Portal de Periódicos da CAPES

Urinary Incontinence in Elderly Women

1998; Elsevier BV; Volume: 33; Issue: 3 Linguagem: Inglês

10.1159/000019574

1873-7560

Emma Gorton, Stuart L. Stanton,

Stoma care and complications

Urinary incontinence is a distressing problem that becomes increasingly prevalent with advancing age, so much so that it is often perceived as a normal part of ageing [1]. Delay in seeking help is common, with almost 40% of elderly women waiting over 5 years before seeing their general practitioner, despite considerable restriction in their daily life [2]. When help is sought the action of the general practitioner is usually limited to taking a urine specimen, prescribing medication or referring to a specialist [3]. In many cases medication is prescribed without the patient being examined or a diagnosis being made. In a survey of general practitioners, 42% reported never using the services of incontinence advisors [4]. Incontinence is associated with significant morbidity, including recurrent infections from long-term catheterization, pressure sores, immobility, and falls [5]. However, effective treatment is available, and thus many women are suffering unnecessarily.There is no absolute age at which a person becomes ‘old’, most articles on incontinence in the elderly refer to a population over 65 years, some however use 55 years as the cut off, and others only include those over 70 years. In this article we will consider women over 65 years as elderly unless otherwise stated.Health problems in the elderly are likely to become an increasing problem over the next few decades as the population ages. Over the next 30 years the population of women over the age of 65 years in England and Wales is expected to increase from the current 4.8 million to 6.9 million so that by the year 2031, 25% of women will be over 65 years old [6]. Thus an increasing awareness of the particular problems of treating incontinence in this age group will be needed.The estimated prevalence of incontinence in the elderly population varies widely, depending on the definition of incontinence used, the study methodology and the population studied. Most studies distinguish between incontinence occurring in elderly women living in the community and those in residential care.Mohide [7] reviewed the published epidemiology studies from 1964 to 1985, and noted that the estimated prevalence of incontinence in the community varied from 1% (if only those whose incontinence was known to healthcare providers was included) to 51% (if any episode of incontinence was included). The prevalence of ‘clinically significant’ incontinence was more consistent at 5–10% [7].More recent surveys have also produced widely variable figures for prevalence of incontinence. In an interview survey, Brockelhurst [3] found that 10% of women over 60 had suffered from incontinence in the previous 2 months compared with 5.7% of younger women. In similar interview surveys in the United States, approximately one third of elderly women suffered from incontinence, which was classified by the investigators as moderately severe in 9–27% [8, 9].Most studies have shown that incontinence increases with age [8, 9, 10, 11], although some have shown that there may be a slight reduction in incidence in women aged 65–69 compared with younger women [12, 13] and Kok et al. [14] in a postal questionnaire survey in the Netherlands found no association between incontinence and age.Not surprisingly the prevalence of incontinence within long-term institutions is much higher, varying from 38 to 55% in studies up to 1985 [7]. In a study of 85-year-old women in Sweden, 191 of 551 (34.7%) women living in their own home were incontinent compared with 93 of 107 (86.9%) living in residential care [15]. Conversely the prevalence in residents of institutional care (including acute care) in Leicestershire in 1990 was ‘only’ 40.4% [16]. The prevalence of incontinence in institutional care will obviously depend on the admission policy of the institution under investigation. For many older persons, incontinence is the final straw precipitating their admission to nursing home care, however, some institutions refuse to take people who are incontinent.Although there is a lot of variability in estimated prevalence of incontinence between different surveys, all agree that it is a common and distressing problem in this age group.Detrusor instability accounts for approximately 60% of incontinence in elderly women presenting to outpatient clinics or living in institutions [17, 18]. However, in a large community survey, comparing continent and incontinent women, only 12% of the women with incontinence were found to have uninhibited detrusor contractions [19]. In the same survey almost 5% of the 65 continent women were found to have detrusor contractions. Other workers have found a surprisingly high prevalence of detrusor contractions on conventional cystometry in continent elderly women, varying from 11% [20] to 42% [21]. Voiding dysfunction is common in elderly women [22] and Resnick and Yalla [23] coined the term ‘detrusor hyperactivity with impaired contractility’ (DHIC) to describe the combination of impaired voiding with detrusor instability. Other workers, however, have disputed the existence of this subclassification of detrusor instability, noting that measures of detrusor contractility vary on repeat testing in the same individual [24].A number of studies have looked at ultrastructural changes that occur with age to attempt to explain the observed urodynamic changes. Thus, Gilpin et al. [25] noted a reduction in the amount of acetylcholinesterase-positive nerves within the detrusor muscle with increasing age. Although the patients in that study had normal urodynamics, most presented with symptoms of urgency and frequency, so it is unclear