R e v i e w A r t i c l e U r in a r y In c o n t in e n c e w it h S pe c ia l R e f e r e n c e to t h e G eriatric Pa tien t PAPADOPOULOS M, MSc Physio (WITS)' JORDAAN R, M Physt (UP)2 1 Department of Physiotherapy, University o f Pretoria Department of Physiotherapy, University of Pretoria A B S T R A C T : P roblem s involving the urinary tract, p a rticu la rly urinary incontinence, tend to become more common with age. Urinary incontinence is a prevalent problem in the elderly and its medical, social and economic costs are significant. Patients are often too embarrassed or unwilling to seek treatment, as it is often seen as an inevitable corollary o f old age, as it is not considered a life threatening ailment and also because they assum e that it is untreatable. The p h ysio th era p ist can p la y a very im p orta nt role in both the p reven tio n a n d m a n ag em en t o f in co n ti­ nence, but sadly, very fe w p hysio th era p ists are p rep a red to take this challenge. The aim o f this review is to provide inform ation, w ith specific reference to the elderly, regarding the prevalence, risk fa c to r s a n d causes o f incontinence. The history a n d exam ining o f the inco ntinen t p a tie n t are d iscu ssed a n d m a n ag em en t o f the different types o f inconti­ nence are m entioned. K E YW O R D S: U R IN A R Y IN C O N TIN E N C E , ELDERLY, P H Y SIC A L T H E R A P Y INTRODUCTION AND BACKGROUND Problems involving the urinary tract, particularly urinary incontinence, tend to becom e more com m on with age (Koyama et al, 1998). Older women experience this problem , as chronic m edical conditions accum ulate and functional impairments interact with age related changes in organ systems, in muscle resilience, and in the central ner­ vous system (Turner & Plymat, 1988). Lower urinary tract dysfunction such as urinary incontinence result in irritative or obstructive symptoms that can inter­ fere with everyday functioning, leading to negative consequences on health related quality of life (Naughton and Wyman, 1997). Patients are often too embarrassed or unwilling to seek treatment, as it is often seen as an inevitable corollary of old age, as it is not considered a life threat­ ening ailment and also because they assume that it is untreatable (Koyama et al, 1998; Chambers, 1998). Despite the considerable prevalence, morbidity and expense, incontinence is neglected by patients and caregivers alike (Branch et al, 1994). This is unfortunate because regardless of an individual’s age, m obil­ ity or mental status, incontinence is never normal (Herzog & Fultz, 1990) and it can be cured or improved in most patients (Resnick, 1996). With the number of elderly increasing in the population, there is a great need for preventative action as well as the management of urinary incontinence. With the increased emphasis on wo­ m en’s health in South Africa, there is a greater awareness for the need o f under­ standing and advice in dealing with incontinence at training institutions. The aim of this review is therefor to provide information, with specific refer­ ence to the elderly, regarding the preva­ lence, risk factors and causes of inconti­ nence. The history and examining of the incontinent patient will be discussed and management of the different types of incontinence will be mentioned. DEFINITION OF TERMS In order to understand urinary inconti­ nence and factors that can influence it, it is important to define the different types of urinary incontinence. These types may be found in isolation or in com bi­ nation with each other. The International Continence Society (ICS) established a committee for the standardisation of ter­ minology of lower urinary tract function in order to compare results of investiga­ tors. The ICS defines urinary inconti­ nence as urine loss that is a social or hygienic problem and which is objec­ tively dem onstrable (Abram s et al, 1990). Urinary incontinence has been classified by Turner and Plymat (1988), as either acute or transient, and estab­ lished. Acute or transient refers to sud­ den onset, usually related to an episode of acute illness such as urinary tract infection, or secondary to environmental factors that impair the individual’s abili­ ty to get to a toilet. Established inconti­ nence is often categorised into 5 types: stress, urge, combined stress/urge, over­ flow and functional incontinence. Stress urinary incontinence (SUI) Stress incontinence indicates the patient’s