Evaluation and Treatment of Incontinence

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1 Evaluation and Treatment of Incontinence

2 Classification of Incontinence Failure to empty: Overflow incontinence Failure to store Stress Incontinence Urge Incontinence

3 Physiology of voiding CNS Brain sends inhibitory impulses to bladder External sphincter coordinated by pons Peripheral Storage: 1. Beta relaxation of dome 2. bladder neck is closed (alpha receptors) Voiding: detrusor contracts (cholinergic receptors)

4 Neurotransmitter Receptors Cholinergic Receptors Adrenergic Receptors Nicotinic Muscarinic α-adrenergic β-adrenergic Subtypes Subtypes Subtypes Adapted from Wein AJ. Exp Opin Invest Drugs. 2001;10:65-83.

floor (N) Trigone (α) Bladder neck (α) Adapted from Abrams P, Wein AJ.

5 Distribution of Cholinergic and Adrenergic Receptors in the LUT Μ = Muscarinic Ν = Nicotinic α = α 1 -adrenergic β = β 2 -adrenergic Detrusor muscle (M,β) Pelvic floor (N) Trigone (α) Bladder neck (α) Adapted from Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; Urethra (α)

The micturition switch and its forebrain influences Acta Physiologica Volume 207, Issue 1, pages 93-109, 16

6 The micturition switch and its forebrain influences Acta Physiologica Volume 207, Issue 1, pages , 16 NOV 2012 DOI: /apha

7 Age related effects on continence Altered mentation Decreased mobility Decreased motivation Poor manual dexterity

8 Development of Geriatric syndromes Mecocci et al., Dem and Ger Cog Dis, 20: 262, 2005 Syndromes: pressure sores, fecal incontinence, urinary incontinence, falls Risk factors: (multivariate analysis of 13,700 patients during hospitalization) Cognitive impairment Age > 85 years old Length of stay > 3 weeks Severe disability

9 Age related changes in urinary Bladder function detrusor underactivity: reduced strength or duration of contraction DHIC: detrusor hyperactivity with impaired contractility decreased ability to postpone urination Urine output: more urine excreted at night

10 Classification of Incontinence Failure to empty: Overflow incontinence Failure to store Stress Incontinence Urge Incontinence

11 Overflow Incontinence Inability to empty bladder Two causes inability to generate bladder contraction Diabetes or other neuropathy age related bladder outlet obstruction BPH, stricture in men Failed bladder neck procedure in women

12 Stress Incontinence Loss of urine in absence of bladder contraction due to reduced outlet (urethral) resistance Common: leak with laugh, cough, sneeze Females: post childbirth, after surgery, aging, medications (alpha blockers) Males: after prostate surgery

13 Urge Incontinence Associated with (uninhibited) bladder contraction or sensory changes Leaking after sudden desire to void Bladder overactivity occurs both sexes with aging or neurologic injury males with obstructing prostate or stricture females obstructed after incontinence surgery

14 Evaluation of incontinence: History Stress incontinence: Do you leak with laughing, cough or sneezing or with increased activity? Urge incontinence: Do you have the sudden urge to urinate and find it difficult to make it to the bathroom?

15 Evaluation of incontinence: History Symptoms of predominantly stress, urge or both Symptoms of overflow: feeling of incomplete emptying, weak stream Duration, association with other medical problems, ADL s Rule out transient causes

16 Evaluation of incontinence: History in a young person Symptoms of neurologic disease: Neuro problem until proven otherwise Change in vision Numbness, tingling, ataxia Fecal incontinence I usually refer to neurology anyone < 35 years old who presents with incontinence

17 Transient causes of incontinence Delirium Infection Atrophic Vaginitis Pharmaceuticals Psychological Excess urine output Restricted mobility Stool Impaction

18 Delirium Due to drug or acute illness Incontinence merely a symptom of bigger problem

19 Infection Can find asymptomatic bacteriuria in 10-30% of elderly, less in younger people If bacteriuric and incontinent, treat with antibiotics Do not repeat the culture after treatment

20 Atrophic Vaginitis symptoms: urgency and dysuria responds to low dose vaginal estrogen Contraindications to estrogen: estrogensensitive tumors, end-stage liver failure and a past history of estrogen-related thromboembolization treat for 1-2 months

21 Medications affecting continence Anticholinergic meds anti-depressants antihistamines anti Parkinson Other sedatives (BZD) alcohol narcotics alpha blockers Diuretics caffeine

22 Psychological Depression neuroses more common in younger people as cause for incontinence

23 Excess urine output excessive fluid intake diuretics: Lasix, caffeine osmotic diuresis in diabetic nocturia may be due to mobilization of fluids but less vasopressin at night with age timing of diuretic? Sleep disturbance? Hx of enuresis

24 Restricted Mobility arthritis Deconditioning/obesity cardiovascular abnormality: CVA, MI, claudication treatment: use bedside urinal or commode, possibly condom catheter

25 Stool Impaction seen in up to 10% in acute hospital or incontinence clinic Common innervation of urethral and rectal sphincter by pudendal nerve results in urge or overflow incontinence may have fecal incontinence treatment: disimpaction

26 Evaluation of Incontinence: Physical exam Neurological examination: stroke, disc disease Urologic: Palpable bladder Prostate in men for nodularity; size does not correlate with obstruction Pelvic exam in women: cystocele, atrophic vaginitis

