Management of Urinary Incontinence in Older Women Dr. Cecilia Cheon Department of Obs. & Gyn. Queen Elizabeth Hospital
Epidemiology Causes Investigation Treatment Conclusion
Elderly Women High prevalence of bladder dysfunction Stigmatization, social isolation Significant cause of disability / dependency Myth can t be cured / improved Ignored by health professionals Costly problem Much remains to be done, reliable data scarce
Incontinence and Falls 6,049 women, average age 78.5, followed for 3 years 55% reported falls, 8.5% fractures 25% reported weekly or more frequent urge UI Odds ratios for urge UI and - Falls : 1.26 (1.14 1.40) - Non-spine fracture : 1.34 (1.06 1.69) Stress UI not associated with falls Brown et al : JAGS-48:721-725,2000
Change in Demographic Pattern Mid-year Population by Age Group 1999 2003 2004 Age group Number ( 000) % Number ( 000) % Number ( 000) % Under 15 1 154.3 17.5 1 069.2 15.7 1 039.7 15.1 15-34 2 058.0 31.1 1 955.8 2.7 1 962.3 28.5 35-64 2 684.2 40.6 2 982.6 43.8 3 061.8 44.5 65 and over 710.0 10.7 795.5 11.7 818.8 11.9 Total 6 606.5 100.0 6 803.1 100.0 6 882.6 100.0
Epidemiology Incontinence of all types with age Incontinence in hospitalized / institutionalized women (40 70% Burton 1984) Unlikely to be due to estrogen deficiency
Prevalence of Female Incontinence vs Age 2005 (HK) Stress Incontinence 20-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 >70 None 88% 97% 75.8% 62% 56.5% 45.2% 42.9% 37.1% 58.6% 54.8% 57.3% Mild 3% 3% 24.2% 36% 36.2% 50% 44.9% 54.8% 31.0% 45.2% 36% Moderate 0 0 0 2% 5.8% 3.2% 8.2% 8.1% 3.4% 0 5.3% Severe 0 0 0 0 1.4% 1.6% 4.1% 0 6.9% 0 1.3% Wong et al 2005
Oestrogens and Incontinence Cochrane Incontinence Group 28 randomised or quasi-randomised trials; 2926 women Oestrogen Vs Placebo: RR: 1.61; CI (1.04-2.49) Statistically higher cure and improvement rate over placebo:stress Incontinence (43% Vs 27%) Urge Incontinence (57% Vs 28%) Overall 50% of women treated with oestrogen improved compared to 25% on placebo No significant differences in frequency, nocturia, urgency No serious adverse events Too few data to assess type, dose and route of administration Moehrer et al, 2004
Oestrogens and Incontinence Heart and Estrogen / Progestin Replacement Study (HERS) 2763 postmenopausal women <80 yrs Greater improvement in placebo (26%) Vs HRT (21%) Greater deterioration in HRT group: 39% Vs 27% Episodes of incontinence increased in the HRT group, decreased in the placebo group (p< 0.001) Combined HRT associated with deterioration in urge and stress incontinence No effect on frequency, nocturia UTI Grady et al, 2001
Oestrogens and Incontinence Nurses Health Study 1976 onwards Biennial mailed questionnaire 39 436 continent menopausal women identified in 1996 4 year follow up to assess risks of incontinence Risk of incontinence higher among women taking HRT: Oral Oestrogen RR: 1.54; CI (1.44-1.65) Transdermal Oestrogen RR: 1.68; CI (1.41-2.00) Oral Oestrogen / Progestin RR: 1.34; CI (1.24-1.44) Transdermal Oestrogen / Progestin RR: 1.46; CI (1.16-1.23) Risk after cessation RR: 1.14; CI (1.06-1.23) 10 years after stopping HRT risks are identical Grodstein et al, 2004
Causes of Urinary Incontinence Transient incontinence UTI Confessional states ( motivation to be dry) Fecal impaction Restricted mobility Depression ( motivations) Drug therapy (α adrenergic blockers, sedatives, diuretics, tricyitic antidepressants
Established incontinence Urodynamic stress incontinence ( ISD) Detrusor overactivity Mixed incontinence Retention with overflow Urethral diverticular Fistulae
Investigations History : type, frequency, amount, neurological / psychological symptoms, past surgical history, medications, social / environmental conditions Physical exam : pelvic examination, bladder distension, POP, stress incontinence, fistula, neurological deficit, rectal exam, dementia assessment, mobility score
Urinary Diary Completed with the help of family / nursing staff Urine x microscopy / culture
Urodynamic Study 60% elderly women do not need urodynamics DO excluded and select patients for surgery Conservative management failed Voiding dysfunction suspected Previous failed continence urge Hilton & Stanton 1981
Urine x Microscopy / Culture Prevalence of UTI with age 1% 20% over 70 years Nicolle et al 1983
