長照體系內失禁評估與處置

台北榮總高齡醫學中心 彭莉甯

Urinary Incontinence

Thirugnanasothy BMJ 2010

Normal urinary continence

Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83.

T10–L2

S2–S4

Innervation of the Lower Urinary Tract (LUT)

Extramuralskeletal muscle

Urethral smooth muscle

Intramural skeletal muscle

Internal sphinctersmooth muscle

Sympathetic hypogastric nerveBrain

Bladder detrusorsmooth muscle

Parasympathetic pelvic nerve

Somatic pudendal nerveExtramuralskeletal muscle

Urethral smooth muscle

Intramural skeletal muscle

Internal sphinctersmooth muscle

Bladder detrusorsmooth muscleT10–L2

S2–S4

Normal Urinary Continence Stable bladder wall Intact pelvic floor Intact neurology Manual dexterity Normal cognition Normal physical function Barrier free environment

Age-Related Changes detrusor contractility urinary flow post-voiding residual urine total bladder capacity ability to postpone voiding Detrusor overactivity (20% of healthy continent) nocturia prostate size Atrophic vagintis & urethritis DuBeau CE.Urinary Incontinence.Geriatric Review Syllabus Fifth Ed.2002-2004.139-148

Definition UI is the involuntary loss of urine that is objectively

demonstrable and a social or hygienic problem.

International Continence Society

Leaking on strain or coughing

Frequency

Urinary incontinence

Symptoms of urinary tract dysfunction

Prevalence of Urinary Incontinence 15-30% of community dwelling persons 65 years and

older. F>M until age 80 years, then M=F Up to 50% in LTCF Under-reported and delay seeking help.

Clinical Impact of Urinary Incontinence

Consequences

“I don’t go out, I don’t even ask anyone round………. I’m so embarrassed about the smell. I do try and keep myself clean but it gets onto your clothes and furniture. Sometimes I wish that I hadn’t survived because it’s no life I’m leading now”

Fe male stroke survivor

Risk Factors for UI 1/3 have multiple conditions Stroke Diabetes Parkinson’s Disease Obesity, CHF, Constipation, TIAs, COPD, Chronic cough Impaired mobility & ADLs Depression Dementia (moderate to severe)

Heterogeneous residents in LTCFDementia and functional impairments are frequent contributors

Heterogeneous residents in LTCFDementia and functional impairments are frequent contributors

Types of Urinary Incontinence Transient UI (Acute) Established UI

(Chronic) Urge UI Stress UI Overflow UI “Functional” UI Mixed UI

Transient Incontinence Lower urinary tract pathology Precipitated by reversible factor Causes: Delirium, UTI, Meds, Psychiatric disorders,

UO, Stool impaction Restricted mobility

Causes of Transient IncontinenceMnemonics: DIAPPERSD DeliriumI InfectionA Atrophic VulvovaginitisP PsychologicalP Pharmacologic agentsE Endocrine, excessive UOR Restricted MobilityS Stool impaction

Resnick NM. Med Grand Rounds. 1984;3:281-290.

Classification of Chronic UI Urge UI Stress UI Overflow UI “Functional” UI Mixed UI

Classification of Chronic UI

Urge Incontinence Most common Detrusor overactivity with uninhibited bladder contraction Unpredictable, abrupt urgency, frequency Post-void residual usually normal (<51ml) Cause:

age impaired ability of brain to send inhibitory signals (stroke, brain mass,

PD) increased afferent stimulation from the bladder(UTI, uterine prolapse) Prostatic hypertrophy in men (leads to hypertrophy of detrusor muscle)

Stress Incontinence most common cause in aging females Cause: child-birth, obesity (increased pressure on pelvic

organs), hysterectomy, radical prostatectomy Leakage occurs with intra-abdominal pressure on

coughing, sneezing, physical activity

Overflow Incontinence Detrusor underactivity and/or outlet obstruction Outlet obstruction=2nd most common cause of UI in

Males Dribbling, weak stream, hesitancy Prolonged urinary retention can lead to detrusor

muscle failure, persisting even after obstruction relieved

Functional Incontinence Unable or unwilling to toilet due to physical impairment,

cognitive dysfunction, environmental barriers No underlying GU dysfunction Diagnosis of exclusion

Leakage accompanied or preceded by urgency

Leakage or exertion, sneezing, or coughing

Leakage owing to bladder outflow obstruction of any cause resulting large post-void residual volume

Inability to reach the toilet in time (mobility, dexterity) or lack of perceived need to (cognitive impairment)

Urinary incontinence in recent 3 days

Urge

Stress

Overflow

Functional

Transient

Summary of Urinary Incontinence

Thirugnanasothy BMJ 2010

History Urinary symptoms

Voiding: hesitancy, poor urinary stream, dribbling Precipitants of urinary leakage such cough, exertion

History of haematuria and recurrent urinary tract infections Bowel symptoms : Constipation, straining, faecal incontinence Fluids Volume: caffeine, carbonated drinks, citrus drinks, sweeteners Medical / Surgical history

Neurological disorders, cognitive disorders, cough Hysterectomy, prostatectomy, pregnancies, mode of delivery

