長照體系內失禁評估與處置

1. 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

2. Urinary Incontinence

3. Normal urinary continence Thirugnanasothy BMJ 2010

4. Sympathetic hypogastric nerve Parasympathetic pelvic nerve Somaticpudendal nerve Innervation of the Lower Urinary Tract (LUT) Brain Bladder detrusorsmooth muscle T10–L2 T10–L2 Bladder detrusorsmooth muscle Internal sphincter smooth muscle Internal sphincter smooth muscle S2–S4 S2–S4 Intramural skeletal muscle Intramural skeletal muscle Extramural skeletal muscle Extramural skeletal muscle Urethral smooth muscle Urethral smooth muscle Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83.

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

6. 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

7. Definition • UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. International Continence Society

8. Symptoms of urinary tract dysfunction Urinary incontinence Leaking on strain or coughing Frequency

9. 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.

10. Clinical Impact of Urinary Incontinence

11. 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

12. 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 LTCF Dementia and functional impairments are frequent contributors

13. Types of Urinary Incontinence • Transient UI (Acute) • Established UI (Chronic) • Urge UI • Stress UI • Overflow UI • “Functional” UI • Mixed UI

14. Transient Incontinence • Lower urinary tract pathology • Precipitated by reversible factor • Causes: Delirium, UTI, Meds, Psychiatric disorders,  UO, Stool impaction • Restricted mobility

15. Causes of Transient Incontinence Mnemonics: DIAPPERS • D Delirium • I Infection • A Atrophic Vulvovaginitis • P Psychological • P Pharmacologic agents • E Endocrine, excessive UO • R Restricted Mobility • S Stool impaction Resnick NM. Med Grand Rounds. 1984;3:281-290.

16. Classification of Chronic UI • Urge UI • Stress UI • Overflow UI • “Functional” UI • Mixed UI

17. Classification of Chronic UI

18. 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)

19. 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

20. 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

21. Functional Incontinence • Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers • No underlying GU dysfunction • Diagnosis of exclusion

22. Summary of Urinary Incontinence Leakage accompanied or preceded by urgency Urge Leakage or exertion, sneezing, or coughing Stress Leakage owing to bladder outflow obstruction of any cause resulting large post-void residual volume Overflow Inability to reach the toilet in time (mobility, dexterity) or lack of perceived need to (cognitive impairment) Functional Urinary incontinence in recent 3 days Transient ThirugnanasothyBMJ 2010

23. History • Urinary symptoms • Voiding: hesitancy, poor urinary stream, dribbling • Precipitantsof urinary leakage such cough, exertion • History of haematuria and recurrent urinary tract infections • Bowel symptoms : Constipation, straining, faecal incontinence • FluidsVolume: 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

24. 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

25. Drugs and urinary incontinence DeMaagd, US Pharm. 2007

26. Prescribing cascade… 85 years-old. Past history: Hypertension Take Norvasc(amlodipine) for BP control Leg edema, Impaired bladder empyting Diuretics （利尿劑） Urgency, Incontinence Take anti-cholingergic drug Constipation, urinary retention Take Laxatives, Insert foley Fecal Incontinence, UTI

27. 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

28. Urinary Diary

29. 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)

30. Treatment options • Non-pharmacological • Medications • Surgery

31. Medication Review • Stop all offending medications • Balance against BP control, heart failure control Environmental Factors • Toilet access – stairs, commode, lighting, privacy. • Mobility – rehabilitation to improve function • Address visual deficits

32. 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

33. 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

34. Medications • Urge incontinence: antimuscarinic drug

35. Adverse effect of Antimuscarinics • Contraindicated:narrow-angle glaucoma, urinary retention and gastric retention. • Increased risk of confusion in dementia patients

36. Antimuscarinic Drugs

39. Medications • Overflow Incontinence • treat cause • -antagonists： relax the muscle of prostate and bladder neck • terazosin, doxazosin,tamsulosin, alfuzosin, silodosin • Low blood pressure, dizziness

40. Medications • Stress incontinence • α- Adrenergic agonists • increasing internal sphincter tone • Pseudoephedrine; weak evidence, no recommend • Duloxetine(Cymbalta): • Increased urethral contraction and sphincter tone

41. Urethral catheters - indications Approx. 80% of health care-related UTI’s are catheter-related • 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

42. 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

43. Treatment options - Surgery • 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

44. 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

45. 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

47. 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