Treatment of Overactive Bladder and Incontinence in

OVERACTIVE BLADDER AND URINARY INCONTINENCE

Treatment of Overactive Bladder and Incontinence in the Elderly Darshan Shah, MD, Gopal Badlani, MD Department of Urology, Long Island Jewish Medical Center, New Hyde Park, NY

The prevalence of urinary incontinence (UI) and overactive bladder rises with age, and elderly people are the fastest-growing segment of the population. Many elderly people assume UI is a normal part of the aging process and do not report it to their doctors, who must therefore make the effort to elicit the information from them. Coexisting medical problems in older patients and the multiple medications many of them take make diagnosis and treatment more complex in this population. Just as the etiology of incontinence is often multifactorial, the treatment approach may need to be multipronged, with behavioral, environmental, and medical components; in any case, it must be targeted to the individual patient. New, less-invasive surgical techniques and devices make surgery more feasible if other therapy fails. [Rev Urol. 2002;4(suppl 4):S38–S43] © 2002 MedReviews, LLC

Key words: Geriatrics • Overactive bladder • Urinary incontinence

he percentage of the population over age 65 has increased dramatically over the past 100 years and is expected to continue to increase well into the 21st century. Furthermore, the segment of this population with the greatest need for health care, those age 85 and older (the “oldest old" or “frail elderly"), is predicted to undergo a rapid expansion, from 10% to 19% by the year 2040.1 The lower urinary tract consists of a group of interrelated structures that function in the adult to bring about efficient and low-pressure bladder filling and low-pressure urine storage with perfect continence. In healthy people, periodic

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voluntary urine expulsion occurs at low pressure. (The definition of low pressure varies widely and differs for men, women, and elderly people.) Urinary dysfunction is the most prevalent problem in the geriatric population, particularly among those admitted to nursing homes (with a prevalence estimated up to 67%). Most urinary dysfunction in the elderly is attributable to lower urinary tract disorders, with incontinence the predominant symptom. Incontinence alone has been shown to occur in up to 30% of the community-dwelling and 50% of the institutionalized elderly.2,3 Overactive bladder (OAB) has

alleviated, provided the type of incontinence present and its cause are determined. Treatment strategies that are effective in the population at large require significant modification in the elderly. Recognizing the problems faced in the treatment of the elderly forms the basis of a successful strategy.

Assessment Difficulties Underreporting The elderly are notorious for underreporting of their incontinence. Experience has shown that the elderly often regard certain symptoms as normal consequences of the aging

Treatment strategies that are effective in the population at large require significant modification in the elderly. the symptom complex of frequency and urgency, with or without incontinence, and is common, with almost equal incidence in men and women even after controlling for pathologic and metabolic conditions that can cause OAB-like symptoms. This new finding supports the idea that OAB should not be overlooked in men and is not only a women’s health issue. The prevalence of OAB without incontinence in elderly women increases slower than that in men. Conversely, the prevalence of OAB with incontinence increases sharply after age 35 years in women, while it increases gradually with age in men.4 The term elderly is ill defined. A 70-year-old community-dwelling, independent individual is in a significantly different category from that of a frail elderly individual of 85 living in a nursing home. There is a whole spectrum in between. The majority of the elderly patients having OAB and urinary incontinence (UI) are effectively treated and/or have their symptoms

process, and it is therefore prudent to probe beyond the evaluation of the chief complaint. In the case of the elderly patient who is unable to adequately relate his or her symptoms as a consequence of dysarthria or aphasia secondary to a dominant hemispheric stroke, dementia, or an organic brain syndrome, it is much more useful to interview the primary caregiver, such as an aide or relative, to help complete the historical picture. Technical Difficulties in Urodynamic Studies Most urodynamic studies are performed when the patient is awake, to allow direct patient assessment of the sensations of filling and urge to void. Sound orientation, good cognition, and active patient participation during the urodynamic studies are required for precise diagnosis of the cause. This may not be feasible in some elderly patients. Thus, studies may need to be repeated, or treatment may need to be initiated based on partial information.

