Urinary Incontinence in Urinary Incontinence in the Elderly the Elderly
Lily A. Arya, MD, MSLily A. Arya, MD, MSAssociate Professor and ChiefAssociate Professor and ChiefAssociate Professor and ChiefAssociate Professor and ChiefPenn UrogynecologyPenn Urogynecology
What is UIWhat is UIWhat is UIWhat is UI
Unwanted leakage of urineUnwanted leakage of urine UI that is a social or hygienic problemUI that is a social or hygienic problem UI that is a social or hygienic problem UI that is a social or hygienic problem
needs treatment needs treatment 11--22
Leads to pad use shame sense of selfLeads to pad use shame sense of self Leads to pad use, shame, sense of selfLeads to pad use, shame, sense of self Bathroom mapping, social isolation Bathroom mapping, social isolation
d d id d iand depression and depression UI has a severe impact on QOLUI has a severe impact on QOL
Prevalence of UI in Prevalence of UI in elderlyelderly
Prevalence of urinary incontinence by decade of life.
Melville JLet al. Urinary incontinence in US women. Arch Intern Med 2005;165:537–42.
How common?How common?
UI is among the 10 most common chronic UI is among the 10 most common chronic
conditions in the U.S.conditions in the U.S.
UI is more common than hypertension, UI is more common than hypertension,
depression or diabetesdepression or diabetes 11--33depression or diabetes depression or diabetes 11 33
Why care?Why care?Why care?Why care?
Clinically significant Clinically significant anxietyanxiety occurs in occurs in 30%30%--50% of women with UI50% of women with UI
Clinically significant Clinically significant depressiondepressionoccurs in 20occurs in 20--30% of women with UI30% of women with UI
UI imposes a severe burden on careUI imposes a severe burden on care--givers givers
UI is the leading cause for admission UI is the leading cause for admission into nursing homes into nursing homes
Fall Risk / MobilityFall Risk / Mobility/ y/ y
> 35% MortalityNocturia
> 35% Mortality in 1 yr17,18
FallLTC admission / PE
Hip Fracture
Cost of Urinary IncontinenceCost of Urinary Incontinence
Incontinence aisleIncontinence aisle Advertisements directed at womenAdvertisements directed at women The direct cost of UI ($12.4 billion annually) is The direct cost of UI ($12.4 billion annually) is
greater than the cost of breast, cervical, uterine greater than the cost of breast, cervical, uterine and ovarian cancers combined.and ovarian cancers combined. 55--66and ovarian cancers combined. and ovarian cancers combined.
NIH is pouring millions of $$ into costNIH is pouring millions of $$ into cost--effective Rxeffective Rx
Barriers to CareBarriers to CareMythMyth FactFact
If the patient is bothered If the patient is bothered by UI, she will tell meby UI, she will tell me
More than 50% women with More than 50% women with severesevere UI do UI do not speak to the physician because of not speak to the physician because of embarrassment embarrassment 77
UI is UI is ‘‘naturalnatural’’ after after childbirthchildbirth
Women often Women often ‘‘acceptaccept’’ UI but it has a UI but it has a severe impact on their selfsevere impact on their self--image, image, emotional well being and interpersonal emotional well being and interpersonal relationshipsrelationships
UI is a UI is a ‘‘normalnormal’’ part of part of agingaging
-- UI increases dependence of older adults UI increases dependence of older adults on careon care--giversgivers-- predisposes admission to LTCpredisposes admission to LTC-- increases the rate of serious medical increases the rate of serious medical conditionsconditionsconditionsconditions
If I get surgery for UI, I If I get surgery for UI, I will end up with a bag.will end up with a bag.
Several nonSeveral non--surgical & minimally invasive surgical & minimally invasive surgical treatments are available for UI.surgical treatments are available for UI.
Stress Urinary IncontinenceStress Urinary Incontinence
Urge IncontinenceUrge IncontinenceUrge IncontinenceUrge Incontinence
Underlying CauseUnderlying Causey gy g
Mixed IncontinenceMixed Incontinence –– Stress + UrgeStress + UrgeMixed Incontinence Mixed Incontinence Stress + UrgeStress + Urge
http://www.urologycenter.com/incontinence.cfm
Case 1Case 1
Ruth: 75 year old G2P2Ruth: 75 year old G2P2 Ruth: 75 year old G2P2Ruth: 75 year old G2P2 High functioning, likes to socializeHigh functioning, likes to socialize
‘P f i l’ l‘P f i l’ l ‘Professional’ volunteer‘Professional’ volunteer “Every time I play tennis I leak urine”.“Every time I play tennis I leak urine”. “ I will stop playing tennis”.“ I will stop playing tennis”.