Drug history Sedatives and hypnotics, antimuscarinics, diuretics, alcohol

Social history Access to toilets and aids; mobility. Impact on quality of life

Adapted from Thirugnanasothy BMJ 2010

Examination General exam

Enlarged bladder, pelvic mass, edema, orthostatic hypotension, heart failure

Neurological exam Functional impairment

Mobility, dexterity (undoing buttons), vision Cognition Rectal exam

Prostate size and nodularity, fecal impaction Pelvic

Prolapse, atrophic vaginitis

Drugs and urinary incontinence

DeMaagd, US Pharm. 2007

Prescribing cascade… 85 years-old. Past history: Hypertension

Take Norvasc(amlodipine) for BP control

Leg edema, Impaired bladder empyting

Urgency, Incontinence

Take anti-cholingergic drug

Constipation, urinary retention

Take Laxatives, Insert foley

Fecal Incontinence, UTI

Diuretics Diuretics （利尿劑）（利尿劑）

Essential investigations Urinalysis – haematuria, glucose, infection

Bloods – glucose, creatinine, sodium, calcium ,+/- PSA

Post-void bladder scan – <100mls ok. Post-void catheter with measure of residual if scan not available

Voiding diary 3 days diary More reliable than patient recall Record type and time of intake, volumes Record time of each micturition and volume (estimate, or actual) Record number of pads used, weigh pads Ask family/carer to assist if patient unable

Urinary Diary時間 喝水量

(cc)尿量(cc)

廁所解尿 少量失禁 大量失禁 失禁原因

上午 5:30 250 V

上午 8:00 50 V 買菜上午 8:50 100

上午 9:50 100 V 利尿劑後 1 小時

上午 10:30 300

上午 11:40 300 V

下午 14:00 250 V

下午 14:20 350 250

下午 16:00 50 V 小跑步去接孫子

晚上 18:00 130 V 炒菜炒一半突然尿急

Further investigations Generally unnecessary unless

Haematuria – micro or macroscopic Urinary retention Pelvic mass Prostate mass / significantly raised PSA New/undiagnosed renal impairment Frequent urinary infections, especially in men

Renal ultrasound Urodynamic studies Cystoscopy Further investigations as per findings (e.g. MRI spinal cord or

brain)

Treatment options

Non-pharmacological

Medications

Surgery

Medication Review Stop all offending medications Balance against BP control, heart failure control

Toilet access – stairs, commode, lighting, privacy. Mobility – rehabilitation to improve function Address visual deficits

Environmental Factors

Non-pharmacological: Cognitive Intact Pelvic floor exercises – for stress / urge /mixed incontinence

First line treatment, 3 months trial needed RCT: improves subjective and objective cure rates

(44% vs. 7% objective cure rates) Need to be cognitively intact – may not suit many older pts

Bladder retraining Increase time interval between voiding Greater effectiveness

Non-pharmacological: Cognitive impairment

Time voiding 2-3 hour time interval, for dependent residents Effective

Prompt voiding ask dependent residents regularly whether they need toileting

assistance. Positive feedback

Habit retraining Identification of a person’s toileting pattern; for dependent residents Cochrane review: no significant difference in the incidence and volume

of incontinence

Urge incontinence: antimuscarinic drug

Medications

Adverse effect of Antimuscarinics

• Contraindicated:narrow-angle glaucoma, urinary retention and gastric retention.

• Increased risk of confusion in dementia patients

Antimuscarinic Drugs

Medications Overflow Incontinence

treat cause -antagonists ： relax the muscle of prostate and

bladder neck terazosin, doxazosin, tamsulosin, alfuzosin, silodosin Low blood pressure, dizziness

Stress incontinence α- Adrenergic agonists

increasing internal sphincter tone Pseudoephedrine; weak evidence, no recommend

Duloxetine(Cymbalta): Increased urethral contraction and sphincter tone

Medications

Urethral catheters - indications

Acceptable reasons to catheterise•Acute urinary retention•Irrigation of haematuria•Need to monitor urinary output•Severe sacral ulcers, to protect skin•Chronic urinary retention only if renal impairment •Measurement of post-void volume (if bladders scan unavailable)

UNACCEPTABLE reasons to catheterise•Immobility•Carer/staff demands •Urinary incontinence•Urinary tract infection

Approx. 80% of health care-related UTI’s are catheter-related

Suprapubic catheters May require anaesthetic, not without complications May be associated with reduced risk of infection Reduced impact on sexual function Only if

assured that a long-term catheter needed no surgical options cannot intermittently self-catheterise

Retropubic suspension procedures To support and restore the bladder neck to its retropubic

location Transvaginal bladder neck suspensions

Less invasive Artificial urinary sphincter

Indication: incontinence due to poor urethral sphincteric mechanism

Urinary diversion Indication: as a last resort in some patients that is refractory

to the above-mentioned Tx options

Treatment options - Surgery

Augmentation cystoplasty Using bowel segments Creation of a low-pressure system will decrease stimulation of

sensory afferents Intermittent catheterization will usually be required to

completely empty the bladder Sacral neuromodulation

Placement of a surgical electrode permanently stimulating S3 afferent or motor nerves

Treatment options - Surgery

Conclusion High prevalence of UI in LTCF Differentiate the causes of UI Functional status, cognitive abilities, comorbidities should

be considered when developing a continence in LTCF. Emphasize the importance of non-pharmacologic

treatment Avoid to use urinary catheter unless under some

circumstances

Urethral catheters

Intermittent catheterisation if at all possible Lower risk of urinary infections Dexterity needed

Medical treatment has failed or surgical is not appropriate Leave catheter in for the minimum time necessary Always review need for existing catheter Catheter must provide more benefits than risks to the

patient Should not be portrayed as easiest option