Evaluation of the Causes and Severity of Geriatric Incontinence

Treating Lower Urinary Tract Symptoms in Older Adults: Intravesical Options

This article provides an overview of the diagnosis and the treatment of lower urinary tract symptoms in older adults complicated by the neurodegenerative changes in the micturition reflex and further confounded by age-related decline in hepatic and renal clearance raising the propensity of adverse drug reactions. The first-line drug treatment for lower urinary tract symptoms, orally administered antimuscarinics, fails to reach the equilibrium dissociation constant of muscarinic receptors even at their maximum plasma concentration and tends to evoke a half-maximal response at a muscarinic receptor occupancy of just 0.206% in the bladder with a minimal difference from exocrine glands, which raises the adverse drug reaction risk. On the contrary, intravesical antimuscarinics are instilled at concentrations 1000-fold higher than the oral maximum plasma concentration and the equilibrium dissociation constant erects a downhill concentration gradient that drives passive diffusion and achieves a mucosal concentration around ten-fold lower than the instilled concentration for a long-lasting occupation of muscarinic receptors in mucosa and sensory nerves. A high local concentration of antimuscarinics in the bladder triggers alternative mechanisms of action and is supposed to engage retrograde transport to nerve cell bodies for neuroplastic changes that underlie a long-lasting therapeutic effect, while an intrinsically lower systemic uptake of the intravesical route lowers the muscarinic receptor occupancy of exocrine glands to lower the adverse drug reaction relative to the oral route. Thus, the traditional pharmacokinetics and pharmacodynamics of oral treatment are upended by intravesical antimuscarinics to generate a dramatic improvement (~ 76%) noted in a meta-analysis of studies enrolling children with neurogenic lower urinary tract symptoms on the primary endpoint of maximum cystometric bladder capacity as well as the secondary endpoints of filling compliance and uninhibited detrusor contractions. The therapeutic success of intravesical multidose oxybutynin solution or oxybutynin entrapped in the polymer for sustained release in the pediatric population bodes well for patients with lower urinary tract symptoms at the other extreme of the age spectrum. Though generally used to predict oral drug absorption, Lipinski's rule of five can also explain the ten-fold lower systemic uptake from the bladder of positively charged trospium over oxybutynin, a tertiary amine. Chemodenervation by an intradetrusor injection of onabotulinumtoxinA is merited for patients with idiopathic overactive bladder discontinuing oral treatment because of a lack of efficacy. However, age-related peripheral neurodegeneration potentiates the adverse drug reaction risk of urinary retention that motivates the quest of liquid instillation, delivering larger fraction of onabotulinumtoxinA to the mucosa as opposed to muscle by an intradetrusor injection can also probe the neurogenic and myogenic predominance of idiopathic overactive bladder. Overall, the treatment paradigm of lower urinary tract symptoms in older adults should be tailored to individual's overall health status and the risk tolerance for adverse drug reactions.

Low dose oral desmopressin for nocturnal polyuria in patients with benign prostatic hyperplasia: a double-blind, placebo controlled, randomized study

PURPOSE

We evaluated the long-term efficacy and safety of low dose oral desmopressin in elderly patients with benign prostatic hyperplasia with more than nocturnal voids and nocturnal polyuria more than 30% of total daily urine volume.

MATERIALS AND METHODS

Eligible patients with benign prostatic hyperplasia older than 65 years with nocturia, nocturnal polyuria and International Prostate Symptom Score 14 or greater were included in the study. All patients received placebo or 0.1 mg desmopressin orally at bedtime. Patients were required to visit the outpatient clinic from the first visit, and after 1, 3, 6 and 12 months of treatment. Patients maintained flow volume charts and used diaries to record voiding data throughout the study. During followup urinalysis, urine sodium, urine osmolality, serum electrolytes, prostate specific antigen, International Prostate Symptom Score, quality of life, transrectal ultrasonography of prostate, uroflowmetry and post-void residual urine volume were performed at each visit.

RESULTS

A total of 115 patients were enrolled in the study and randomized as 58 in the placebo group and 57 in the desmopressin group. Desmopressin significantly decreased nocturnal urine output and the number of nocturia episodes, and prolonged the first sleep period (p < 0.01). Compared to before treatment desmopressin gradually decreased serum sodium and induced statistically but not clinically significant hyponatremia after 12 months of treatment. No serious systemic complications were found during medication.