Case 2Case 2
Marge: 83 year old Marge: 83 year old
Lives at home with help from daughter & aide Lives at home with help from daughter & aide
Needs assistance with IADLs > 75% of the timeNeeds assistance with IADLs > 75% of the time
Marge is always looking for a bathroomMarge is always looking for a bathroom
Daughter : “She never want to go anywhere”Daughter : “She never want to go anywhere”
“Nothing can be done. I don’t want a bag”.“Nothing can be done. I don’t want a bag”.g gg g
The First StepThe First StepThe First StepThe First Step
Ask the Question!Ask the Question! Never use the term ‘incontinence’!Never use the term ‘incontinence’! ‘Are you having trouble controlling your ‘Are you having trouble controlling your
bladder?’‘bladder?’‘D l k i h h &D l k i h h & Do you leak urine when you cough & Do you leak urine when you cough & sneeze? sneeze?
Do you leak on the way to the bathroom?Do you leak on the way to the bathroom? Do you leak on the way to the bathroom?Do you leak on the way to the bathroom? A single question by an MD increases A single question by an MD increases
reporting of UI by 20% reporting of UI by 20% p g yp g y
Basic Work up of UI in Basic Work up of UI in ppElderlyElderly Help dispel MythsHelp dispel Myths
–– ‘Nothing can be done’‘Nothing can be done’
–– ‘If I get surgery, I will end up with a bag’‘If I get surgery, I will end up with a bag’
Review Medications: that cause UI, AntiReview Medications: that cause UI, Anti--cholinergic burdencholinergic burden
Assess Mobility Issues / Fall riskAssess Mobility Issues / Fall risk
Assess Cognitive IssuesAssess Cognitive Issuesgg
Assess and treat Constipation, UTI Assess and treat Constipation, UTI
Exam and TestingExam and Testing UrinalysisUrinalysis Exam: cough stress test atrophicExam: cough stress test atrophic Exam: cough stress test, atrophic Exam: cough stress test, atrophic
vaginitis, post void residual volumevaginitis, post void residual volume
Leave it to the urogynecologist !Leave it to the urogynecologist !
Urodynamics: not essential for a basicUrodynamics: not essential for a basic Urodynamics: not essential for a basic Urodynamics: not essential for a basic work upwork up
Medications that cause UIMedications that cause UIMedications that cause UIMedications that cause UI
Loop DiureticsLoop Diuretics AntipsychoticsAntipsychotics AntipsychoticsAntipsychotics Tricyclic antidepressantsTricyclic antidepressants
Al h d i bl kAl h d i bl k Alpha adrenergic blockersAlpha adrenergic blockers Calcium channel blockersCalcium channel blockers ACE inhibitorsACE inhibitors GabapentinGabapentin GabapentinGabapentin
Treatment of UI in elderlyTreatment of UI in elderlyTreatment of UI in elderlyTreatment of UI in elderly
Behavioral TreatmentBehavioral Treatment MedicationsMedications MedicationsMedications AntiAnti--incontinence ringsincontinence rings
Mi i ll I i SMi i ll I i S Minimally Invasive SurgeryMinimally Invasive Surgery
Behavioral TreatmentBehavioral TreatmentBehavioral Treatment Behavioral Treatment Bladder DiaryBladder Diary
Behavioral Rx Behavioral Rx continuedcontinued
ConstipationConstipation
Acute onset of Constipation/Stool Acute onset of Constipation/Stool I i UII i UIImpaction: can cause temporary UIImpaction: can cause temporary UI–– Distended sigmoid can block Distended sigmoid can block