27 Evaluation of Incontinence: Lab and other studies Urinalysis: evaluate hematuria- > 3 RBC per hpf, not just positive dip Urine culture if pos LE or nit Post void residual: rules out overflow If post void residual elevated (>100 ml) BUN/Creatinine renal ultrasound

28 Diagnosis of incontinence 1. Rule out transient causes 2. Check post void residual Elevated: Overflow Low: by history Stress incontinence Urge Incontinence

29 Treatment of Stress Incontinence Kegel exercises 10 seconds, 50x per day, for 8 weeks Medication- (Imipramine 10 tid to 25 tid) Anticholinergic if mixed incontinence Collagen/Durasphere injection Surgery: Pubovaginal sling, sphincter

30 Treatment of Urge Incontinence Behavioral timed/prompted voiding access to urinal or commode Anticholinergic meds do not stop the urge-only delay it

31 Treatment of Urge Incontinence Pharmacologic: anticholinergic medication Oxybutynin: Ditropan, Ditropan XL, oxytrol patch Tolterodine: Detrol Darifenacin: Enablex Solifenacin: Vesicare Trospium: Sanctura Fesoterodine: Toviaz

32 Significant Reduction in Frequency per 24 Hours % Mean Reduction From Baseline Placebo 11% Detrol 16% * Detrol LA 17% ** *P = vs placebo **P = vs placebo Mean Values Placebo n = 508 Detrol 2 mg bid n = 514 Detrol LA 4 mg qd n = 507 Intention-to-treat population 1 patient missing Baseline Change from baseline Based on the ratio of mean reduction and mean baseline values for the treatment group Data on file. Pharmacia Corporation.

Distribution of Muscarinic Receptors in Target Organs of the Parasympathetic Nervous System Dizziness CNS Somnolence Impaired Memory & Cognition Iris/Ciliary Body = Blurred Vision Lacrimal Gland =

33 Distribution of Muscarinic Receptors in Target Organs of the Parasympathetic Nervous System Dizziness CNS Somnolence Impaired Memory & Cognition Iris/Ciliary Body = Blurred Vision Lacrimal Gland = Dry Eyes Salivary Glands = Dry Mouth Heart = Tachycardia Gall Bladder Stomach = Dyspepsia Colon = Constipation Muscarinic receptors are also located in the CNS. Bladder (detrusor muscle) Adapted from Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

Metabolism of Immediate-Release Oxybutynin Metabolized by the cytochrome P450 enzyme system in the liver and gut wall Primary active metabolite is N-desethyloxybutynin (N-DEO) OXY-IR is metabolized

34 Metabolism of Immediate-Release Oxybutynin Metabolized by the cytochrome P450 enzyme system in the liver and gut wall Primary active metabolite is N-desethyloxybutynin (N-DEO) OXY-IR is metabolized in the upper GI tract Results in high N-DEO levels Immediate-release oxybutynin (OXY-IR) Ditropan XL [package insert]. Mountain View, CA: ALZA Pharmaceuticals; Gupta SK. J Clin Pharmacol. 1999;39:

35 CNS Effects in the elderly from anticholinergic medications Crossing the blood brain barrier Charge Size of molecule Lipophilic Potential candidates with less CNS side effects Trospium: more charged- quaternary amine Tolterodine: large molecule Oxytrol: reduces metabolites with side effects by eliminating first pass through liver- less N-deo

36 Treatment of Urge Incontinence Beta 3 agonist: Myrbetriq (mirabegron) 25 and 50 mg Relaxes bladder smooth muscle Side effects: no CNS or constipation Increased blood pressure: 1 mm Hg in study Urinary retention nasopharyngitis

$permanent lead Require change of leads or battery 5-10 years Effective for refractory frequency and urgency/urge incontinence$

37 Treatment of Urge Incontinence Sacral Neuromodulation Initial trial of peripheral nerve evaluation (PNE) or first stage with more permanent lead Require change of leads or battery 5-10 years Effective for refractory frequency and urgency/urge incontinence wwwww

38 Treatment of Urge Incontinence: Posterior tibial nerve stimulation

39 Treatment of Urge Incontinence: Botox injection into bladder Pivotal studies 50 % reduction: 57-77% 75% reduction: 44-55% Dry: 23-34% Risk: urinary retention

40 Treatment of urinary retention Medication: alpha blockers Surgery Neuromodulation for non obstructive retention Prostate surgery in men Urethrolysis /sling removal in women Catheterization Foley Intermittent catheterization Suprapubic tube

41 Catheterization Self catheterization clean not sterile change catheter every few weeks do not use prophylactic antibiotics Indwelling catheters: Foley or SP tube change every 6-8 weeks do not use prophylactic antibiotics Antibiotics with catheters: for fever

Disclosures. Geriatric Incontinence and Voiding Dysfunction. Agenda. Agenda. UI: a Geriatric Syndrome. Geriatric Syndromes 9/7/2018.

Disclosures. Geriatric Incontinence and Voiding Dysfunction. Agenda. Agenda. UI: a Geriatric Syndrome. Geriatric Syndromes 9/7/2018. Disclosures Geriatric Incontinence and Voiding Dysfunction None Shachi Tyagi MD, MS Assistant Professor Division of Geriatric Medicine University of Pittsburgh Medical Center UI: a Geriatric Syndrome Geriatric