urinary incontinence and its complications.pptx

urinary incontinence

1. URINARY INCONTINENCE IN ELDERLY PRESENTED BY- DR. PRANAY GIRIPUNJE MODERATOR – DR. (PROF) A.K SAHA SIR

2. T yp e s of U rinary Incontinence in elderly UI is simply defined a s involuntary leakage of urine Urge - incontinence occurs suddenly without warning, no holding time, leak on the way to the bathroom . Stress - no urgency, occurs with activity due to increase intra abdominal pressure (i.e. exercise, coughing, laughing, sneezing) and more common in women. Overflow - mechanical forces (physical movement) on an over- distended bladder ( which can be from Benign Prostate Hypertrophy or Diabetes) causes incontinence. Functional - leak as a result of functional limitations (i.e. mobility problems, spinal cord compression, stroke) OVERACTIVE BLADDER – include symptom of urgency with increase frequency and nocturia (40 % of elderly population suffer from this)

3. MICTURATION REFLEX

4. Reversible Caus e s of U rinary incontinence in elderly

5. Causes Mnemonic - DIAPERS D elirium I nfection of the bladder or urethra A trophic vaginitis P harmaceuticals, including alcohol, caffeine and artificial sweeteners E xcess excretion R estricted mobility S tool impaction

6. 1) LOWER URINARY TRACT CAUSES IN ELDERLY Urinary tract infection Atopic vaginitis/ urethritis Stool impaction with irritation of bladder/partial bladder outlet obstruction TREATMENT Antimicrobial therapy for UTI Topical estrogen for vaginitis (not primary treatment but help to prevent recurrent infection) Stool softeners and laxatives

7. 2) INCREASE URINE OUTPUT IN ELDERLY Metabolic causes (hyperglycemia , hypercalcemia) Excess caffeine or fluid intake Volume overload condition like congestive heart failure Venous insufficiency with oedema TREATMENT Better control of diabetes mellitus Diuretics with sodium restriction Leg elevation for venous insufficiency

8. 3)IMPARED ABILITY Delirium Chronic illness, severe injury Psychological( depression , anxiety) Neurogenic bladder due to conditions like stroke, spinal cord compression , multiple sclerosis TREATMENT Diagnosis and treatment of underling cause Use of toilet substitute (like bedside commode) Appropriate pharmacological treatment

9. TYPES OF NEUROGENIC BLADDER

10. 4)DRUGS DIURETICS -- causes polyuria, frequency, urgency ANTICHOLINERGICS – causes constipation, incomplete bladder emptying ALPHA ADRENERGIC BLOCKERS- urethral relaxation ALPHA ADRENERGIC AGONIST- urethral contraction and potentiate incomplete bladder emptying CALCIUM CHANNEL BLOCKERS, PREGABALIN , GABAPENTIN – oedema with nocturia ALCOHOL- polyuria, frequency, sedation, delirium, immobility CAFFEINE – polyurea, bladder irritation

11. A) Focused History - because these symptoms are often hidden out of embarrassment or fear . Active medical condition especially diabetes, congestive heart failure should be ruled out Type and amount of fluid intake (especially caffeine) Type of incontinence stress or urge or mixed Frequency , timing, number of episodes Neurological conditions like stroke ,parkinsonism , spinal cord compression.  Evaluation of urinary incontinence

12. b)Physical Examination MOBILITY- gait disturbance , ability to go for self toilet should be assessed MENTAL STATUS- cognitive function compatible with ability to self toilet , mood and affect NEUROLOGICAL- focal sign that can suggest any CNS condition , signs of parkinsonism ABDOMINAL- bladder distension , suprapubic distension RECTAL- sphincter tone, impaction of faeces , masses, size and contour of prostate PELVIC – atrophic vaginitis (friability, inflammation, bleeding)

13. c) Postvoid residual This test must be done with a full bladder, straining during test can alter the result In older patient postvoid residual between 0ml to 100ml is normal Residual between 100 – 200 ml must be interpreted based on symptoms Value of >200 ml is abnormal

14. SOURCE – HARRISONS 21 st EDITION

15. TREATMENT STRESS INCONTINENCE Pelvic muscle (Kegel exercise) Behavioural interventions like timed voiding and double voiding to avoid residual urine Topical estrogen to strengthen periurethral tissue Peri-urethral injection to provide bulking and support Surgical bladder neck suspension or sling for sever incontinence

16. “Squeeze like you’re trying to hold back gas” Pelvic Floor Muscle Exercises (Kegels)

17. For stress UI squeeze pelvic floor muscles before sneezing, coughing, or lifting Stress U rinary Incontinence Strategy – “Squeeze before you Sneeze”

18. 2)URGE AND OVERACTIVE BLADDER SYMPTOMS Pelvic muscle (Kegel exercise) Behavioural interventions like timed voiding and double voiding to avoid residual urine Antimuscarinic (oxybutynin 5/10/15 mg, darifenacine 15mg, solifenacine 5 mg) or beta 3 adrenergic (mirabegron , vibegron )

19. When the urge strikes… Stop and stay still Squeeze pelvic floor muscles Relax rest of body Concentrate on suppressing urge Wait until the urge subsides Walk to bathroom at normal pace Antimuscarinic and beta 3 adrenergic drugs Urge UI Suppression – “Freeze & Squeeze” 81 % 39 % 6 8 % 20 40 60 1 80 B e h a v i o r a l D r u g C o n t r o l Treatment for Urge Incontinence in Women

20. 3)Incontinence with incomplete bladder emptying Alpha adrenergic antagonist ( tramsulosins , silodosin) with 5 alpha reductase inhibitor if prostate is enlarged (like prazosins ) Antimuscarinic or beta 3 adrenergic can be added if unresponsive to initial treatment Bladder training and double voiding intermittent catheterization

21. Most UI can be treated by primary care providers Consider referral for:      recurrent urinary tract infections post void residual > 200 mL pelvic pain associated with UI hematuria (asymptomatic) UI with new neurologic symptoms When to refer to a specialist…

22. UI is not an inevitable part of aging UI is amenable to treatment in many cases and can be managed by primary care providers Behavioral treatments are effective options for older adults with UI Consider family caregiver burden and needs related to the management of UI Conclusion

23. THANK YOU