h i lh i lparasympathetic sacral nerves, pressure parasympathetic sacral nerves, pressure on bladderon bladder
Ch i ti ti k t t tCh i ti ti k t t t Chronic constipation makes treatment Chronic constipation makes treatment of UI more difficultof UI more difficult
Behavioral Rx Behavioral Rx continuedcontinued
Recurrent UTIRecurrent UTI
In RCTs, vaginal estrogen cream In RCTs, vaginal estrogen cream reduces recurrent UTI reduces recurrent UTI
http://www.drannieevans.com/images/Pic1.jpg
Behavioral Rx Behavioral Rx continuedcontinued
Pelvic floor exercisesPelvic floor exercises
Pelvic Muscle Exercises Pelvic Muscle Exercises –– KegelKegel
M k ti t ti i th iM k ti t ti i th i–– Makes patients proactive in their own careMakes patients proactive in their own care
–– Improves efficacy of other treatmentsImproves efficacy of other treatments
“Don’t let gas come out”“Don’t let gas come out”
10 squeezes three times a day10 squeezes three times a dayq yq y
Bladder Training Bladder Training
–– Frequent voluntary voidingFrequent voluntary voiding
Institutionalized PatientsInstitutionalized Patients
Behavioral treatment is the mainstay in Behavioral treatment is the mainstay in institutionalized patientsinstitutionalized patients
50% prevalence of UI/OAB50% prevalence of UI/OAB2323
Timed Voiding, Rx of UTI and Timed Voiding, Rx of UTI and constipationconstipation
Don’t Fear the BeersDon’t Fear the Beers2424
–– Oxybutynin IR, Tolterodine IR on Beers CriteriaOxybutynin IR, Tolterodine IR on Beers Criteria–– CMS list of Unnecessary Drugs: CMS list of Unnecessary Drugs:
2525AnticholinergicsAnticholinergics2525
AntiAnti--cholinergic Medicationscholinergic Medications
Annoying SideAnnoying Side--effects : Dry mouth, constipationeffects : Dry mouth, constipation
ElderlyElderly vulnerability to toxicity: Cognitive S Evulnerability to toxicity: Cognitive S E Elderly Elderly vulnerability to toxicity: Cognitive S.E.vulnerability to toxicity: Cognitive S.E.
600 known anti600 known anti--cholinergic medications cholinergic medications
–– Increased antiIncreased anti--cholinergic load overallcholinergic load overall
Low efficacy in clinical practiceLow efficacy in clinical practice
Adherence is shockingly low: 10% at 1 yrAdherence is shockingly low: 10% at 1 yr
Use if behavioral treatment fails, monitor carefullyUse if behavioral treatment fails, monitor carefully
Rings and PessariesRings and PessariesRings and PessariesRings and Pessaries
AntiAnti--incontinence incontinence rings are for rings are for treating SUItreating SUI
Pessaries can Pessaries can iisometimes worsen sometimes worsen
SUI SUI
Rings: Stress or Mixed Rings: Stress or Mixed ggincontinenceincontinence
If fi d th t fit Ri k E iIf we find one that fits, Efficacy is 50%
Risks: Erosion, Cleaning
Surgery for UISurgery for UISurgery for UISurgery for UI
For properly selected casesFor properly selected cases
Is UI affecting her quality of life?Is UI affecting her quality of life?–– Is UI affecting her quality of life?Is UI affecting her quality of life?–– SUI vs. UUISUI vs. UUI–– UI only or UI with Prolapse?UI only or UI with Prolapse?