CONCLUSIONS

Low dose oral desmopressin is an effective and well tolerated treatment for nocturnal polyuria in the lower urinary tract symptoms of patients with benign prostatic hyperplasia. Long-term desmopressin therapy gradually decreases serum sodium and it might induce hyponatremia even in patients without initial hyponatremia. For long-term desmopressin administration serum sodium should be assessed carefully, at least at 1 week after treatment.

Urinary incontinence

Urinary incontinence (UI) is a problem that affects more than 16 million Americans, most of them women. Although nearly half of the elderly in America have episodes of UI, it is not a normal consequence of aging. It remains a largely neglected problem despite its considerable prevalence, morbidity, and expense. This article reports on a successful proactive health risk screening process to treat this major problem.

Efficacy of desmopressin in the treatment of nocturia: a double-blind placebo-controlled study in men

OBJECTIVE

To investigate the efficacy and safety of oral desmopressin in the treatment of nocturia in men.

PATIENTS AND METHODS

Men aged >/=18 years with verified nocturia (>or=two voids/night) and nocturnal urine production greater than their maximum functional bladder capacity were recruited. A 3-week dose-titration phase established the optimum desmopressin dose (0.1, 0.2 or 0.4 mg). After a 1-week 'washout' period, patients who responded in the dose-titration period were randomized to receive the optimal dose of desmopressin or placebo in a double-blind design for 3 weeks.

RESULTS

In all, 151 patients entered the double-blind period (86 treated with desmopressin, 65 with placebo). In the desmopressin group 28 (34%) patients and in the placebo group two (3%) patients (P<0.001) had fewer than half the number of nocturnal voids relative to baseline; the mean number of nocturnal voids decreased from 3.0 to 1.7 and from 3.2 to 2.7, respectively, reflecting a mean decrease of 43% and 12% (P<0.001). The mean duration of the first sleep period increased by 59% (from 2.7 to 4.5 h) in the desmopressin group, compared with an increase of 21% (from 2.5 to 2.9 h) in the placebo group (P<0.001). The mean nocturnal diuresis decreased by 36% (from 1.5 to 0.9 mL/min) in the desmopressin group and by 6% (from 1.7 to 1.5 mL/min) in the placebo group (P<0.001). The mean ratio of night/24-h urine volume decreased by 23% and 1% (P<0.001), and the mean ratio of night/day urine volume decreased by 27% and increased by 3% (P<0.001) for the desmopressin and placebo groups, respectively. In the double-blind treatment period, similar numbers of patients had adverse events; 15 (17%) patients in the desmopressin and 16 (25%) patients in the placebo group. Most adverse events were mild. Serum sodium levels were <130 mmol/L in 10 (4%) patients and this occurred during dose-titration.

CONCLUSIONS

Orally administered desmopressin is an effective and well-tolerated treatment for nocturia in men.

Urinary incontinence in the older man

Older men experience UI less often than older women, but the disruption and bother they experience because of UI is significant. Several anatomic differences between men and women account for different pathophysiology of incontinence. In men, overflow incontinence and detrusor instability predominate; stress incontinence is seen only in cases in which men have had prostate surgery. Reported symptoms of urgency and urge incontinence may be particularly difficult to interpret clinically in men because they might indicate detrusor instability or bladder outlet obstruction causing uninhibited contractions. The medical evaluation of UI is similar for men and women; men being evaluated for UI need a postvoid residual. Noninvasive measurement of urine flow may add to the diagnostic accuracy of detecting bladder outlet obstruction, but the results may not agree with results obtained by pressure-flow studies. Prostate surgery can result in UI, and biofeedback can be an effective treatment. Near-continual leakage after prostate surgery seems to be most responsive to artificial sphincter implantation. Male nursing home patients with UI present a different challenge in that mental and physical dysfunction must be addressed. Staff-dependent interventions are the most appropriate.

Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure

OBJECTIVE

To develop a condition-specific measure for assessing the impact of urge urinary incontinence (UI) on the quality of life (QoL) of older persons.

DESIGN

A 32-item Urge Impact Scale (URIS) was drafted using content area data from focus groups composed of urge incontinent older persons. Pilot testing in 21 urge incontinent persons (mean age 67.7 years) resulted in the elimination of eight items by internal consistency, skew, and patient response criteria. The resulting scale (URIS-24) was tested for reliability (internal consistency and test-retest correlation) and construct validity (correlation with UI severity from voiding records) in a separate group of 27 urge incontinent persons (89% women, mean age 72 years). Factor analysis of URIS-24 data from the combined 48 persons was used to explore the conceptual structure underlying urge UI-related QoL.

