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長照體系內失禁評估與處置
台北榮總高齡醫學中心 彭莉甯
Urinary Incontinence
Normal urinary continence
Thirugnanasothy BMJ 2010
Innervation of the Lower Urinary Tract (LUT)
Brain
T10–L2
T10–L2
Bladder detrusor
Bladder
smooth muscle
detrusor
smooth muscle
Internalsphincter
sphincter
Internal
smoothmuscle
muscle
smooth
S2–S4
S2–S4
Intramural skeletal
skeletal muscle
muscle
Intramural
Extramural
Extramural
skeletalmuscle
muscle
skeletal
Urethral
smooth muscle
muscle
Urethral smooth
Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83.
Normal Urinary Continence
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Stable bladder wall
Intact pelvic floor
Intact neurology
Manual dexterity
Normal cognition
Normal physical function
Barrier free environment
Age-Related Changes
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detrusor contractility
urinary flow
post-voiding residual urine
total bladder capacity
ability to postpone voiding
Detrusor overactivity (20% of healthy continent)
nocturia
prostate size
Atrophic vagintis & urethritis
DuBeau CE.Urinary Incontinence.Geriatric Review Syllabus Fifth Ed.2002-2004.139-148
Definition

UI is the involuntary loss of urine that is objectively
demonstrable and a social or hygienic problem.
International Continence Society
Symptoms of urinary tract dysfunction
Hesitancy
Post-voiding
dribbling
Urgency
Urinary incontinence
Leaking on strain
or coughing
Frequency
Prevalence of Urinary Incontinence
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15-30% of community dwelling persons 65 years and
older.
F>M until age 80 years, then M=F
Up to 50% in LTCF
Under-reported and delay seeking help.
Clinical Impact of Urinary Incontinence
Physical
• Increased fall
risks
• Sleep
deprivation
• Pressure sore
• Urinary tract
infection
Psychological
• Depression
• Anxiety
• Social
withdrawal
• Interference
with activities
• Increase care
burden
Socioeconomical
• Increased cost
of care
• Pad
• Clothes
• Caregiver
Consequences

“I don’t go out, I don’t even ask anyone round………. I’m so
embarrassed about the smell. I do try and keep myself clean but
it gets onto your clothes and furniture. Sometimes I wish that I
hadn’t survived because it’s no life I’m leading now”
Fe
male stroke survivor
Risk Factors for UI
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1/3 have multiple conditions
Stroke
Diabetes
Parkinson’s Disease
Obesity, CHF, Constipation, TIAs, COPD, Chronic cough
Impaired mobility & ADLs
Depression
Dementia (moderate to severe)
Heterogeneous residents in LTCF
Dementia and functional impairments are frequent contributors
Types of Urinary Incontinence
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
Transient UI (Acute)
Established UI
(Chronic)
 Urge UI
 Stress UI
 Overflow UI
 “Functional” UI
 Mixed UI
Transient Incontinence
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Lower urinary tract pathology
Precipitated by reversible factor
Causes: Delirium, UTI, Meds, Psychiatric disorders, 
UO, Stool impaction
Restricted mobility
Causes of Transient Incontinence
Mnemonics: DIAPPERS
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D
I
A
P
P
E
R
S
Delirium
Infection
Atrophic Vulvovaginitis
Psychological
Pharmacologic agents
Endocrine, excessive UO
Restricted Mobility
Stool impaction
Resnick NM. Med Grand Rounds. 1984;3:281-290.
