrogen)
Treat Reversible Causes
Management of Geriatric Incontinence and OAB
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EducationEnvironmental
Clear well-lit path to toiletBedside commodes, urinals
CathetersFor skin problems, retention, palliative
care/patient preference
Garments/pads
Supportive Measures
Management of Geriatric Incontinence and OAB
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Chronic Indwelling Catheters
Significant, irreversible retention Skin lesions/surgical wounds Patient comfort/preference
Appropriate indications
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Management of Geriatric Incontinence and OAB
Undergarments and PadsNonspecificFoster dependencyExpensive
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Management of Geriatric Incontinence and OAB
Stress incontinence• Periurethral injections• Bladder neck suspension• Sling procedure• Artificial sphincter
Urge incontinence• Implantable stimulators• Augmentation cystoplasty
Surgical Interventions
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Management of Geriatric Incontinence and OAB
Behavioral Interventions “Bladder Training”
• Education• Urge suppression techniques• Pelvic muscle rehabilitation
With and without biofeedback Toileting programs
• Prompted voiding (and others)
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Pelvic Muscle ExercisesLocate pelvic muscles
Repeat in setsof up to 10
3-4 times/day, and use in
everyday life
Relax completely for
at least 10 seconds
Squeeze muscles tightly for up to
10 seconds
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Burgio et al: JAMA 280: 1995, 1998
Management of Geriatric Incontinence and OABBehavioral vs. Drug Treatment
0
5
10
15
20
Baseline 2 4 6 8
Time, wk
Acc
iden
ts p
er W
eek,
No.
Behavioral Drug Control
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Much betterBetterAble to wear fewer padsCompletely satisfiedContinue treatment Wants another treatment
Management of Geriatric Incontinence and OAB
Behavior
742676789714
513156495876
273934284376
Drug ControlPatient Perceptions
Burgio et al: JAMA 280: 1995, 1998
Behavioral vs. Drug Treatment
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Prompted Voiding
Protocol• Opportunity (prompt) to
toilet every 2 hours• Toileting assistance if
requested• Social interaction and
verbal feedback• Encourage fluid intake
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Prompted Voiding
Reduces severity by half 25%-40% of frail nursing
home patients respond well UI episodes decrease
from 3 or 4 per day to 1 or fewer
Responsive patients can be identified during a 3-day trial
Efficacy in Research Studies
Ouslander JG et al. JAMA 273:1366-70
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Management of Geriatric Incontinence and OAB
Drug Therapy
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Lower Urinary Tract Cholinergic and Adrenergic Receptors
Detrusor muscle (M)
Trigone ()Bladder neck ()
Urethra ()
Μ=muscarinic =1-adrenergic
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Motor Innervation of the BladderNeurotransmitter: Acetylcholine
Receptors: Muscarinic
Pelvic Nerve Contraction
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Ouslander J. N Engl J Med. 2004;350:786-799
Motor Innervation of the Bladder
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Ouslander J. N Engl J Med. 2004;350:786-799
Sensory Innervation of the Bladder
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Drug Therapy for Stress Incontinence
Limited efficacy Two basic approaches:
Estrogen to strengthen periurethral tissues (not effective by itself)
Alpha adrenergic drugs to increase urethral smooth muscle tone (no drugs are FDA approved for this indication)
Pseudoephedrine (“Sudafed”) Duloxitene (“Cymbalta”)
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Drug Therapy for Urge UI and OAB
Antimuscarinic/Anticholinergics -Blockers
• Men with concomitant benign prostatic enlargement
Estrogen (topical)• May be a helpful adjunct for women with
severe vaginal atrophy and atrophic vaginitis DDAVP (Off label in the U.S.)
• Carefully selected patients with primary complaint of nocturia
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Drug Therapy for Urge UI and OAB
Darifenacin (“Enablex”) Oxybutynin (“Ditropan”)
• IR • ER (“ XL”)• Patch (“Oxytrol”)
Solifenacin (“Vesicare”) Tolterodine (“Detrol”)
• IR• Long-acting (“LA”)
Trospium (“Sanctura”)
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Drug Therapy for UI and OAB
Several factors influence the decision to use pharmacologic therapy:
Degree and bother of symptoms
Patient/family preference
Risk for side effects/co-morbidity
Responsiveness to behavioral interventions
Cost
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Drug Therapy for Urge UI and OAB
Anticholinergics: meta-analysis• 32 trials; most double-blind; 6,800 subjects• Significant effects on:
Incontinence and voiding frequencyCure/improvementBladder capacity
• Modest clinical efficacy vs. placebo• Measured over short time periods
Herbison P, et al. BMJ. 2003;326:841-844
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Drug Therapy for Urge UI and OAB
Efficacy ~ 60 - 70% reduction in urge UI ~ 30 - 50% placebo effect
Efficacy is similar in elderly vs. younger Adverse events
Dry mouth ~ 20-25% (~ 5% “severe”) Others – less common
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Iris/Ciliary Body = Blurred VisionLacrimal Gland = Dry Eyes
Salivary Glands = Dry Mouth
Heart = Tachycardia
Stomach = GERD
Colon = Constipation
Bladder = Retention
CNS
Potential Side Effects of Antimuscarinic Drugs
SomnolenceImpaired Cognition
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Antimuscarinics and Cognition
• Antimuscarinic drugs used for the bladder can theoretically cause cognitive impairment
• ACh is a pivotal mediator of short-term memory and cognition
• Cholinergic system involvement in Alzheimer’s disease has been clearly established
• Of the 5 muscarinic receptors M1 appears most involved in memory and learning
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Antimuscarinic Drugs and Cognition
Tolterodine
Oxybutynin,Solifenacin
Trospium
• Low lipophilicity• Charged• Relatively “bulky”
• High lipophilicity,• Neutral• Relatively “small”
• Relatively “bulky”• Highly polar
+
Vasculature CNSBBB
++++
++ +
+
++++
++++
++
++
++
++
++
+
Darifenacin • Lipophilic, small• “M3 selective”
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Summary1. UI and OAB are common conditions in the geriatric
population, and are associated with considerable morbidity and cost
2. The pathophysiology is multifactorial, and many potentially reversible factors can contribute
3. All patients should have a basic diagnostic assessment, and selected patients should be referred for further evaluation
4. A variety of treatment options are available; behavioral interventions and drug therapy for urge UI and OAB are most commonly prescribed
5. Treatment should be guided by patient preference, their most bothersome symptoms, and the pathophysiology felt to underlie these symptoms