Difficulty in Interpretation of Findings When interpreting urodynamic data in the elderly patient, it is important to realize that normal age-related physiologic changes may significantly alter the measured urodynamic parameters; which may be present independently of the patient’s presenting symptoms. Several normal age-related changes occur in the lower urinary tract,5 including the development of uninhibited detrusor contractions in at least 10% of women and 25%–35% of men; an increase in nocturnal fluid excretion; prostatic enlargement in men; urethral shortening and sphincter weakening in women; a decrease in bladder capacity in both sexes; and possibly a decrease in detrusor contractility. General Condition of the Patient OAB with or without incontinence is considerably more common among men and women with cancer, diabetes, congestive heart failure, or neurogenic disorders.6 Associated illnesses, comorbidities, vision loss, decreased hand dexterity, memory loss, cognitive dysfunction, or use of medication for other health problems make assessment and therapy more complex. Multifactorial Etiology In addition to anatomic and physiologic changes in elderly patients leading to voiding dysfunction, the multiplicity of conditions that can affect the lower urinary tract confuses the picture. Thus, coexisting cerebrovascular accident and bladder outlet obstruction secondary to benign prostatic hypertrophy (BPH) can both lead to OAB; separation of the two requires sophisticated urodynamic techniques such as micturating urethral pressure profile.5 Detrusor instability and stress UI in females is another example. The most difficult to correctly diagnose and treat is detrusor hyperactivity with impaired contractility (DHIC).7


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Treatment of OAB and Incontinence in the Elderly continued

Treatment Strategies Transient Incontinence Incontinence secondary to transient causes is present in 33% of community-dwelling elderly people and in more then half of patients who are hospitalized.8 The reversible or transient causes of incontinence can be recalled using the mnemonic DIAPPERS.5 Delirium- and confusion-related incontinence needs treatment of the underlying cause of the confusional state, and the patient needs medical rather than bladder management.5 Symptomatic urinary tract infection (UTI) causes urgency, dysuria, and incontinence mainly in the elderly. Asymptomatic bacteruria does not cause incontinence.9 In atrophic vaginitis and urethritis, incontinence is usually associated with urgency and occasionally a sense of scalding dysuria. Low-dose estrogen (eg, 0.3–0.6 mg of conjugated estrogen per day orally or vaginally) relieves vaginal dryness and atrophy, but patients need concomitant behavioral therapy or anticholinergic drugs for their urge incontinence. Among women assigned to treatment with hormone therapy alone, incontinence was more likely to worsen and less likely to improve than among women assigned to placebo.10 Pharmaceuticals associated with UI include sedative-hypnotics, diuretics, and anticholinergic and adrenergic agents. The drug may have to be discontinued and/or the patient switched over to a similar agent with fewer side effects affecting the urinary tract.11 Psychological causes of incontinence, seems to affect elderly less frequently as compared to younger individuals. Once the psychological disturbances (depression, life-long neurosis, etc) has been treated, persistent incontinence needs further evaluation. Excess urine output secondary to excessive fluid intake, diuretics, or metabolic abnormalities

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(hyperglycemia and hypercalcemia) can lead to frequency. Disorders associated with fluid overload (eg, congestive heart failure, hypoalbuminemia, drug-induced peripheral edema) and calcium channel blockers can cause incontinence in elderly individuals. Excess output is a likely contributor when incontinence is associated with nocturia. Restricted mobility is a very common cause of geriatric incontinence. Mobility restriction can result from many treatable conditions, such as arthritis, hip deformity, postural or postprandial hypotension, claudication, spinal stenosis, heart failure, poor eyesight, fear of falling, stroke, foot

and those who are not fit to undergo surgery, behavioral therapy and environmental changes may decrease the magnitude of symptoms.15 In habit training, or timed voiding, patients with UI attempt to void voluntarily on a schedule at predetermined intervals. Patient involvement and appropriate level of cognitive function is required in this therapy. In elderly people who are community dwellers, this program is easier to implement and has minimal side effects.16,17 An option in patients with poor cognition, memory loss, or impaired ability to initiate voiding voluntarily is prompted voiding, in which a caregiver prompts the

