About: One Out of Two Older Americans Is Incontinent
MD News, November/December 2006
By: Raymond A. Bologna, M.D.
One of the top reasons older Americans end up in a nursing facility is lack of bladder control. What typically happens is that the person falls and sustains an injury during the night, because they get up frequently to urinate or have an accident. In fact, more than 50% of nursing facility admissions are related to this problem.
The annual cost for caring for incontinence in nursing facilities is estimated to be more than $5 billion dollars. That number doesn’t account for costs associated with purchasing absorbent pads and diapers, which costs an individual thousands of dollars per year. Nor does it account for the loss of self-esteem. The question is this: Can we improve the quality of life for these older Americans and potentially avoid the consequences of lack of bladder control like falls, fractures, and nursing home admissions?
Women should not accept this as normal part of having children or aging.
The most common forms of bladder control seen in women are overactive bladder (urinary frequency and urgency) urge incontinence and stress urinary incontinence. Urinary urgency and urge incontinence tend to be the most troublesome. Evaluation begins with a history, voiding diary and physical exam.
The history and voiding diary provide insight into the patient’s fluid intake, bowel habits and previous continence procedures. On examination, an evaluation of estrogen status, prolapse, and post-void residual may lead to treatment options. Urine cultures and cytology are routinely sent as well. An older woman’s only symptom of a urinary tract infection often is worsening bladder control. Further evaluation and testing can be done with cystoscopy and urodynamics.
There are many treatment options for overactive bladder, urgency, and urge incontinence. In many cases the goal is simply to give them a little more time to get to the bathroom. A recent study demonstrated a 57% reduction in incontinence episodes with behavioral modification and pelvic floor therapy. Obviously, this has to be a motivated patient. Many of these patients can also benefit from timed voiding and a reduction in bladder irritating fluids.
Multiple anticholinergic medications are available to reduce the number of urge incontinent episodes. The side effect profile is a concern with our older population, particularly the impact on cognition. Current research is available demonstrating that the more recent anticholinergics may have a less negative affect on cognitive ability.
When conservative treatments fail, InterStim® is an option. InterStim, by Medtronic, is a pacemaker-like device that is implanted as an outpatient procedure in two stages. During the first stage, a lead or small wire is percutaneously positioned near the S3 nerve root via the S3 foramen. The patient goes home with an external generator and their progress is tracked for two weeks. If they have had a greater than 50% improvement in their symptoms, they return for implanting the generator. This has been a well tolerated by our older patients and has significantly benefited all age groups.
For patients with stress incontinence and or prolapse, multiple conservative or minimally invasive procedures are available. Many patients will experience improvement with a pessary. Out patient procedures are now available for the treatment of both stress incontinence and prolapse. This has reduced the surgical risks and benefited all women.
It is not just a prostate problem.
At age 68, the number of men with voiding dysfunction equals the number of women. Beyond age 70, the percentage of men with urinary frequency, urgency, urge incontinence and nocturia becomes greater than women. Male voiding dysfunction is no longer just a prostate issue. The challenge for the health care provider is to determine if the male patient has a prostate problem, bladder problem or both. Men usually present with the compliant of urinary urgency, urge incontinence, nocturia and frequency.
The differential diagnosis includes benign prostatic hypertrophy (BPH), prostatitis, urethral stricture, bladder stone, bladder cancer or an overactive bladder (OAB). The initial urologic evaluation includes a urinalysis, cytology, urine culture and PSA. The examination includes a digital rectal exam (DRE), ultrasound post-void residual and often cystoscopy. Assuming a normal urinalysis, cytology, culture and PSA, the diagnosis is usually between BPH and OAB.
Men with symptomatic BPH typically will have an elevated post-void residual and prostatic enlargement on examination and cystoscopy. Urodynamics can help further delineate BPH versus OAB.
First-line therapy for BPH includes Saw Palmetto, alpha-blockers and 5-alpha reductase inhibitors. The mechanism of action of Saw Palmetto is proposed to include anti-inflammatory activity, blocked conversion of testosterone to dihydrotestosterone (DHT), and prostate epithelial involution similar to effects noted with the use of finasteride (Proscar). Alpha blockers such as tamsulosin (Flomax), alfuzosin (Uroxatrol), doxazosin (Cardura) and terazosin (Hytrin) work by relaxing the smooth muscle around the bladder neck and prostate allowing men to urinate easier. Finasteride (Proscar) and dutasteride (Avodart), 5-alpha reductase inhibitors, lower the levels of DHT (dihydrotestosterone), which is a major cause of prostate growth. Lowering DHT leads to shrinkage of the enlarged prostate gland. Decrease in prostate size and improvement in symptoms may take a minimum of six months. Surgical treatment includes minimally invasive therapies such as transurethral microwave or needle ablation of the prostate; the traditional TURP is being replaced by surgical laser therapy.
Once it is identified that a patient does not have a significantly elevated post void residual and no sign of a urinary tract infection or prostatitis, many of these men may be suffering from OAB. The treatment options for men with OAB are the same as women. Behavioral modification and a reduction in caffeine and alcohol may improve symptoms. Anticholinergics include oxybutinin (Ditropan XL, transdermal oxybutinin, Oxytrol), tolterodine (Detrol LA), darifenacin (Enablex), solifenacin (VESIcare), trospium (Sanctura).
All of these agents are directed towards reducing the frequency and strength of the inappropriate bladder muscle contraction. Studies have shown no significant increase in post void residual with anticholinergics; however, it’s important to discuss this possibility with patients. When conservative measures fail other options are available for OAB.
Like with female patients, InterStim therapy is effective for men with overactive bladder and non-obstructive urinary retention. Botox is now in trials for both OAB and BPH either injecting into the bladder or the prostate. The current trials will provide insight on effectiveness and duration of improvement in symptoms.
Male voiding dysfunction provides a unique challenge, particularly in identifying if the symptoms are due to a prostate problem, bladder issue or both. Fortunately, there is testing available such as urodynamics to provide valuable information and multiple treatment options both pharmacologic and minimally invasive for both disease states.
It’s clear that taking action to address this highly treatable disorder is an important step toward improving quality of life and reducing the number of older Americans in assisted living and nursing home facilities.