Classification of Chronic UI
Urge UI
 Stress UI
 Overflow UI
 “Functional” UI
 Mixed UI
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Classification of Chronic UI
Urge Incontinence
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Most common
Detrusor overactivity with uninhibited bladder
contraction
Unpredictable, abrupt urgency, frequency
Post-void residual usually normal (<51ml)
Cause:
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age
impaired ability of brain to send inhibitory signals (stroke, brain
mass, PD)
increased afferent stimulation from the bladder(UTI, uterine
prolapse)
Prostatic hypertrophy in men (leads to hypertrophy of detrusor
muscle)
Stress Incontinence
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most common cause in aging females
Cause: child-birth, obesity (increased pressure on pelvic
organs), hysterectomy, radical prostatectomy
Leakage occurs with  intra-abdominal pressure on
coughing, sneezing, physical activity
Overflow Incontinence
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Detrusor underactivity and/or outlet obstruction
Outlet obstruction=2nd most common cause of UI in
Males
Dribbling, weak stream, hesitancy
Prolonged urinary retention can lead to detrusor
muscle failure, persisting even after obstruction
relieved
Functional Incontinence
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Unable or unwilling to toilet due to physical impairment,
cognitive dysfunction, environmental barriers
No underlying GU dysfunction
Diagnosis of exclusion
Summary of Urinary Incontinence
Leakage accompanied or preceded by urgency
Urge
Leakage or exertion, sneezing, or coughing
Stress
Leakage owing to bladder outflow obstruction of
any cause resulting large post-void residual volume
Overflow
Inability to reach the toilet in time (mobility,
dexterity) or lack of perceived need to (cognitive
impairment)
Urinary incontinence in recent 3 days
Functional
Transient
Thirugnanasothy BMJ 2010
History
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Urinary symptoms
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Voiding: hesitancy, poor urinary stream, dribbling
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Precipitants of urinary leakage such cough, exertion
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History of haematuria and recurrent urinary tract infections
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Bowel symptoms : Constipation, straining, faecal incontinence
Fluids Volume: caffeine, carbonated drinks, citrus drinks, sweeteners
Medical / Surgical history
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Drug history
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Neurological disorders, cognitive disorders, cough
Hysterectomy, prostatectomy, pregnancies, mode of delivery
Sedatives and hypnotics, antimuscarinics, diuretics, alcohol
Social history
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Access to toilets and aids; mobility. Impact on quality of life
Adapted from Thirugnanasothy BMJ 2010
Examination
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General exam
 Enlarged bladder, pelvic mass, edema, orthostatic hypotension, heart
failure
Neurological exam
Functional impairment
 Mobility, dexterity (undoing buttons), vision
Cognition
Rectal exam
 Prostate size and nodularity, fecal impaction
Pelvic
 Prolapse, atrophic vaginitis
Drugs and urinary incontinence
DeMaagd, US Pharm. 2007
Prescribing cascade…
85 years-old. Past history: Hypertension
Take Norvasc(amlodipine) for BP control
Leg edema, Impaired bladder empyting
Urgency, Incontinence
Take anti-cholingergic drug
Constipation, urinary retention
Take Laxatives, Insert foley
Fecal Incontinence, UTI
Diuretics
（利尿劑）
Essential investigations
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Urinalysis – haematuria, glucose, infection
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Bloods – glucose, creatinine, sodium, calcium ,+/- PSA
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Post-void bladder scan – <100mls ok. Post-void catheter with measure
of residual if scan not available
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Voiding diary
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3 days diary
More reliable than patient recall
Record type and time of intake, volumes
Record time of each micturition and volume (estimate, or actual)
Record number of pads used, weigh pads
Ask family/carer to assist if patient unable
Urinary Diary
時間
喝水量
(cc)
尿量
(cc)
廁所解尿
V
上午
5:30
250
上午
8:00
50
上午
8:50
上午
9:50
上午
10:30
上午
11:40
300
V
下午
14:00
250
V
下午
14:20
下午
16:00
50
晚上
18:00
130
少量失禁
大量失禁
失禁原因
買菜
V
100
100
V
利尿劑後1小時
300
350
250
小跑步去接孫
子
V
V
炒菜炒一半突
然尿急
Further investigations
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Generally unnecessary unless
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Haematuria – micro or macroscopic
Urinary retention
Pelvic mass
Prostate mass / significantly raised PSA
New/undiagnosed renal impairment
Frequent urinary infections, especially in men
Renal ultrasound
Urodynamic studies
Cystoscopy
Further investigations as per findings (e.g. MRI spinal cord or
brain)
Treatment options
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Non-pharmacological
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Medications
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Surgery
Medication Review
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Stop all offending medications
Balance against BP control, heart failure control
Environmental Factors
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Toilet access – stairs, commode, lighting, privacy.