OAB with or without incontinence is considerably more common among men and women with cancer, diabetes, congestive heart failure, or neurogenic disorders. problems, and confusion.5 A careful search for and identification of these or other correctable causes can decrease urinary symptom scores. If not, a urinal or bedside commode may still improve or resolve the incontinence. Stool impaction stimulates opioid receptors,12 leading to urge and/or overflow incontinence. Typically there is associated fecal incontinence as well. Disimpaction restores continence. Behavioral and Environmental Changes Once the diagnosis is established, targeted therapy is initiated. Treatment for nocturnal polyuria, the most common complaint, includes evening fluid restriction, mid- to late afternoon or early evening diuretics, compressive stockings, and leg elevation throughout the day whenever patient is sitting.13,14 For elderly patients who do not have any evidence of sphincteric incontinence

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patient to void at specific time intervals. One can expect a 50% or more reduction in frequency of incontinence following prompted voiding treatment in elderly chronic care patients.18 This method is labor intensive, as stopping the intervention often leads to reversal of improvement. Patient-perceived improvement in one study was greatest for behavioral treatment (74% “much better" vs 50.9% and 2.9% for drug treatment and placebo, respectively). Only 14% of patients receiving behavioral treatment wanted to change to another treatment, versus 75.5% in each drug treatment and placebo group.19 When behavioral and drug therapy for urge incontinence were combined in older patients, additional benefit was noted, with improvement from a mean 57% reduction of incontinence with singlemode therapy to 85% reduction of incontinence with combined therapy.20


Pharmacologic Therapy Bladder suppressant medications are added only as necessary, to augment rather than supplant the toileting regimen. The urologist’s goal in treating OAB and incontinence in the elderly is to restore a socially acceptable level of urinary continence, requiring the minimal use of pads. Bladder contraction is a result of acetylcholine-induced stimulation of postganglionic parasympathetic muscarinic receptor sites in bladder smooth muscle. Atropine and atropinelike agents therefore depress involuntary contraction of any etiology.21 While none may be superior to propantheline for uninhibited contractions in vitro, they differ substantially in their side effects; propantheline may be the worst such agent for frail elderly patients because of its propensity to induce or exacerbate confusion.5 Immediate-release oxybutynin and imipramine have been well studied but still have side effects, such as moderate to severe dry mouth. Both once-daily controlled-release and immediate-release oxybutynin chloride yield reductions in urge incontinence and total incontinence episodes (statistically much better) compared to placebo. A lower incidence of dry mouth was reported for controlled-release than for immediate-release oxybutynin.22 Tolterodine, a new potent and competitive anticholinergic developed for the treatment of OAB, has been shown to be selective for activity in the bladder over the salivary gland in animal studies.23 A randomized, double-blind study comparing extended-release oxybutynin with immediate-release tolterodine for OAB concluded that “evaluation of efficacy indicated extended-release oxybutynin was statistically significantly more effective than tolterodine, also yielding fewer episodes of total incontinence and micturition frequency."24

In a study of healthy volunteers, oxybutynin caused demonstrable EEG changes compared to tolterodine and trospium chloride that caused no demonstrable changes.25 Cognitive impairment is a clinical concern with anticholinergics. Extended-release tolterodine has been shown to be marginally superior to immediate-release tolterodine, with further decline in dry mouth as a side effect.26 Many of these trials have had a limited number of patients more than 65 years of age and extremely small numbers in the frail elderly group. Thus, the theoretical benefits of once-daily preparations are not well established in elderly population. In elderly women with mixed UI, imipramine or phenylpropanolamine hydrochloride–guaifenesin increase bladder outlet resistance; imipramine has an additional effect of increasing bladder capacity.21 However, their use

