Incontinence in the Elderly

Is it not strange that desire should so many years outlive performance? '-'W. Shakespeare''

=Objectives=

Identify the autonomic innervation of the bladder, prostate, and urethra and how it relates to the therapy of disorders involving these organs.

 * detrusor muscle
 * the detrusor muscle of the urinary bladder is innervated by parasympathetic neurons (S2-S4)


 * internal sphincter
 * the internal sphincter is innervated by sympathetic efferents (T12-L2). Upon filling of the bladder, these neurons are inhibited contributing to the relaxation of the internal sphincter.


 * prostate
 * the prostate is innervated by both parasympathetic (pelvic splanchnic nerves S2-S4) and sympathetic nerves (inferior hypogastric plexus). Note that alpha-adrenergic antagonist are effective in limiting prostatic hypertrophy.


 * urethra
 * afferent nerves of the spongy and bulbar urethra are derived from the pudendal nerve.



Enumerate the symptoms of urinary tract obstrution

 * Slow stream/dribble
 * trouble initiating flow (hesitancy)
 * Urinating in fits and starts (intermittency)
 * Frequent daytime urination (frequency)
 * Nocturia (getting up at night more than once.)
 * Overflow or urge incontinence
 * Poor emptying of the bladder (objective; based on postvoid residual or PVR, i.e. the bladder ultrasound machine)
 * Sense of not emptying the bladder (subjective)
 * Urinary retention (subjective or objective by clinical testing)

Recognize commonly used pharmacologic agents used to treat lower urinary tract disorders

 * Benign Prostate Hyperplasia agents
 * Alpha-adrenergic blockers: competitively bind to alpha receptors on the prostatic muscle. All of the drugs are felt to have equal efficacy.  Drugs are: doxasin, terazosin, tamsulosin, and alfuzosin
 * 5-alpha reductase inhibitors: These drugs decrease the level of available 5-alpha reductase prior to testosterone binding to the enzyme, thus reducing levels of dihydrotestosterone that are derived from such a bond. Drugs are finasteride and dutasteride.
 * New concept: combination therapy! Alpha blocker + 5-alpha reductase inhibitor - combination is better than either alone in preventing urinary retention.
 * As a side note, know that UTI, renal insufficiency, urinary retention, bladder calculi and decompensated bladder are all complications of BPH.
 * Nocturnal Enuresis
 * Non-medical treatments: decrease fluid intake at night, change diuretic schedule (admin in late afternoon or early evening), and/or catheterize at bedtime.
 * Medical treatment: imipramine (TCA with anti-cholenergic action) given for children, anticholinergic at bedtime, and DDAVP, i.e. desmopressin acetate (intranasal or oral).
 * Menopausal Urinary Tract
 * Hormone replacement therapy given to treat diminished tissue elasticity, thinning of lining tissues of urethra and vagina, increased fragility of tissues, decreased amount and acidity of vaginal secretions, and vaginal narrowing and shortening.
 * Can be systemic or local therapy, effects on incontinence are controversial, but known to improve tissue integrity and prevent UTI.
 * Local HRT: estrogen cream, vaginal suppository, or Estring
 * Stress Incontinence
 * THERE IS NO DRUG FDA-APPROVED FOR SUI. Imiprimine was previously given, now duloxetine used off-label.
 * Collagen injections sometimes given to "bulk up" the urethra. Drugs are contigen, coaptite, macroplastique and durasphere.
 * Overactive bladder
 * Anticholinergic agents, such as tolteridone, oxybutynin, and trospium (quart amine), are considered first-line therapy for UI, suppressing or reducing involuntary bladder contractions, and also addressing the symptoms of idiopathic detrusor overactivity (OAB). Newer therapies include darifenicin and solifenacin (M3 selective inhib).
 * Alpha-adrenergic receptors predominate in the internal urethral sphincter (IUS)
 * Overflow incontinence
 * the obstructive symptoms associated with overflow incontinence can be treated with 5a-reductase inhibitors (finistride, dutasteride) and alpha-adrenergic receptor antagonists. a-blockers include prazosin and dosoasin.  Tamsulosin has some a1a specificity and which results in less orthostatic hypotension.

Diabetes Mellitus
(Hampel C et al. Diabetes mellitus and bladder function. What should be considered? Urologe A. 2003 Dec;42(12):1556-63. -- this is just taken from the abstract of a german article!)
 * Diabetic cystopathy: impaired bladder sensation, increased bladder capacity, sometimes accompanied by voiding difficulties and residual urine.
 * Autonomic and peripheral neuropathy: lead to detrusor hyposensitivity, and chronic overstretching of the bladder leads to myogenic detrusor hypocontractility.
 * Secondary complications: recurrent UTIs, vesicorenal reflux, nephrolithiasis, and pyelonephritis

Stroke

 * Urinary incontinence
 * Urinary retention
 * [Is this it?]

Parkinson's Disease
(Winge and Fowler. "Bladder dysfunction in Parkinsonism: Mechanisms, prevalence, symptoms, and management." Movement Disorders. Volume 21 Issue 6, Pages 737 - 745)
 * Nocturia, urgency and frequency are top complaints (BPH may be a co-morbidity, nothing to do with the Parkinsons!!!)
 * Urge incontinence
 * Overactive bladder

=Links & References=
 * Recommended: Gary Ciment, "Review of the Peripheral Nervous system & Urinary continence", Neuroscience Lecture.