if these represent truly normal bladders. Elbadawi et al. [26] studied the ultrastructure of the detrusor in elderly patients subdivided according to symptoms. The patients with detrusor instability were found to have a dysjunctional pattern with widened intercellular spaces, a reduction in normal intermediate junctions and two distinctive types of cell junction (a protrusion junction and ultra-close abutment) [27]. It is thought that these junctions allow rapid transmission of electrical signal so that there is synchronous contraction of a large number of detrusor cells [27]. In the normal ageing detrusor, a dense band pattern was noted with zones of electron-dense thickening, within the sarcolemmae with depleted caveola [28]. A separate subgroup was noted in both groups in which there was widespread degeneration of muscle cells and axons, these specimens corresponded to the subjects with impaired contractility [27, 28]. Part of the explanation for the increased incidence of incontinence in elderly women may be due to alterations in urethral function. Early studies on maximum urethral pressure showed that it declined with age in normal women [29] and those with stress incontinence [30]. However, the numbers were small making it difficult to control for confounding variables such as parity and previous surgery. It has been suggested that studies of pressure flow curves can be used as an alternative approach to studying urethral function, by calculating the urethral resistance [31]. Using this approach, Wagg et al. [31] found that there was a reduction in detrusor pressure at opening with increasing age in the absence of significant changes in flow rate. From this they postulated that the urethral resistance declines with age. However, pressure flow studies are poorly reproducible in women [32], and so the differences may not be real.A detailed general medical history and examination is important to assess underlying conditions that may be contributing to her incontinence or her ability to cope with it. Difficulty holding urine is associated with important health and functional measures, such as depression, stroke, chronic cough, faecal incontinence and difficulties performing activities of daily living [8]. There is a particularly strong association between poor mobility and incontinence [14], and it is not hard to imagine how reduced mobility from a fractured hip will convert a patient who is coping with detrusor instability into one who becomes incontinent. Underlying neurological disease may be important. However, a nihilistic approach to incontinence in the demented patient is not justified as incontinence is more closely correlated to mobility than to cognitive function [33]. It is also unclear if the association of Parkinson’s disease with incontinence is due the Parkinson’s disease itself or to age-related change [34]. The degree of cognitive impairment can be assessed by the abbreviated mental test score, but to ensure meaningful results, medical staff need to be trained in its use and scoring [35].Chronic constipation should be excluded as faecal impaction can cause voiding difficulties with resultant overflow incontinence. A midstream specimen of urine should be sent for microscopy as a urinary tract infection can precipitate incontinence.Medication needs to be carefully reviewed, as many elderly patients are taking drugs, such as tricycle antidepressants, calcium channel antagonists or beta blockers that may affect lower urinary tract function [36]. Approximately 30% of elderly women use diuretics, although epidemiological studies have shown no difference in the prevalence of incontinence in patients on diuretics compared with those not taking them. However, there is some evidence that patients who have detrusor instability are more likely to suffer incontinence if they are taking diuretics [37].Her social situation needs to be carefully assessed, for instance, is there a caregiver available to assist with toiletting, and how much is the bladder interfering with the patient’s normal life? Environmental factors such as access to the toilet may be important [38] and can be improved with appropriate involvement of social services.An assessment of severity is important, both to plan treatment and to determine its effect. Voiding records can be used to provide information on the number of incontinence episodes, the functional bladder capacity, and urine output. High urine output due to diabetes, diuretic therapy, caffeinated beverages, or excessive fluid intake will exacerbate frequency [5], and although most patients with incontinence already practise fluid restriction, there is an association between the amount of urine lost (as measured on 24-hour pad test) and fluid intake. However, not all patients can complete voiding diaries, in one study 24% of cognitively intact elderly patients were unable to complete even a modified diary recording only ‘accidents’ [39].Pad weighing tests using a standardized fluid intake and exercise regime have been recommended to quantify urine loss [40], but there is significant interpatient and intrapatient variability [41]. Unfortunately in the elderly population these tests are particularly unreliable as there is delayed diuresis in response to a fluid load, and the patient may be unable to complete the test because of reduced mobility [5]. Indeed in many patients the 1-hour pad test may fail to demonstrate incontinence despite severe leakage during 24-hour monitoring [42].It is well known that there is a poor correlation between symptoms and urodynamic findings [43], and this is as true in the older population as it is for younger women. For instance, in a study of 200 consecutive women aged over 55 years referred to an incontinence clinic, the clinical diagnosis was found to match the urodynamic diagnosis in