ing the post-void residual volume, eliminating hydronephrosis (if present) and preventing urosepsis. For patients with retention > 600 mL, an indwelling catheter is used to decompress the bladder for 7–14 days, while potential contributing factors to impaired detrusor function (eg, fecal impaction, drug adverse effects) are eliminated. If the decompression does not fully restore bladder function, augmented voiding techniques (double voiding or implementation of Crede’s maneuver or the Valsalva maneuver during detrusor contraction) may help. Bethanechol 40–200 mg/day orally in divided doses is occasionally useful for a patient whose bladder contracts poorly due to use of an anticholinergic drug that cannot be discontinued. Residual volume should be monitored so that bethanechol can be discontinued if ineffective.27 In our experience, bethanchol chloride is not efficacious

When behavioral and drug therapy for urge incontinence were combined in older patients, additional benefit was noted. may be limited in patients with hypertension and arrhythmias. Pharmacologic treatment in elderly patients predominantly having nocturnal polyuria consists of oral or intranasal antidiuretic hormone with caution. Close monitoring of serum electrolytes for hyponatremia is mandatory. Antidiuretic hormones are not to be given to elderly patients with a history of congestive heart failure. Regardless of the drug employed, the general principle for pharmacologic treatment of the elderly patient is to start with a low dose and increase it slowly, based on an understanding of the agent’s pharmacokinetics and pharmacodynamics. For DHIC, the treatment is individualized. Therapy is directed at reduc-

for improving bladder emptying in DHIC. If the detrusor is acontractile after decompression, any intervention is likely to be futile, and the patient should undergo clean intermittent catheterization or have an indwelling urethral catheter placed. Antibiotic prophylaxis against UTI is probably warranted, with intermittent catheterization, if the patient has frequent symptomatic UTIs or has an abnormal heart valve or an orthopedic prosthesis; such prophylaxis is not useful with indwelling catheterization. If intermittent catheterization is performed in an institutional setting, a sterile rather than a clean technique should be used because of the prevalence and virulence of bacteria in such a setting.28


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Treatment of OAB and Incontinence in the Elderly continued

Surgical Management Surgical management of UI in the elderly can play a role when medical and behavioral treatment fails. The surgical approach in the elderly is based on the patient’s and/or the family’s wishes and the patient’s mental status; it may involve modification of standard surgical techniques to decrease invasiveness, decrease length of hospitalization, decrease anesthesia use, and hasten

used for up to 30 days. The Conticath allows voiding with much less discomfort, and there are few contraindications to its use. Its use is overstated as only one trial demonstrated efficacy in acute retention and not in chronic retention. Additionally, in these highrisk patients, a permanent prostatic stent can be used. The UroLume30 (permanent stent) functions similarly to the temporary stent and can be placed with the patient under local

If intermittent catheterization is performed in an institutional setting, a sterile rather than a clean technique should be used because of the prevalence and virulence of bacteria in such a setting. recovery. These factors override the goal of long-term success. Anesthesiologists recommend waiting 3–6 months after a hemorrhagic stroke before giving elective general or regional anesthesia. Elderly patients receiving antiplatelet therapy or anticoagulants should have these medications stopped 7 days before the day of surgery and restarted 24–48 hours after surgery. Detrusor overactivity in elderly males can be due to the normal aging process, or it may be secondary to outflow obstruction or neurologic causes. Urethral obstruction in the elderly can be treated as in young patients. Alpha-adrenergic receptor antagonists can be used safely even in debilitated nursing home patients with cardiovascular disease. The quicker operative procedures, such transurethral incision (TUIP) of the prostate, may be performed in those who are not fit to undergo transurethral prostatectomy. Other options are temporary or permanent prostatic stents or catheters. The Conticath29 (temporary stent) bridges the space between the bladder neck and the prostate, ending proximal to the external sphincter, and can be