Mobility – rehabilitation to improve function
Address visual deficits
Non-pharmacological: Cognitive Intact
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Pelvic floor exercises – for stress / urge /mixed incontinence
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First line treatment, 3 months trial needed
RCT: improves subjective and objective cure rates
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(44% vs. 7% objective cure rates)
Need to be cognitively intact – may not suit many older pts
Bladder retraining
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Increase time interval between voiding
Greater effectiveness
Non-pharmacological: Cognitive impairment
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Time voiding
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Prompt voiding
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2-3 hour time interval, for dependent residents
Effective
ask dependent residents regularly whether they need toileting
assistance.
Positive feedback
Habit retraining
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Identification of a person’s toileting pattern; for dependent residents
Cochrane review: no significant difference in the incidence and volume
of incontinence
Medications
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Urge incontinence: antimuscarinic drug
Adverse effect of Antimuscarinics
• Contraindicated:narrow-angle glaucoma, urinary retention and gastric
retention.
• Increased risk of confusion in dementia patients
Antimuscarinic Drugs
Medications
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Overflow Incontinence
 treat cause
 -antagonists： relax the muscle of prostate and
bladder neck
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terazosin, doxazosin, tamsulosin, alfuzosin, silodosin
Low blood pressure, dizziness
Medications
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Stress incontinence
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α- Adrenergic agonists
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increasing internal sphincter tone
Pseudoephedrine; weak evidence, no recommend
Duloxetine(Cymbalta):
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Increased urethral contraction and sphincter tone
Urethral catheters - indications
Approx. 80% of health care-related UTI’s are catheter-related
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Acceptable reasons to catheterise
Acute urinary retention
Irrigation of haematuria
Need to monitor urinary output
Severe sacral ulcers, to protect skin
Chronic urinary retention only if renal impairment
Measurement of post-void volume (if bladders scan unavailable)
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UNACCEPTABLE reasons to catheterise
Immobility
Carer/staff demands
Urinary incontinence
Urinary tract infection
Suprapubic catheters
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May require anaesthetic, not without complications
May be associated with reduced risk of infection
Reduced impact on sexual function
Only if
 assured that a long-term catheter needed
 no surgical options
 cannot intermittently self-catheterise
Treatment options - Surgery
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Retropubic suspension procedures
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Transvaginal bladder neck suspensions
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Less invasive
Artificial urinary sphincter
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To support and restore the bladder neck to its retropubic
location
Indication: incontinence due to poor urethral sphincteric
mechanism
Urinary diversion
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Indication: as a last resort in some patients that is refractory
to the above-mentioned Tx options
Treatment options - Surgery
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Augmentation cystoplasty
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Using bowel segments
Creation of a low-pressure system will decrease stimulation of
sensory afferents
Intermittent catheterization will usually be required to
completely empty the bladder
Sacral neuromodulation
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Placement of a surgical electrode permanently stimulating S3
afferent or motor nerves
Conclusion
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High prevalence of UI in LTCF
Differentiate the causes of UI
Functional status, cognitive abilities, comorbidities should
be considered when developing a continence in LTCF.
Emphasize the importance of non-pharmacologic
treatment
Avoid to use urinary catheter unless under some
circumstances
Urethral catheters
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Intermittent catheterisation if at all possible
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Lower risk of urinary infections
Dexterity needed
Medical treatment has failed or surgical is not appropriate
Leave catheter in for the minimum time necessary
Always review need for existing catheter
Catheter must provide more benefits than risks to the
patient
Should not be portrayed as easiest option