only 110 women [44]. Likewise in a study of 135 elderly women referred to an incontinence clinic, presenting symptoms were predictive of urodynamic findings in only 64% of women with stress incontinence and 55% with pure urge incontinence [45]. Part of the discrepancy between clinical findings and urodynamic results may be due to the poor sensitivity of urodynamics. Studies comparing ambulatory monitoring with conventional urodynamics have shown that there is a greater correlation between symptoms and urodynamic findings when a combination of ambulatory and conventional urodynamics are used [46].Because of the expense of urodynamic equipment, simple cystometry in which detrusor contractions are seen as an increase in the height of a column of fluid, has been suggested as an alternative to multichannel cystometry. In comparison with multichannel cystometry, simple cystometry has an 88% sensitivity and 75% specificity for the diagnosis of detrusor instability. It is possible that the poor specificity was due to false negative of multichannel cystometry as all but one of these women had symptoms of urgency [47]. Recently, Resnick et al. [48] have compared simple cystometry with multichannel videocystometry and found that simple cystometry was most likely to result in a misclassification of patients with DHIC [48]. They were able to improve the accuracy of the simple cystometry by combining the results with a clinical stress test. Where the results of the simple cystometry and clinical stress test agreed, the diagnosis was accurate, so multichannel cystometry was only required where the test results were discordant [48]. Simple cystometry may have a place in assessment of nursing home patients, as access to more sophisticated urodynamic equipment may be limited [49]. However, it is still an invasive test as catheterization is required and so its role in the assessment of ambulant women with incontinence is more limited.An evaluation of incontinence is incomplete without an assessment of the effects on the woman’s quality of life. In a survey of 239 women aged over 70 living in the community, 17.9% were found to be incontinent, and there was a significant relationship between incontinence and older persons’ perceived limitations in usual role activities. However, there was no relationship between incontinence and limitations in social activities [50].Before active treatment of incontinence is commenced there should be an attempt to evaluate factors outside the urinary tract which may be contributing to the incontinence. Thus an assessment of the patient’s functional status, identification of other medical conditions, such as diabetes and neurological disease, and a detailed list of medications is important [51].Although urinary tract infection may be a cause of the sudden development or worsening of incontinence, there is no evidence that treatment of otherwise asymptomatic bacteruria in nursing home residents improves continence status [52].Conservative treatment of incontinence, using bladder drill, pelvic floor exercises, and general advice about fluid intake and bowel habits, avoiding both the use of drugs and surgery, can result in a sustained improvement in quality of life [53]. Such treatment can be initiated by the local continence advisor, who can also provide advice on appropriate pads and other protective clothing.Behavioural therapy with a combination of pelvic floor exercises, biofeedback, and bladder retraining can provide a substantial improvement for many women without the risks of surgery or the side effects of medical treatment. Of 70 people referred to a multidisciplinary incontinence team, 47 were considered appropriate for behavioural therapy, of whom 26 participated in behavioural therapy resulting in a significant improvement, 14 dropped out or had a poor response, and in 7 the response was unknown as they were unable to complete a voiding diary [54].Bladder drill has been shown to decrease the number of incontinent episodes in women over 55 years with either stress incontinence or detrusor instability [55]. There was no correlation between urodynamic diagnosis and the change in the number of incontinent episodes, and few of the urodynamic variables showed any change pre- and posttreatment, with no correlation between any changes and change in severity. This suggests that bladder drill works by affecting behaviour rather than physiology, with knowledge of the mechanism of incontinence leading to the patient making functional and adaptive changes to improve continence [56].Unfortunately, increasing age adversely affects the outcome from conservative treatment. For example in a study of biofeedback and electrical stimulation in the treatment of both stress and urge incontinence, the overall success rate was 64%. However, increasing age and hypo-oestrogenism were found to be adverse features [57].In the nursing home population poor cognitive function adversely effects the success of biofeedback and pelvic floor exercises. Prompted voiding has been shown to be effective in reducing incontinence in approximately 40% of patients [58, 59]. Surprisingly, there is no correlation between response and cognitive function or urodynamic diagnosis, but those who respond well can be identified during a 3-day trial of prompted voiding [58].Rarely, some women will need to be managed with long-term urethral catheterization. This is associated with a number of problems, including blockage, by-passing and haematuria. Many patients find the catheter uncomfortable, and remain dependent on nursing support [60]. Suprapubic catheterization is an alternative, but has not been properly evaluated [61]. Thus, in some women incontinence can be significantly reduced by attention to factors outside the urinary tract which may be exacerbating the problem. Simple behavioural