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anesthetic for minimal discomfort. It has proven to be an effective, lowrisk therapy. UroLume is placed in same location as temporary stent (prostatic urethra) for bladder outlet obstruction secondary BPH. Efficacy demonstrated up to 7 years in those with detrusor function. Detrusor function must be present for the stent to work, unlike the catheter that passively drains the urine. In the patient with parkinsonism and bladder outlet obstruction secondary to BPH, frequency and urgency do not predictably respond to TUIP. In fact, TUIP may make the condition worse. Use of a temporary prostatic stent is a novel idea as a way to try to predict response to bladder outlet resistance reduction surgery. Less invasive endoscopic procedures, such as transurethral microwave therapy,31 transurethral needle ablation,32 and holmium or Indigo laser prostatectomy, may prove useful in high-risk cases. In elderly females with mixed stress and urge incontinence and stress UI causing significant bother, detrusor dysfunction should be addressed before treating urethral incontinence. Urethral hypermobility

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and/or intrinsic sphincter deficiency may be treated using procedures requiring local anesthesia. Periurethral or transurethral collagen injection has 20% to 30% 5-year success rates;33 a pubovaginal sling, with or without bone anchors, may use autologous rectus fascia or fascia lata,33 allogenic donor cadaver fascia,34 or synthetic polypropylene.35 Today, pubovaginal sling procedures are performed with minimal tension on the sling, and new-onset incontinence necessitating urethrolysis have been decreased to 3% and 2%, respectively.36 Tension-free vaginal tape procedures are performed under local anesthesia, with a success rate of 91%, a 7% improvement rate, and a 2% failure rate.37 Patients usually go home within 24 hours of surgery without a urethral catheter. In high-risk patients without significant prolapse, tension-free vaginal tapes or similar devices (SPARC®, American Medical Systems, Minnetonka, MN) may become the preferred means of treating this type of stress UI. The newest intervention providing an option in the management of women with OAB is sacral neuromodulation. Percutaneous peripheral afferent nerve stimulation with Percutaneous Stoller Afferent Nerve Stimulator, a device manufactured by UroSurge, Inc. of Coralville, IA, presents a minimally invasive and potentially therapeutic alternative to other current treatment options for patients with documented urgency/frequency syndrome, with no treatment-related side effects.38 Their efficacy in the elderly population is not established.

Conclusion The prevalence of OAB with or without incontinence increases with age in both women and men. It should not be considered part of the “normal aging process." It can be effectively


treated with behavioral changes; judicious use of medication and/or minimally invasive surgical interventions; improvement in quality of life and self-esteem is an attainable goal. References 1. 2.

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elderly people. JAMA. 1986;256:372–379. Hellstrom PM, Sjoquist A. Involvement of opioid and nicotinic receptors in rectal and anal reflex inhibition of urinary bladder motility in cats. Acta Physiol Scand. 1988;133:559–562. Weiss JP, and Blaivas J .G. Nocturia. J Urol. 2001;163:5. Reynard JM, Cannon A, Yang Q, et al. A novel therapy for nocturnal polyuria: a double blind randomized trial of frusemide against placebo. Br J Urol. 1998;81:215. O’Donnell PD Doyle R. Biofeedback therapy technique for treatment of urinary incontinence. Urology. 1991;37:432. Ouslander JG,Blaustein J, Connor A, Pitt A. Habit training and oxybutynin for incontinence in nursing home patients: a placebo-controlled trial. J Am Geriatr Soc. 1998;36:40. Snape J, Castleden CM, Duffin HM, Ekelund P. Long-term follow-up of habit re-training for bladder instability in elderly patients. Age Ageing. 1989;18:192–194. Schnelle JF, Traughber B, Swell VA, et al. Prompted voiding treatment of urinary incontinence in nursing home patients. J Am Geriatr Soc. 1989;37:1051. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women. JAMA. 1998;280:1995–2000. Burgio KL, Locher JL, Goode PS, et al. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc. 2000;48:370–374. Wein AJ, Levin RM, Barrett DM. Voiding function: relevant anatomy, physiology and pharmacology. In: Gillenwater J. Adult and Pediatric Urology. Chicago: Year Book Medical Publishers; 1987:800–862. Anderson RI, Mobley D, Blank B, et al for the OROS Oxybutynin Study Group. Once daily controlled versus immediate release oxybutynin chloride for urge urinary incontinence. J Urol. 1999;616:1809–1812. Nilvebrant L, Anderson KE, Gillberg PG, et al. Tolterodine: a new bladder-selective antimuscarinic agent. Eur J Pharmacol. 1997;327:195–207. Sand PK, Appell R, Dmochowski R, et al. Randomized, double blind study to compare extended release oxybutynin and tolterodine for overactive bladder. Mayo Clin Proc. 2001;76:358–363. Todorova A, Dimpfel W. Effect of tolterodine, trospium chloride, and oxybutynin on the central nervous system. J Clin Pharmacol.