statement of involuntary loss of urine during physical exertion. An increase in intra-abdominal pressure is normally transmitted across the bladder wall, leading to an increase in intra­ vesical pressure. Women with SUI have a dam aged urethral sphincteric mechanism that is unable to cope with the rise of pressure inside the bladder. Any transient rise in intra-abdominal CORRESPONDENCE: Mrs M Papadopoulos Department of Physiotherapy University of Pretoria PO Box 667 Pretoria 0001 Tel: (012) 354-2023 SA J o u r n a l o f Physiotherapy 1999 \ ( o l 55 No 3 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pressure seen with coughing, laughing or physical exercise, therefor leads to an involuntary loss of a small volume of urine (Gupta et al, 1998; Turner & Plymat, 1988; Iqbal & Castleden, 1997). Genuine stress incontinence (GSI) is defined as the involuntary loss of urine occurring when, in the absence of detrusor con­ traction, the intravesical pressure exceeds the maximum urethral pressure (Abrams et al, 1990). Urge incontinence or detrusor instability (Ul) Urge incontinence (UI) or detrusor instability is defined as the involuntary loss of urine, which is preceded by a sudden strong desire to void and may occur during day or night (Iqbal & Castleden, 1997). The unwanted and untimely contraction of smooth muscles of the bladder cause rise in intravesical pressure that overcome even a normal urethral sphincteric m echanism . The detrusor contraction causes a sense of urgency and the urine loss is uncontrol­ lable (Gupta et al, 1988). Combined stress / urge incontinence This is the presence of both stress and urge incontinence together (Turner & Plymat, 1988). Overflow incontinence Overflow incontinence is any involun­ tary loss of urine associated with over distension o f the bladder. It is common­ ly seen in men with outflow obstruction due to prostate hypertrophy. Other caus­ es are anticholinergic drugs and neuro­ logical conditions leading to poor blad­ der contraction such as diabetic auto­ nomic neuropathy (Turner & Plymat, 1988; Gupta et al, 1988). Functional incontinence In functional incontinence the urethra and bladder are normal, but the patient is unable to get to the toilet due to mental or physical disabilities (Iqbal & Cast­ leden,1997; Turner & Plymat, 1988). PREVALENCE OF URINARY INCONTINENCE Urinary symptoms are very common in the healthy population and estimates of the prevalence vary, depending on the sample investigated (Johnson & Busby- W hitehead, 1997). Urinary incontinence affects 15% to 30% of the population and for unique physiologic reasons, incontinence is twice as prevalent in women as in men. The most prevalent form of urinary incontinence among women is stress incontinence (Bergh- mans et al, 1996). Urinary incontinence is common in patients with dementia and is more prevalent in demented than in non-dem ented older individuals (Skelly & Flint, 1995). Thomas & Plymat (1980) demonstrated a gradual increase in the prevalence of incontinence with age, with approxi­ mately 40% of women in their eighties suffering from the condition. Robinson (1997) agrees with the fact that the prevalence of incontinence increases with age and with declining health. According to Thom (1998) the estimated prevalence of urinary incontinence for elder women range from 17 to 55% (median =35%). Burgio et al (1991) further mentioned that there is a higher prevalence of urinary incontinence am ongst white wom en than other races. Walters et al (1993) also found that urinary incontinence is not frequent amongst Chinese, Eskimo and black women. More research regard­ ing the influence of race on urinary incontinence needs to be undertaken. Thom (1998) concluded that an accurate estimate of the prevalence of urinary incontinence depends on specifying the definition of incontinence, the age and gender of groups studied. RISK FACTORS AND CAUSES ASSOCIATED WITH GERIATRIC INCONTINENCE Understanding the specific remediable risk factors for incontinence is paramount to prevention (Rosenthal & McMurtry, 1995). E stablished risk factors are advanced age, gender and parity (Barret & Wein, 1991). Because age and disease affect both urinary tract function and compensatory mechanisms, any additional drug or dis­ ease, even outside the urinary tract, can precipitate leakage. There are condi­ tions, which may worsen or precipitate incontinence in someone who was just managing. These include urinary infec­ tion, oestrogen