Assess frailty: one of the best predictors of postAssess frailty: one of the best predictors of post operativeoperative–– Assess frailty: one of the best predictors of postAssess frailty: one of the best predictors of post--operative operative outcomeoutcome
Most surgery for UI is office based or outpatientMost surgery for UI is office based or outpatient Most surgery for UI is office based or outpatientMost surgery for UI is office based or outpatient Admission is rarely neededAdmission is rarely needed
Four Minimally Invasive Four Minimally Invasive yyProcedures for UIProcedures for UI
SUISUI UUIUUI
Bulking AgentsBulking Agents Bladder Bladder PacemakerPacemaker
SlingSling Botox InjectionsBotox Injections
Periurethral Bulking Periurethral Bulking ggAgentsAgents Office procedureOffice procedure Local anesthesiaLocal anesthesia 10 minutes10 minutes Success Rate: Success Rate: Success ateSuccess ate50% 50% --75% at 1 year75% at 1 year Risk: TemporaryRisk: Temporary Risk: Temporary Risk: Temporary
retentionretention
Sling surgerySling surgerySling surgerySling surgery
For SUIFor SUI Minimally invasiveMinimally invasiveyy Outpatient Outpatient 30 min 30 min 3030 MAC anesthesiaMAC anesthesia Success: 75Success: 75--80%80% Success: 75Success: 75 80%80% Risk: bleeding, Risk: bleeding,
infection, injuryinfection, injuryinfection, injuryinfection, injury
Botox Injections in the Botox Injections in the jjbladderbladder Office procedureOffice procedure 10 minutes under 10 minutes under
local anesthesialocal anesthesia Efficacy: 75% at 8 Efficacy: 75% at 8
m to 1 yrm to 1 yr Risk: urinary Risk: urinary
retention 2%retention 2%
http://cdn.medicosconsultants.com/images/monograph/33d066a9-34ff-4a1a-b38b-d10983df3300/bot01-0009-01.jpg
Botox injectionsBotox injectionsBotox injectionsBotox injections
Bladder Pacemaker: Bladder Pacemaker: Sacral Nerve stimulationSacral Nerve stimulation
Since 1997Since 1997Similar to a cardiacSimilar to a cardiac Similar to a cardiac Similar to a cardiac pacemakerpacemaker
22--stage procedurestage procedure Each stage takes 30Each stage takes 30--45 45
minutesminutes Local anesthesiaLocal anesthesia Local anesthesiaLocal anesthesia Efficacy: 75% for 4 yrsEfficacy: 75% for 4 yrs Risk: no trunk MRIRisk: no trunk MRI
Two stage Bladder Two stage Bladder ggPacemakerPacemaker
Bladder PacemakerBladder PacemakerBladder PacemakerBladder Pacemaker
Botox Bladder PacemakerBotox Bladder PacemakerBotox Bladder PacemakerBotox Bladder Pacemaker
Nerve endings in Nerve endings in bladder musclebladder muscle
Afferent nerves of the Afferent nerves of the bladderbladder
Efficacy: 75%Efficacy: 75% Efficacy: 75%Efficacy: 75%
Office BasedOffice Based Outpatient Outpatient
$3000/$3000/-- per yearper year $15 K for 4 years$15 K for 4 years
ROSETTAROSETTAROSETTAROSETTA
Randomized controlled trial of Bladder Randomized controlled trial of Bladder pacemaker vs. Botox injectionpacemaker vs. Botox injectionp jp j
CostCost--effectiveness studyeffectiveness study Penn is a part of the 8Penn is a part of the 8 center Networkcenter Network Penn is a part of the 8Penn is a part of the 8--center Network center Network
sponsored by the NIHsponsored by the NIHW h h f il d tiW h h f il d ti Women who have failed conservative Women who have failed conservative treatment and medicationstreatment and medications
Case 1Case 1
Ruth: 75 year old P2Ruth: 75 year old P2 ‘Professional’ volunteer‘Professional’ volunteer Professional volunteerProfessional volunteer Diagnosis: SUIDiagnosis: SUI
R Bi f db k i h PT ( b fi )R Bi f db k i h PT ( b fi ) Rx: Biofeedback with PT (some benefit)Rx: Biofeedback with PT (some benefit) AntiAnti--incontinence ring: she hated itincontinence ring: she hated it Refused bulking agent, had slingRefused bulking agent, had sling Walked a 3 K six months after surgeryWalked a 3 K six months after surgeryg yg y
Case 2 Continued…Case 2 Continued…
Marge: 83 year old P2Marge: 83 year old P2
Lives at home with help, ‘Bathroom mapping’Lives at home with help, ‘Bathroom mapping’Lives at home with help, Bathroom mappingLives at home with help, Bathroom mapping
