URINARY INCONTINENCE IN THE. Summary

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1 Age and Ageing (984) 3, H. D. H. EASTWOOD Consultant in Geriatric Medicine R WARRELL' Senior Registrar in Geriatric Medicine URNARY NCONTNENCE N THE ELDERLY FEMALE: PREDCTON, N D AG NOSS AND OUTCOME Department of Geriatric.,- - _ A... -,,-.,-,- Medicine Centre Block, Level E Southampton General Hospital Southampton S9 4XY OF MANAGEMENT Summary An algorithmic approach to the diagnosis of urinary incontinence in elderly females has been evaluated in a prospective series of 65 patients by comparing the clinical diagnosis arrived at using a modified form of a published algorithm with the subsequent urodynamicfindings. The general validity of the concept was confirmed. The major errors in clinical diagnosis occurred in subjects with stress incontinence, emphasizing that presentation with this symptom was likely to warrant urodynamic study. n patients with detrusor instability it was shown to be possible to predict the likely response to conventional management of their incontinence after three months, on the basis of an arithmetic score derived from the cystometric findings. NTRODUCTON The place of urodynamic studies in the clinical management of urinary incontinence in the elderly female remains debatable. This is shown by articles in the British Medical Journal, where Castleden et al. (98) took an opposing view from that of Hilton and Stanton (98) the first group being enthusiastic for urodynamic studies, the second querying their value on a routine basis, except in patients with stress incontinence, and proposing an algorithmic approach to diagnosis. This approach was illustrated by a retrospective analysis of patients referred for urodynamic study to their unit. The purpose of the first part of this study was to assess the validity of the algorithmic approach in a different setting. n a prospective series of elderly females referred for management to the Southampton Geriatric Unit, an algorithm modified from that published was used to arrive at a clinical diagnosis and then followed by urodynamic studies. n Hilton and Stanton's algorithm, cystometry was suggested in all cases presenting with the symptoms of stress incontinence to distinguish between the possible causes. n the algorithm used in this study a clinical distinction was attempted in patients with this symptom, in that patients with stress incontinence alone were diagnosed as having sphincter incompetence and those with urgency, frequency and/or urge incontinence additional to stress incontinence were diagnosed as having sphincter incompetence and detrusor instability. n the second part of the study, patients with detrusor instability were classified on the basis of the findings at cystometry according to the degree of deviation from the normal. They were then treated conventionally with toilet training and antispasmodic Present address: Geriatric Department, Plymouth General Hospital.

2 Urinary ncontinence in the Elderly Female: Prediction in Diagnosis 23 drugs. The outcome of treatment of their incontinence after three months was then determined from the patient's chief carer and this was correlated with their cystometric findings. Patients and Methods Sixty-five elderly females, with a mean age of 82 (range 68 94) years, who were referred consecutively with established urinary incontinence for urodynamic investigation were included in the study. The referring doctor was asked to use the modified algorithm in the Figure to classify, on clinical grounds, the likely cause of the patient's incontinence into one of the four major diagnostic categories suggested by Hilton and Stan ton (98). Vaginal f abnormality found, refer to gynaecologists Bladder palpable NCONTNENCE MSU culture - Examination Abdominal -nfected - - Antibiotics - Rectal- Faecal impaction- - Enemas Bladder impalpable No stress incontinence detrusor instability Stress incontinence demonstrated Additional symptoms of frequency, urgency and urge incontinence urethral sphincter incompetence with detrusor instability No additional symptoms sphincter incompetence Figure. Clinical algorithm for the diagnosis of urinary incontinence in elderly women modified from published algorithm (Hilton & Stanton 98). The patients were then investigated as a side-ward procedure by means of simple medium-flow supine cystometry and the fluid bridge flow test as described by Shawer et al. (98). These tests were selected as requiring minimal equipment, which would be within the purchasing power of most departments of geriatric medicine if they were so interested and yet would enable the majority of patients to be successfully urodynamically classified. n two of the patients, further evaluation was needed by means of subtracted pressure flow cystometry with postural stress tests. These tests were undertaken when stress incontinence on standing was marked and yet the fluid bridge flow test and supine cystometry results were normal, suggesting the need for further investigation.

3 232 H. D. H. Eastwood and R. Worrell Thirty-six patients denned as having detrusor instability using the nternational Continence Society's criteria were scored for the degree of abnormality on cystometry using a numerical index derived from the presence or absence of bladder sensations, bladder volume at which instability occurred and the nature of the unstable contractions. The details of the scoring system, which we have called the cystometric index, are shown in Table. Bladder sensation Bladder volume at which instability occurs Nature of unstable contraction Table. Cystometric index of bladder instability Desire to void or bladder filling sensation Sensation of imminence of micturition < SO ml 5-3 ml > 3 ml Able to be inhibited even if only partially Height of unstable contraction 5-6 cm H 2 O > 6 cm H 2 O Present Absent Present Absent Yes No Score These patients were then treated for their instability by means of toilet training and standard antispasmodic drug therapy. At the end of three months each patient's incontinence level was re-assessed and they were placed in one of two groups depending on whether they had become continent or had had a greater than 5% improvement in their incontinence levels or alternatively if the situation had not changed, or less than 5% improvement had occurred. RESULTS The comparison between the diagnoses derived by clinical application of the algorithm and urodynamic studies is shown in Table. n four patients a urethral stenosis was found and, until this had been dilated, urodynamic studies could not be completed. Table. Comparison of algorithmic and urodynamic diagnoses in prospective series at Southampton geriatric unit. Algorithmic result Urodynamic diagnosis Treat as detrusor instability 52 Detrusor instability 42 Normal 4 Acontractile bladder 3 nstability with urethral stenosis 3 Urethral sphincter incompetence 5 Urethral sphincter incompetence 2 Posturally induced detrusor instability 2 Acontractile bladder Mixed detrusor instability with Detrusor instability urethral sphincter incompetence 7 nstability with urethral stenosis Mixed D and US Acontractile bladder 4 Voiding difficulty Voiding difficulty

