Management of Urinary Incontinence in the Elderly
Urinary incontinence can be defined as uncontrolled or unrecognized issued urine within a certain amount or quite often, resulting in psychosocial problems or health problems. Urinary incontinence affects about 15-30% of old age (elderly) living in the house, which then resulted in a third of those treated in the chronic care.
Clinically, urinary incontinence can cause redness (rash) on the perineum, decubitus ulcers, urinary tract infections, even urosepsis, falls, and fractures. Psychosocial, urinary incontinence is associated with embarrassment, stigmatization, isolation, depression, and the risk of care (institutionalization).
Although elderly patients often neglect urinary incontinence and regarded as a normal part of the aging process, urinary incontinence is something abnormal at all ages, and can be treated and often curable, even at a very advanced age. However the way, successful management requires understanding the impact of normal aging and factors outside the urinary tract to the urogenital system.
At all ages, incontinence depends on adequate mobility, mental status, motivation, and the function of the lower urinary tract. Although urinary incontinence in younger patients are rarely associated with a deficit outside the urinary tract, such a deficit is common in elderly patients. This deficit is very important to detect because it can cause incontinence and interventions may not be effective until the problem outside the urinary tract is settled.
Lower urinary tract changes with age, although without any illness. Bladder capacity, contractility, and the ability to withstand urination decreased in elderly men and women, while strength and long time close the urethra, decreased along with increasing age in women. Enlarged prostate in most men that often cause obstruction. In men and women, the prevalence of bladder contractions increased, whereas the residual volume after voiding increased to 50-100 ml. In addition, most of the elderly are often excrete fluid intake at night, although did not have kidney disease, peripheral edema and prostatism. These changes improve sleep disorder, causing urination 1-2 times at night in most healthy elderly.
Urinary Incontinence Evaluation in Elderly Patients
The purpose of evaluation are:
1. Identify whether urinary incontinence occur temporary or permanent.
2. Assess the patient's environment.
3. Knowing the support available for patients.
4. Detect conditions that are rare but serious that may underlie the occurrence of urinary incontinence such as lesions in the brain and spinal cord, bladder or prostate carcinoma, bladder stones, hydronephrosis, bladder decreasing resistance and detrusor dyssynergia.
Systematically by anamnesis, physical examination and then by investigation sought above factors. In the anamnesis also evaluated the pattern of fluid intake of patients, medications are taken (diuretic, psychotropic, anticholinergic), certain diseases (diabetes mellitus, stroke, dementia, etc.) and symptoms related to urinary tract (dysuria, urinary disorders)
All time urination and the amount of urine, and the incidence of urinary incontinence noteworthy for 2-7 days. These records can provide valuable diagnostic key. For example, incontinence that occurs only between the hours of 8:00 to noon, probably caused by diuretics are taken in the morning.
Physical examination includes examination of the abdomen, rectum, and genitals to look for an enlarged prostate or bladder or sacral nerve disorders. In patients who are already frail elderly, to consider the status of mobility and mental status, because it is associated with the occurrence of urinary incontinence. Bladder palpable on physical examination may indicate overflow incontinence due to obstruction of the bladder, or bladder not contraction. Large cystocele showed stress incontinence, perianal hypesthesia indicate overflow incontinence due to sacral denervation. The existence of parkinsonism or a history of stroke directs the possibility of an urgency incontinence due to bladder instability.
The following approach may be relatively non-invasive, accurate, cost-effective and well tolerated. The first stage is to identify the type of overflow incontinence (residual urine greater than or equal to 450 ml), when clinically appropriate, the patient may be referred to a urologist and can be catheterized. Because the obstruction is rare in female patients, diagnosis is generally between stress incontinence or detrusor overactivity. Leakage due to stress or pressure to look for examination by asking questions to the patient, if the patient is elderly woman felt that her bladder was full, asked to rest and cough strongly immediately, so that leaks can be readily observed. Not only regular leakage during stress maneuvers performed is strong evidence that it was not a stress incontinence.
In men, the type of stress urinary incontinence is rare. The problem is usually encountered distinguish detrusor overactivity with obstruction. The next stage is to look for the possibility of hydronephrosis in men with residual urine exceeds 200 ml, and refer to or empty the bladder (decompression). When hydronephrosis was not found but there is obstruction, the patient referred for the possibility of surgery. For another, in patients with symptoms of urge incontinence, allegedly due to detrusor overactivity can be given the treatment. Medications to relax the bladder should be avoided in patients with residual urine of 150 ml or more. The same approach is also recommended in patients with cognitive impairment can be observed closely. Patients elderly man without urge incontinence who failed to empirical therapy, and impaired cognitive function should be referred.
Bibliography
Resnick NM. Urinary Incontinence. Lancet 1995; 346: 94-9.
Palmer RM. Ambulatory Management of Urinary Incontinence in The Elderly. Geriatrics 1990; 45: 61-6.
Ouslander JG. Incontinence. In: Hazzard WR, et al (eds). Principles of Geriatric Medicine and Gerontology. International Edition. New York, McGraw-Hill. 1994: 1229-50.
Van Der Cammen, Rai GS, Exton-Smith AN. Urinary Incontinence. In: Manual of Geriatric Medicine. Singapore. Churchill Livingstone, 1991: 254-63.
Mc Guire EJ. Identifying and Managing Stress Incontinence in The Elderly. Geriatrics. 1990; 45: 44-52.