treatments have been shown to be successful in helping many women without any side effects, but both patient and clinician must be motivated to persevere with treatment.The role of oestrogen therapy is not established. Although the incidence of incontinence increases after the menopause, it is unclear to what extent this is due to the menopause, or to the general effect of ageing. All four functional layers of the urethra, the epithelium, the connective tissue, vascular tissue and muscle are affected by oestrogen status. Although early studies showed subjective benefit with the use of oestrogens, they were uncontrolled, and lacking in objective measures [62]. In a meta-analysis of the role of oestrogen in treatment of incontinence, 166 articles looking at the effects of oestrogen on postmenopausal urinary incontinence were identified, but only 6 of theses were randomized controlled trials [63]. There was no standardization in patient selection, study design, oestrogen used, follow-up and outcome variables measured. There was a small subjective improvement, but minimal evidence of an effect on objective outcome [63]. In a more recent study of 83 hypo-oestrogenic women with stress incontinence, urge incontinence or mixed incontinence, no difference was found in subjective or objective outcome measures after 3 months’ treatment with conjugated equine oestrogen and medroxyprogesterone acetate compared with controls [64].In the pharmacological treatment of detrusor instability, oxybutynin is the most commonly used agent. It acts as an anticholinergic and smooth muscle relaxant, and has been shown to improve symptoms in both pre- and postmenopausal women [65, 66]. Sadly, in the nursing home population the addition of oxybutynin adds little to prompted voiding in the control of urge incontinence [67]. In the ambulatory elderly it results in subjective improvement in 86% of patients compared with 55% using placebo [68]. The same study showed a reduction in urinary daytime frequency, but no change in the number of incontinent episodes [68].Other agents which can be used in the pharmacological treatment of incontinence include the anticholinergic propantheline, and smooth muscle relaxants such as dicyclomine or flavoxate [69]. Tricyclic antidepressants have central and peripheral anticholinergic actions and so are commonly used. Their effects may be additive with other antimuscarinic or antispasmodics and so a combination can be particularly helpful [69]. Unfortunately drug treatment is often limited by side effects, particularly dry mouth, blurred vision and constipation. Newer agents, such as tolterodine, which are more specific for the M3 receptor in the bladder should be more effective with fewer side effects [70].Thus medical treatment of incontinence can be helpful in patients with detrusor instability but is often limited by side effects, especially in elderly women.In a review of the success of surgical treatment of stress incontinence, Jarvis [71] found that the most effective operation is the colposuspension. In selected elderly women this procedure is as effective as in younger women, with reported success rates of 88–90% [72, 73]. Unfortunately many elderly women are unsuitable for this procedure because of vaginal narrowing and atrophy [74], in addition general health problems in this group of women will reduce their ability to withstand major surgery. The endoscopic bladder neck suspension is a less invasive procedure, and so could provide an alternative. Golomb et al. [75] found that the success rate of the Raz needle suspension was similar in women over age 65 compared with younger women. Griffith-Jones and Abrams [76] reported 66% objective cure rate with the Stamey, with follow-up of 9 months to 5 years. However, research from our unit has shown a much lower cure rate of 39% for the Stamey endoscopic bladder neck suspension at 3-month follow-up [77], and 46% for the Pereyra modification [74]. Likewise, other workers have noted that although the initial success rate of needle suspension procedures may be high their long-term success rate is disappointing. For example, O’Sullivan et al. [78] reported a cure rate of only 18% 5 years after surgery, suggesting that its role is limited.Because of the high risk of voiding dysfunction, sling procedures are usually avoided in elderly women. Recently, however, Carr et al. [79] compared the success rates and morbidity of sling procedures in women over 70 compared with younger women and found no difference in outcome between the two groups, with all 19 of the elderly women cured, and none having long-term voiding dysfunction.Periurethral injections of collagen offer a valuable alternative for patients who wish to avoid major surgery. Subjective improvement can be obtained in 79% of women 1 year after collagen injections, falling to 69% at 2 years. There are minimal complications and the procedure can be performed as a day case under local anaesthesia [80].Thus surgical treatment of incontinence remains an option for the elderly, as carefully selected patients will do well with major surgery and periurethral injections may be considered in those in whom it is contraindicated.Urinary incontinence is a common and important problem in elderly women. It is partly related to functional changes due to diseases outside the urinary tract affecting the patient’s mobility and recognition of the need to use the toilet appropriately, and partly due to structural changes in the detrusor muscle and urethra that occur with age.A careful assessment is important to evaluate functional causes of incontinence and to make an accurate diagnosis of the underlying bladder abnormality. Appropriate treatment can result in a significant improvement in the woman’s quality of life and should not be denied on the grounds of age alone.