SETTING

University-affiliated community-based practice and tertiary hospital.

PARTICIPANTS

Community-dwelling women and men, older than age 60 and with urge incontinence at least twice weekly, recruited from newspaper, newsletter, and radio advertisements.

RESULTS

Cronbach's alpha for URIS-32 was 0.84, and for URIS-24 it was 0.94. When administered (mean +/- standard deviation) 9.2 +/- 5.1 days apart, URIS-24 had good test-retest reliability for total scores (interclass coefficient = .88, concordance coefficient = .88), and individual item scores at time 2 were within 1 point (on a 5-category Likert scale) of time 1 answers for 89% of responses. URIS-24 scores had modest but nearly significant correlation with the number of UI episodes (r = -0.39, P = .05). Factor analysis revealed a three component structure corresponding to psychological burden, perception of personal control, and self concept.

CONCLUSIONS

The URIS-24 is an internally-consistent, highly reproducible tool for the assessment of the QoL impact of urge UI on older persons. It can be used to evaluate QoL impact by specific items as well as by overall score. Compared with other UI-specific QoL measures, the URIS-24 had similar or superior internal consistency, test-retest reliability, and validity, but it is the first measure designed and tested specifically for older persons with urge UI. These results also highlight the multifactorial structure of urge UI-related QoL and the importance of its psychological dimensions.

Urinary incontinence among a 65-year old Swedish population: medical history and psychosocial consequences

Urinary incontinence (UI) is a disability caused by an impairment, which can lead to a handicap of importance for nursing care. This means that UI is not only a practical-medical concern but also a socio-economic problem. The purpose of the study was to determine the prevalence of UI among 65 year-olds in a Swedish Health Care District and to compare gender differences concerning medical history and psychosocial consequences. In a Primary Health Care District, a questionnaire pertaining to UI was mailed to all women and men 65 years of age (N = 458). A total of 91% (n = 419) was sufficient for data analysis, which was performed by descriptive and inferential statistics. It was found that 28% (n = 61) of the women and 9% (n = 21) of the men were afflicted with UI. Women reported significantly more urge incontinence (p < .05) as well as stress incontinence (p < .05). Information from the health service about UI had been given to 46% (n = 28) of the women and 33% (n = 7) of the men. The strongest reason reported, both in women (42%, n = 26) and men (40%, n = 8), for not seeking help from the health service was that UI was a normal condition for people of their age. Most of the women had to urinate at least twice per night (42%) compared to once per night (44%) for the men. It is important to establish a UI clinic at every main Primary Health Care Centre which builds on nursing care and whose aim is to inform the general public that UI is a common problem, that it leads to psychosocial consequences, and that the health service can offer active rehabilitation interventions.

Treatment of postprostatectomy urinary incontinence with behavioral methods

Prostate cancer is the most commonly diagnosed cancer in men. The radical prostatectomy is the treatment of choice for localized cancer; however, this surgery carries with it the potential complication of urinary incontinence postoperatively. The increasing number of radical prostatectomies each year will thus lead to a growing number of patients suffering from postprostatectomy urinary incontinence. According to the medical literature, the treatment of postprostatectomy incontinence is almost always limited to pharmacological or surgical therapy. Because of the failure of the standard treatment options, many men are left to live with their incontinence. The guidelines for the treatment of urinary incontinence recommend the use of behavioral methods as first-line treatment for stress and urge incontinence. The potential treatment of postprostatectomy incontinence with the use of behavioral methods has a promising future for the advanced practice nurse and for the men who are affected.

Urologic care in long-term facilities

The urologic care of the institutionalized elderly is confounded by the high prevalence of comorbid conditions. There is also a challenge to provide cost effective care to this group that requires a disproportionate share of health care resources. Bacteriuria, hematuria, and problems of urine control and drainage provide unique clinical conditions that must be dealt with.

Geriatric incontinence

Regardless of age, mobility, mentation, or institutionalization, incontinence is never normal. By attenuating physiologic reserve, aging increases the likelihood of becoming incontinent in the setting of additional physiologic, pharmacologic, or pathologic insults. Because many of these problems lie outside the urinary tract, so too must the diagnostic and therapeutic focus. Such a strategy, however, coupled with a multifactorial, creative, persistent, and optimistic approach, increases the chances of a successful outcome and generally rewards patient and physician alike.