Moody M. Incontinence. Patient Problems and Nursing Care, Heinemann Nursing, Oxford, 1990.
Clinically, urinary incontinence can cause redness (rash) on the perineum, decubitus ulcers, urinary tract infections, even urosepsis, falls, and fractures. Psychosocial, urinary incontinence is associated with embarrassment, stigmatization, isolation, depression, and the risk of care (institutionalization).
Although elderly patients often neglect urinary incontinence and regarded as a normal part of the aging process, urinary incontinence is something abnormal at all ages, and can be treated and often curable, even at a very advanced age. However the way, successful management requires understanding the impact of normal aging and factors outside the urinary tract to the urogenital system.
At all ages, incontinence depends on adequate mobility, mental status, motivation, and the function of the lower urinary tract. Although urinary incontinence in younger patients are rarely associated with a deficit outside the urinary tract, such a deficit is common in elderly patients. This deficit is very important to detect because it can cause incontinence and interventions may not be effective until the problem outside the urinary tract is settled.
Lower urinary tract changes with age, although without any illness. Bladder capacity, contractility, and the ability to withstand urination decreased in elderly men and women, while strength and long time close the urethra, decreased along with increasing age in women. Enlarged prostate in most men that often cause obstruction. In men and women, the prevalence of bladder contractions increased, whereas the residual volume after voiding increased to 50-100 ml. In addition, most of the elderly are often excrete fluid intake at night, although did not have kidney disease, peripheral edema and prostatism. These changes improve sleep disorder, causing urination 1-2 times at night in most healthy elderly.
Urinary Incontinence Evaluation in Elderly Patients
The purpose of evaluation are:
1. Identify whether urinary incontinence occur temporary or permanent.
2. Assess the patient's environment.
3. Knowing the support available for patients.
4. Detect conditions that are rare but serious that may underlie the occurrence of urinary incontinence such as lesions in the brain and spinal cord, bladder or prostate carcinoma, bladder stones, hydronephrosis, bladder decreasing resistance and detrusor dyssynergia.
Systematically by anamnesis, physical examination and then by investigation sought above factors. In the anamnesis also evaluated the pattern of fluid intake of patients, medications are taken (diuretic, psychotropic, anticholinergic), certain diseases (diabetes mellitus, stroke, dementia, etc.) and symptoms related to urinary tract (dysuria, urinary disorders)
All time urination and the amount of urine, and the incidence of urinary incontinence noteworthy for 2-7 days. These records can provide valuable diagnostic key. For example, incontinence that occurs only between the hours of 8:00 to noon, probably caused by diuretics are taken in the morning.
Physical examination includes examination of the abdomen, rectum, and genitals to look for an enlarged prostate or bladder or sacral nerve disorders. In patients who are already frail elderly, to consider the status of mobility and mental status, because it is associated with the occurrence of urinary incontinence. Bladder palpable on physical examination may indicate overflow incontinence due to obstruction of the bladder, or bladder not contraction. Large cystocele showed stress incontinence, perianal hypesthesia indicate overflow incontinence due to sacral denervation. The existence of parkinsonism or a history of stroke directs the possibility of an urgency incontinence due to bladder instability.
The following approach may be relatively non-invasive, accurate, cost-effective and well tolerated. The first stage is to identify the type of overflow incontinence (residual urine greater than or equal to 450 ml), when clinically appropriate, the patient may be referred to a urologist and can be catheterized. Because the obstruction is rare in female patients, diagnosis is generally between stress incontinence or detrusor overactivity. Leakage due to stress or pressure to look for examination by asking questions to the patient, if the patient is elderly woman felt that her bladder was full, asked to rest and cough strongly immediately, so that leaks can be readily observed. Not only regular leakage during stress maneuvers performed is strong evidence that it was not a stress incontinence.
In men, the type of stress urinary incontinence is rare. The problem is usually encountered distinguish detrusor overactivity with obstruction. The next stage is to look for the possibility of hydronephrosis in men with residual urine exceeds 200 ml, and refer to or empty the bladder (decompression). When hydronephrosis was not found but there is obstruction, the patient referred for the possibility of surgery. For another, in patients with symptoms of urge incontinence, allegedly due to detrusor overactivity can be given the treatment. Medications to relax the bladder should be avoided in patients with residual urine of 150 ml or more. The same approach is also recommended in patients with cognitive impairment can be observed closely. Patients elderly man without urge incontinence who failed to empirical therapy, and impaired cognitive function should be referred.
Bibliography
Resnick NM. Urinary Incontinence. Lancet 1995; 346: 94-9.
Palmer RM. Ambulatory Management of Urinary Incontinence in The Elderly. Geriatrics 1990; 45: 61-6.
Ouslander JG. Incontinence. In: Hazzard WR, et al (eds). Principles of Geriatric Medicine and Gerontology. International Edition. New York, McGraw-Hill. 1994: 1229-50.
Van Der Cammen, Rai GS, Exton-Smith AN. Urinary Incontinence. In: Manual of Geriatric Medicine. Singapore. Churchill Livingstone, 1991: 254-63.
Mc Guire EJ. Identifying and Managing Stress Incontinence in The Elderly. Geriatrics. 1990; 45: 44-52.
Moody M. Incontinence. Patient Problems and Nursing Care, Heinemann Nursing, Oxford, 1990.