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2001;41:636–644. Van Kerrebroeck P, Kreder K, Jonas V, et al. Tolterodine once-daily: superior efficacy and tolerability in the treatment of the overactive bladder. Urology. 2001;57:414–421. Downie JW. Bethanechol chloride in urology-a discussion of issues. Neurourol Urodyn. 1984;3:211–222. Resnik NM. Voiding dysfunction and urinary incontinence. In: Cassell CK, Riesenberg D, Sorensen L, Walsh J, eds. Geriatric Medicine, 2nd ed. New York: Springer-Verlag; 1990:501–508. Lightner DJ, Barrett DM, Schmidt R, et al. Conticath: a simple new catheter designed for incontinence and volitional voiding past the obstructed urethra. J Urol. 1998;159:303. Gajewaski JB, Chancellor MB, Ackman CF et al. Removal of UroLume endoprosthesis: Experience of North American Study group for detrusor sphinctor dyssynergia application J Urol. 2000 Mar;163(3):773–776. Francisca EA, Keijzers GB, d’Ancona FC, et al. Lower energy thermotherapy in the treatment of benign prostatic hyperplasia: long term followup results of a multicenter international study. World J Urol. 1999;17:279–284. Issa MM, Perez-Brayfield M, Patros J, et al. A prospective study of transperineal prostatic block for transurethral needle ablation for benign prostatic hyperplasia: the Emory university experience. J Urol. 1999;162:1636–1639. Marinkovic S, Mian H, Evankovich M, et al. Burch versus the pubovaginal sling. Int Urogynecol J. 1998;8:260. Wright EJ, Iselin CE, Webster GD. Pubovaginal sling using cadaveric allograft fascia lata for the treatment of intrinsic sphincter deficiency [abstract 828]. J Urol. 1998;159(suppl):214. Hom D, Desautel MG, Lumerman JH, et al. Pubovaginal sling using polypropylene mesh and Visica bone anchors. Urology. 1998;51:708. Chaikin DC, Blaivas JG, Rosenthel J. Pubovaginal fascial sling for all types of stress urinary incontinence: long term analysis. J Urol. 1998;160:1312. Ulmsten U, Falconer C, Johnson P. A multicenter study of tension free vaginal tape for surgical treatment of stress urinary incontinence. Int Urologynecol J Pelvic Floor Dysfunct. 1998;9:210–213. Litwiller SE, Govier FE, Kreder KJ, et al. Percutaneous peripheral nerve simulation for urgency/frequency syndrome [abstract]. J Urol. 2000;163:226. Abstract 1003.

Main Points • Normal age-related physiologic changes may affect urodynamic parameters independently of the presenting symptoms, making interpretation difficult. • Urinary incontinence (UI) is underreported among elderly patients, who may assume it to be a normal consequence of aging. • Successful treatment of overactive bladder and UI in the elderly patient depends on correct determination of the type and cause of the incontinence. • UI in elderly patients may be transient or long-term. • Many cases of UI respond to simple measures like fluid restriction or changes in toileting regimen. • Drug treatment must be tailored according to etiology and patient condition, in some cases. • An increasing number of options are available for surgical treatment should it prove necessary.


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