Urinary Disorders in elderly Women

Urinary Disorders• Related to infection• Related to oestrogen deficiency• Related to continence

Lower Urinary Tract DysfunctionRelated to Continence• Abnormalities of storage and filing phase• Abnormalities of the voiding phase• Combination of the above two

Incontinence• Urinary incontinence is the uncontrollable leakage ofurine.• It is more common in the elderly• Urinary incontinence is not a natural process ofageing.

Types of Incontinence• Stress Incontinence ( leakage of urine when you cough,sneeze, laugh or lift something heavy)• Urge Incontinence (leakage of urine before you canreach a toilet)• Overflow Incontinence (Inability to stop urine fromconstantly dribbling out; full bladder but you havedifficulty emptying it completely )• Functional Incontinence (Women with cognitive,psychological and physical impairment)• Fistula ( A false connection between the bladder or theureter to the vagina )

HistoryEvaluation of urinary symptoms1) Do you leak urine with activities such aslaughing, sneezing, coughing, and/or exercise?2) Are there times when you have the urge to urinate but leak before you get tothe bathroom?3) Do you leak urine daily, weekly, monthly, or less than once a month?4) When you leak would you characterize the loss as drops, small splashes, ormore than small splashes?5) Do you wear protective pads, and if so, how many per day?6) How often do you get up at night to urinate?7) How many times do you void during the course of the day?8) Do you ever leak without a preceding urge or stress?9) Do you ever feel that you do not completely empty your bladder?10) Do you have bladder pain or pain with voiding?

HistoryCo morbid Factors• Medical – Diabetes, Stroke, chronic lung disease,obesity, cognitive impairment• Surgical - Hysterectomy,vaginal or bladder surgery• Obstetric - Parity, vaginal deliveries, intervalbetween pregnancies• Gynaecological – Pelvic organ prolapse• Oestrogen status• Trauma

Drugs That Affect Urinary FunctionDRUGAlpha-adrenergic blockersAlpha-adrenergic agonistsBeta-adrenergic agonistsCalcium channel blockersAntidepressants,antipsychoticsAnticholinergicsNarcoticsDiureticsCaffeineAlcoholSIDE-EFFECTDecrease urethral toneIncrease urethral tone, urinaryretentionInhibited detrusor function,urinary retentionUrinary retentionUrinary retentionUrinary retentionUrinary retentionUrinary frequency and urgencyUrinary frequency and urgencyUrinary frequency and urgency

Evaluation• Bladder diary• 24 hour record• Type and amount of fluid consumed• Number and volume voids• Leaks in each hour• Activity engaged at the time of leak

Examination• General - Obesity• CVS• Respiratory• CNS• Abdominal – masses, ascites• Pelvic – inflammation, infection, atrophy, oestrogenstatus, urethra, uterus, adnexa, pelvic muscle toneand strength• Per rectal examination – fecal impaction, occult blood

Investigations• MSU for urinalysis• Urine for culture & ABST• Cystoscopy (If indicated)• Pyridium test (bright Orange urine)• Simple cystometry• Multi channel subtracted cystometry• Vedio cystometry• Ultrasound evaluation

Treatment• Conservative management• Behavioral modifications• Pelvic floor exercises• Medical management (Drugs)• Electrical stimulation• Magnetic beam stimulation• Surgical Treatment• Colposupension• Tension free Vaginal Tape (TVT and TVT O )• Periurethral injection of bulking agents

Behavioral Modification• Drink 6-8 glasses of water daily unless your doctor has instructedotherwise.• Limit your intake of alcohol and caffeinated drinks.• Take a balanced diet that includes all food groups and keep within ahealthy weight range.• Include enough fluid and fibre in your diet and exercise regularly toprevent constipation that can lead to poor bladder control.• Practice good bladder habits by regularly emptying your bladder.Holding back for too long when a bladder is full, or persistentlyemptying it when it is not, can both cause abnormal bladder function.Bladder retraining• Do pelvic floor exercises regularly to strengthen the musclessupporting the outlet of the bladder.• Avoid precipitating factors such as obesity, chronic cough, sneezingand heavy lifting etc.

Stress Incontinence• Non Surgical• Pelvic floor exercises• Surgical• Colposupension• Tension free Vaginal Tape (TVT and TVT O )• Periurethral injection of bulking agents

Overactive Bladder(Urgency,Frequency,Urge Incontinence)• Detrusor Instability (Idiopathic)• Detrusor hyperreflexia (Due to known neurologiccondition)

Overactive Bladder -Treatment• Bladder retraining• Electrical stimulation (Sacral nerve root Neuromodulation)• Stimulate pelvic floor and urethral muscles, inhibitsdetrusor contractility• Pharmacologic management• Anticholinergic agents• Oxybutynin chloride• Tolterodine (Bladder selective, less systemic side effects)• Tricyclic Antidepressants• Imipramine hydrochloride (Improves bladder storage andhypertonicity)• Synthetic vasopressin• DDAVP (Decreases urine production, use with caution in elderly)

Overflow Incontinence• Due to outlet obstruction(Prolapse,Stricture) orunderactive detrusor muscle (Diabetic neuropathy,multiple sclerosis,spinal cord injury,radical pelvicsurgery)• Surgical treatment only to relieve obstruction• Intermittent self-catheterization• Treat the underlying etiology

Cystitis• Bacterial• MSU culture and sensitivity• Appropriate urinary antiseptics• Non-bacterial• Local estrogen• Anticholinergics• Urethral dilatation

Urinary Disorder• Problem of incontinence• Problem of bladder irritability• Structural problem• Inflammatory• Psychogenic

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