deficiency, increased solute load as in diabetes mellitus and uraemia and drugs like diuretics, seda­ tives and antidepressants (Iqbal & Castleden, 1997). Thus, the cause of incontinence must be viewed differently in older and younger individuals. The causes of geriatric incontinence are divided into those lying outside the urinary tract and those within it. Causes outside the urinary tract generally pro­ duce transient incontinence and respond to treatm ent o f the external factors, while those within the urinary tract pro­ duce established incontinence (Resnick, 1996). Rosenthal & McM urtry (1995) m entioned that transient causes of incontinence that should be explored in all patients include delirium, restricted mobility and retention, infection, inflam­ mation, faecal impaction, polyuria and pharmaceuticals (see table I). Age related anatomic and physiologic changes associated with incontinence With age, bladder capacity declines, residual urine volumes increase, involun­ tary bladder contractions are common, mobility is more likely to be impaired and sex-specific changes occur. In women, there is a decline in bladder out­ let and urethral resistance secondary to the influence on pelvic musculature of diminished levels of circulating oestrogen TABLE 1: DRUGS THAT MAY AFFECT CONTINENCE Antipsychotic agents - (anticholinergic and sedating) Antihistamines - (very anticholinergic and sedating) Antidepressants - (most anticholinergic and sedating) Decongestants - (may cause urinary retention by acting on alpha and beta receptors) Diuretics - (may overwhelm older person's ability to toilet) Antihypertensive Alcohol 16 SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 2: AN EXAMPLE OF A VOIDING DIARY TIME WET DRY VOLUME VOIDED COMMENTS 6 H 0 0 W 300ml Leaked on w ay to bathroom 7H 00 D - - 8H 00 D 80ml - 9H 00 w - - 10H 00 w 50ml Soaked on w ay to bathroom 11H 00 D - 12H 00 D - 13H 00 w 350ml Wet with coughing (Rosenthal & McM urtry, 1995). W hen oestrogen levels decline, women are also at risk for developing atrophic vaginitis, which in itself may cause dysuria, urgency and urinary tract infections (Williams & Pannill, 1982). In men, the well-known and nearly inescapable phe­ nomenon of prosthetic enlargement can lead to decreased flow rates, destrusor instability and overflow incontinence (Rosenthal & McMurtry, 1995). The elderly are prone to functional incontinence, since impairment of daily activities such as the ability to transfer, walk dress and toilet, increases with age. McGrother et al (1990) mention that this is a common cause of urinary inconti­ nence, occurring in up to one fifth of patients (Rosenthal & McMurtry, 1995). It should however be remembered that even in functionally impaired individuals, incontinence may be due to uretheral obstruction or stress incontinence (Res­ nick et al 1989). Resnick et al (1995) and Resnick et al (1989), mentioned further that normal lower urinary tract function is the exception in even healthy and continent elderly individuals and is rarely found in functionally impaired individuals, thus viewing functional impairment as a contributor to inconti­ nence rather than a cause. A compre­ hensive rehabilitation programme aimed at addressing functional impairment and the use of continence aids should be tried in all such patients. HISTORY AND PHYSICAL EXAMINATION The path towards diagnosis begins with the taking of a comprehensive history. This should document all urinary symp­ toms, past medical and surgical prob­ lems, past gynaecological and obstetric history, any intercurrent medical disorder and social and sexual history. Patients should be asked about the length of the time they have had incontinence and the mode of onset, as there may be a clear association with an event such as an operation, stroke, and onset of diabetes mellitus or prescription of a drug. The severity is important because it allows the investigator to judge the seriousness of the condition and its impact on the patient’s social life and sexual relation­ ship. The amounts of tea, coffee, choco­ late, fizzy drinks, citrus juices, alcohol and other fluids consumed in a 24-hour period should be noted. Also important is the obstetric/gynaecological, medical and drug history (Iqbal & Castleden, 1997). The voiding diary (see table 2) com ­ plements the history and often proves useful when devising therapy. These diaries give information on drinking and voiding behaviour, number of pads used, frequency of voiding and