Prevalence of Incomplete Bladder Emptying in Elderly Convalescent elderly wards PVR > 100 ml + patients already on foley ~34.4% 9.2% PVR >400 ml requiring immediate catheterization Prevalence of UTI if PVR > 100 ml (>46.2%) Tam et al 2005
Treatment General measures Treat UTI / constipation Maximize mobility Improve toilet access Assess medications Rationalize fluid intake Ensure regular toileting
Specific Therapeutic Measures Pelvic floor exercise Bladder retraining Electrical stimulation Drug therapy Surgery Catheterization
Pelvic Floor Exercise Mixed incontinence common in elderly Difficulty in learning Poor compliance Disappointing results Biofeedback can be of assistance Electrical stimulation /? Electromagnetic chairs may be beneficial
Drug Therapy HRT controversial, aid wound healing prior to surgery, improve general wellbeing Duloxetine DDAVP (with caution), exclude heart failure Anti-cholinergics / antimuscarinics / selective M3 receptors blockers (given in low does, steps up gradually)
Duloxetine Hydrochloride The first drug to be developed specifically for stress incontinence Serotonin and noradrenaline reuptake inhibitor Increased levels of 5-HT & NA stimulate output from the pudendal motor nucleus in vivo Presumed improved urethral function in women
Duloxetine Overview Results from four double blind placebo controlled randomised clinical trials have shown: Consistent and significant reduction in Incontinence Episode Frequency (IEF) by 50%- 100% (>53% women) Significant improvement in Quality of Life More than 60% of women rated their symptoms as improved Safe and effective in the management of SUI Lilly, 2004
Duloxetine in SUI first pharmacological treatment with evidence from several large randomised controlled trials improves UI and QoL at all levels of severity and in patients awaiting surgery effects are optimal after 4 weeks of therapy nausea is the most common AE but - 67-88% of the patients continue with the treatment - nausea resolved in 40-60% within 1 week
Surgery Severe symptoms Should not be withheld on the basis of age alone RA / LA procedure improve safety Important to identify those at particular risk of developing voiding difficulties post-op CISC discussed prior to surgery
Options Anterior colporrhaphy with bladder buttress Colposuspension (open / laparoscopic) Subiurethral sling (TVT / TOT) Injectables (expensive)
Postoperative Care More Attention Early mobilization Chest physiotherapy Suprapubic bladder drainage
Concomittent Procedures Common POP surgery
Patient with Cocommittent Procedure Together with Continence Surgery Colpo TVT Age No Yes No Yes 35-45 12 4 3 2 29% 46-55 69 38 22 9 36% 56-65 36 13 24 16 33% 66-75 3 12 28 45 58% 76-85 5 2 17 32 61% >85 1 0 4 3 38% 136 69 98 107
Mixed Incontinence Common in elderly Control DO first, minimizing need for surgery Persistence of DO warned
Age Distribution of Continence Surgery in QEH (Colpo + TVT) Age No. Success rate 35-45 21 4.5% 46-55 138 34% 56-65 89 22% 66-75 98 24% 76-85 56 14% >85 8 1.5% Total 410
Objective / Subjective Success rate of colposuspension 3-5 years + 74% success in elderly women 86% for all ages Stanton & Cardozo 1980
Outcome of Continence Surgery Age Residual USI Objective Outcome No USI Success rate UTI Bladder injury 35-45 2 19 90% 4.8% 4.8% 46-55 20 118 86% 2.9% 2.9% 56-65 12 77 87% / 4.5% 66-75 12 86 88% 1% 3% 76-85 8 48 86% 3.6% 3.6% >85 2 6 75% 2.5% / 56 354 86%
Outcome of Continence Surgery Subjective Outcome Age Not satisfactory Satisfactory Success rate 35-45 1 20 95% 46-55 6 132 96% 56-65 3 86 97% 66-75 4 94 96% 76-85 3 53 95% >85 0 8 100% 17 393 95.9%
Catheterization Voiding dysfunction common in elderly Urodynamic assessment (differentiate obstruction from poor detrusor function) Treat treatable reversible causes (overdistension following surgery, drugs, fecal impaction, pelvic mass, POP, acute illness / immobility)
Catheterization Cholinergics detrusor activity α adrenergic agonits / skeletal muscle relaxants urethral resistance CISC preferred Antibiotics prophylaxis not indicated except for recurrent UTI Asymptomatic bacteriuria does not require treatment
Conclusion Urinary dysfunction / incontinence with age Aging population Complex incontinence more common Treatment usually promising