4 Urinary ncontinence in the Elderly Female: Prediction in Diagnosis 233 The inaccuracy of trying to distinguish between urethral sphincter incompetence (genuine stress incontinence) and mixed detrusor instability with sphincter incompetence on clinical grounds in the elderly patient is shown by the wide range of diagnoses found on urodynamic testing. Three patients clinically diagnosed as having detrusor instability were found to have acontractile bladders and would have been inappropriately treated using the algorithm, but the majority of cases in this group were correctly diagnosed. The correlation between the cystometric score and the outcome of management is given in Table. Table. Outcome of management compared with cystometric score Patients with no change or incontinence worse after 3 months Patients with more than 5% improvement X 2 = 9.,d.f.l;.>P>. DSCUSSON Cystometric score The main conclusion of this study is confirmation of the validity of the approach recommended by Hilton and Stanton. t was not possible on clinical grounds to classify patients presenting with the symptoms of stress incontinence and they need urodynamic study. Simple supine cystometry will also not accurately define the occasional elderly patient with posturally induced detrusor instability in whom provocation tests need to be performed. Patients with non-emptying acontractile bladders will mimic in their symptoms those with detrusor instability. The prevalence of such patients needs to be determined, but if treated for detrusor instability with antispasmodic medication some will go into retention with deterioration in their incontinence levels, and their condition will warrant review. The fact that obstruction to catheterization for cystometry was found resulted in the diagnosis of four cases of urethral stenosis which were not in themselves producing obvious symptoms of poor urine flow or clinically detectable retention. Three of these patients had associated detrusor instability but, in contrast to the situation in men, relief of the stenosis in women does not result in reversion of the instability (Farrar et al. 976). When the degree of disturbance of bladder function was assessed by means of the cystometric index it could be shown that the patients with the most disturbed bladder function were those least likely to respond to the conventional treatment of detrusor instability by toilet training and antispasmodic therapy. Where nursing time is limited it would be possible, using such an index, to select patients on the basis of their likeli

234 H. D. H. Eastwood and R. Worrell hood to respond to treatment, and then to concentrate the nursing resources on those patients most likely to benefit.

5 234 H. D. H. Eastwood and R. Worrell hood to respond to treatment, and then to concentrate the nursing resources on those patients most likely to benefit. Alternatively, other methods of management could be sought for those showing the more disturbed type of index. The fact that only out of 36 patients with detrusor instability had more than a 5% improvement in their incontinence levels at the end of three months may seem disappointing, but may reflect the fact that only the more resistant patients are referred for investigation in the first place. These results compare poorly with the 7 out of 2 patients responding to a similar regime reported by Sogbeim and Awad (982) but while all cases in their series were demonstrated to be unstable, the relative severity of bladder disturbance cannot be compared. Whether a cystometric index is a satisfactory way of expressing disturbed bladder function is a point for debate. An instability index has been described on the basis of the height of unstable detrusor contractions and the bladder volume at which it occurs (by Murray et al. 982), but such a measurement discounts the sensory element of bladder function, the loss of which is an important factor in the genesis of incontinence. There would now seem to be a need for some agreed means of quantifying detrusor instability in order to compare patient series. ACKNOWLEDGEMENTS We thank colleagues in the Department of Geriatric Medicine at Southampton for referring patients for investigation. REFERENCES CASTLEDEN, C. M., DUFFN, H. M. & ASHER, M. J. (98) Clinical and urodynamic studies in elderly incontinent patients. Br. Med.J. 282, 3-5. FARRAR, D. J., OSBORNE, J. L., STEPHENSON, T. P., WHTESDE, C. G., WER, J., BERRY, J., MLROY, E. J. G. & WARWCK, R. TURNER (976) A urodynamic view of bladder outflow obstruction in the female: factors influencing the results of treatment. Br.J. Urol. 47, HLTON, P. & STANTON, S. L. (98) An algorithmic method for assessing urinary incontinence in elderly women. Br. Med.J. 282, MURRAY, K., HOWELL, S. & LEWS, P. (982) The effect of opioid blockade on idiopathic detrusor instability. Proc. Annu. Meet. nt. Continence Soc SHAWER, M., BROWN, M. & SUTHERST, J. (98) Diagnosis of bladder neck incompetence without use of capital equipment. Br. Med. J. 283, SOGSEM, S. K. & AWAD, S. A. (982) Behavioral treatment of urinary incontinence in geriatric patients. Can. Med. J. 27, 863^.

Video-urodynamics. P J R Shah Institute of Urology and UCH

Video-urodynamics. P J R Shah Institute of Urology and UCH Video-urodynamics P J R Shah Institute of Urology and UCH Bladder Function Storage Capacity and Pressure Emptying Pressure/flow/emptying URODYNAMIC INVESTIGATIONS Free urine flow rate Urethral pressure