amount of involuntary urine loss (Resnick, 1996). A careful physical examination should then be carried out, after which the need for further investigation may be assessed. Intensive investigation is not required in all cases, but treatment with­ out knowing the underlying pathology can result in a despondent patient. In all conditions, certain basic investigations, such as sending a mid-stream specimen of urine for culture, should be performed prior to treatment (Cardozo et al, 1993). Physical examination The skin in the groin and around the external genitalia should be assessed for redness, soreness, excoriation and m onilia infection. Palpation may reveal bladder, uterine or ovarian masses. Rec­ tal examination assesses the size of the prostate, presence or absence of faecal impaction, the anal sensation and tone. Vaginal examination may reveal atro­ phic vaginitis, prolapse or fistulae (Iqbal and Castleden, 1997). Pelvic floor strength, graded from O to 3, should be assessed by the squeeze felt on vaginal examination with the patient trying to contract the paravaginal muscles (Worth et al, 1986). A perineo- meter can be used to get an objective recording of pelvic m uscle strength (Cardazo et al 1993). It should be noted that the severity of GSI depends not only on the condition of the pelvic floor, but also on the posture, respiration, move­ ment as well as the general physical and psychological condition (Wells et al, 1991; Tapp et al, 1989). Tests for hearing, eyesight and mental state also give an indication of compliance with instruc­ tion (Iqbal & Castleden, 1997). MANAGEMENT OF URINARY INCONTINENCE As the causes of geriatric incontinence are usually m ultiple, concurrent, and extend beyond the urinary tract, the therapeutic approach m ust as well. T reatm ent program s should also be individualised. Stress incontinence Conservative treatment is the method of first choice and includes one or more o f the following options: pelvic floor exercises, vaginal cones, electrical sti­ mulation with or without biofeedback and hormone replacement therapy (Iqbal & Castleden, 1997). Therapy further in­ cludes weight loss if the patient is obese, treatm ent of precipitating conditions such as cough, instruction in physical manoeuvres (Norton & Baker, 1995) SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) and rarely insertion of a pessary (Suarez et a/,1991; Zeitlin & Lebherz, 1992). Pelvic floor exercises and vaginal cones Pelvic floor exercises described first by Kegel in 1948, are designed to improve the strength of the pelvic floor m uscula­ ture and thereby the urethral sphincter functions (Iqbal & Castleden, 1997). Pelvic floor exercises are low-risk inter­ ventions and effective in the reduction of involuntary loss of urine in patients with SUI. Plevnik (1985) m entioned that vaginal cones can be used to educate women on the contraction of their pelvic floor muscles. By gradually increasing the weight, the strength of the pelvic floor contractions will increase. Wilson & Herbison (1995) concluded that pelvic floor exercises, properly taught, are still the mainstay of physiotherapy in the treatment of SUI. Electrical stimulation and biofeedback Interferential therapy entails electrical stimulation of the pelvic floor muscles through an electrode placed in the vagina or rectum. It can be used alone or in combination with traditional pelvic floor exercises (Wilson & Herbison, 1995). An incontinent patient can be taught, with the aid of biofeedback, to be selec­ tive in the use of the pelvic floor mus­ cles. Bump et al (1991) have found that approximately 30% of women are unable to perform an isolated pelvic contraction following written or verbal instruction. It is hypothesised that in pelvic floor re-education, biofeedback will enhance the effect of the exercise programme and im prove m otor unit recruitm ent and functional activity (Knight & Laycock, 1994). Berghams et al (1996) concluded in his study that adding biofeedback to pelvic muscle floor exercises might be more effective than pelvic floor muscle exercises after 6 months. Hormone replacement therapy Oestrogen have been used for some time for the treatment of patients with stress incontinence. A recent m eta-analysis has shown that although oestrogen may pro­ duce a subjective improvement in uri­ nary incontinence, objective evidence for improvement is not convincing (Fantl et al 1994). Urge incontinence (detrusor instability) Bladder drill and adherence