Diagnosis: UUIDiagnosis: UUIRx: Bladder diary Kegel Vaginal E2 LowRx: Bladder diary Kegel Vaginal E2 Low Rx: Bladder diary, Kegel, Vaginal E2, Low Rx: Bladder diary, Kegel, Vaginal E2, Low dose antidose anti--cholinergic over 12 wkscholinergic over 12 wksBl dd P kBl dd P k Bladder PacemakerBladder Pacemaker
Can now sit through a baseball gameCan now sit through a baseball game Home made sconesHome made scones
Role of the GeriatricianRole of the GeriatricianRole of the GeriatricianRole of the Geriatrician
Ask the Question!Ask the Question! Dispel Myths about treatment!Dispel Myths about treatment! Dispel Myths about treatment! Dispel Myths about treatment! Review MedicationsReview Medications
Ch k f UTI & ti tiCh k f UTI & ti ti Check for UTI & constipationCheck for UTI & constipation Conservative Rx: Bladder Diary, Pelvic Conservative Rx: Bladder Diary, Pelvic
PT, ? low dose antiPT, ? low dose anti--cholinergiccholinergic Procedures: Provide basic informationProcedures: Provide basic information
When to ReferWhen to Refer
Incontinence not responding to conservative Incontinence not responding to conservative
t t tt t ttreatmenttreatment
Significant prolapse Significant prolapse
Elevated PVRElevated PVR
H Pel i ge i di tionH Pel i ge i di tion Hx Pelvic surgery, irradiationHx Pelvic surgery, irradiation
associated neurologic conditionsassociated neurologic conditions
UI ProvidersUI ProvidersUI ProvidersUI Providers
Lily Arya, Urogyn, HUP and RadnorLily Arya, Urogyn, HUP and Radnor Heidi Harvie Urogyn PAH and CHHHeidi Harvie Urogyn PAH and CHH Heidi Harvie, Urogyn, PAH and CHHHeidi Harvie, Urogyn, PAH and CHH Ariana Smith, Urology, PAH and HUPAriana Smith, Urology, PAH and HUP
ReferencesReferences
1. William D. Steers. Overactive Bladder (OAB): What We Thought We Knew and What We 1. William D. Steers. Overactive Bladder (OAB): What We Thought We Knew and What We
Know TodayKnow Today European Urology Supplements, Volume 1, Issue 4, July 2002, Pages 3European Urology Supplements, Volume 1, Issue 4, July 2002, Pages 3--1010
2. Newman DK, Wein AJ. Managing and Treating Urinary Incontinence. Chapter 1. 2. Newman DK, Wein AJ. Managing and Treating Urinary Incontinence. Chapter 1.
Introduction. 2009. Second Edition. Health Professions Press, Baltimore, MD, USAIntroduction. 2009. Second Edition. Health Professions Press, Baltimore, MD, USA
3. Ouslander JG. Management of Overactive Bladder. New England J of Medicine. 2004: 3. Ouslander JG. Management of Overactive Bladder. New England J of Medicine. 2004:
350 786350 786 799799350, 786350, 786--799.799.
4. Urinary Incontinence in US women: a population based study. Melville JL, Katon W, 4. Urinary Incontinence in US women: a population based study. Melville JL, Katon W,
Delaney K, Newton K.Arch Intern Med. 2005 Mar 14;165(5):537Delaney K, Newton K.Arch Intern Med. 2005 Mar 14;165(5):537--42.42.
5 W TH d H TW E i t f i i ti i 1995 U l 19985 W TH d H TW E i t f i i ti i 1995 U l 1998 5. Wagner TH and Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998; 5. Wagner TH and Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998;
51; 35551; 355--361361
6. Varmus H. Disease specific estimates of direct and indirect costs of illness and NIH 6. Varmus H. Disease specific estimates of direct and indirect costs of illness and NIH
support Bethesda MD: National Institution of Healthsupport Bethesda MD: National Institution of Healthsupport. Bethesda, MD: National Institution of Healthsupport. Bethesda, MD: National Institution of Health
7. Fultz NH, Burgion K, Diokno KC et al. Burden of stress urinary incontinence for 7. Fultz NH, Burgion K, Diokno KC et al. Burden of stress urinary incontinence for
community dwelling women. Am J Obstet Gynecol 2003;189, 1275community dwelling women. Am J Obstet Gynecol 2003;189, 1275--12821282
8 Sampselle Carolyn M et al Continence for Women: A Test of AWHONN’s Evidence8 Sampselle Carolyn M et al Continence for Women: A Test of AWHONN’s Evidence 8. Sampselle, Carolyn M., et al. Continence for Women: A Test of AWHONN s Evidence8. Sampselle, Carolyn M., et al. Continence for Women: A Test of AWHONN s Evidence--
Based Protocol in Clinical Practice.Based Protocol in Clinical Practice. J WOCNJ WOCN 2000;27:1092000;27:109--17.17.