to a voiding schedule is the mainstay of treatment in patients with Ul, providing that they understand and comply with the regi­ men (Jarvis & Millar, 1980). Pelvic floor muscle exercises may also be beneficial in this group o f patients (Rosenthal & McMurtry, 1995). There are many drugs (eg atropine sulphate, diphenhydramine etc) which have been shown to be effective in some patients with detrusor instability, although none of these drugs have been shown to be convincingly better than the others (Baigrie et al, 1988; Robinson and Castleden, 1994). These medications may have other adverse anti-cholinergic effects, such as dry mouth, constipation, blurred vision and confusion, which may have other detrimental effects on the geriatric patient. Overflow incontinence The cause determines the treatm ent of this problem. If obstruction is present, surgery (eg prostatectomy) is usually indi­ cated (Rosenthal & McMurtry, 1995). Patients should however not be rushed into operations since many studies have shown that patients can happily wait many years before there symptoms require operation (Wasson etal, 1995; Ball etal, 1981). Alpha-blockers and s-alpha reduc­ tase inhibitors may be successful for patients w ith overflow incontinence due to prosthetic hyperplasia (Iqbal & Castleden, 1997). Other Surgical treatments have a limited role in the treatm ent of geriatric urinary incontinence. Patterns of problems exist with incontinence, including pelvic sup­ port defects and bowel and bladder dys­ function. Each of the major elements must be treated to achieve the best out­ comes. Urodynamic testing should be used to confirm the cause of inconti­ nence before selecting a surgical proce­ dure. M inim ally invasive procedures include periurethral collagen injections (Gallaway, 1997). R esnick (1996) m entioned that in the case of m edication causing the incontinence (see table I), it should be questioned why the patient was still on the drug and decided whether the m edi­ cation could be substituted or disconti­ nued. Medications that are very anti­ cholinergic such as diphenhydromine or amitriptyline hydrochloride, are frequent offenders and may be replaced by a drug that is better tolerated (Rosenthal & McMurtry, 1995). No known research exists on the influ­ ence of liquid intake versus the results of treatment (decrease of involuntary urine loss). According to Brink (1990), influ­ encing the liquid intake pattern is an important strategy in the decrease and elimination of incontinence, because of the relationship between liquid intake and urination. However, the biological plausibility and the causal link between liquid intake and the measure and fre­ quency of involuntary urine loss need to be further researched and proven (Bergh- mans et al, 1996). CONCLUSION U rinary incontinence is a prevalent problem in the elderly and its medical, social and economic costs are signifi­ cant. Incontinence may be transient or longstanding; reversible causes must be ruled out. When the type of incontinence is known, appropriate treatment may bring improvement in symptoms or a return to continence. The treatment of patients with urinary incontinence requires a planned approach after a history, physical examination and appropriate investigations. With a persistent, creative and opti­ mistic approach, most patients experience substantial improvement if not complete restoration of continence. There are significant short and long­ term benefits to the quality of life of older patients with incontinence when treated by conservative measures. To achieve satisfactory results from intervention (in the long term), informa­ tion and supervision by the physiothera­ pist throughout the process of therapy are essential, especially concerning the adequate use of the pelvic floor muscles and behaviour micturition. In order to achieve a permanent positive result from physiotherapy, patients have to incorpo­ rate the newly acquired abilities into daily life. 18 SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) REFERENCES A bram s P, B laivas JG, Stantan SL, Andersen JF (1990): T he standardisation o f term inology o f low er urinary tract function. British Journal o f Obstetrics and G ynaecology (Suppl) 6: 1-16. B aigrie RJ, K elleher JP, F aw cett DP, P en gelly AW (1988): O xybutynin: Is it safe? British Journal o f U rology 62: 3 1 9 -3 2 2 . 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SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )