Voiding Problems and Urinary Incontinence in the Geriatric Patient

Abstract

Urinary incontinence (UI) is defined as the involuntary loss of urine. It is common, under-reported, and morbid. More so in older adults than in younger adults, urinary incontinence may be multifactorial and is therefore considered among geriatric syndromes. For this reason, typical clinical symptom-based approaches may be subeffective and potentially harmful. In this chapter, we approach the problem by proposing that understanding incontinence first requires understanding the determinants of social urinary continence. Unlike standard bladder-centric clinical approaches, incontinence extends beyond the aging lower urinary tract. Urinary incontinence rarely occurs as an isolated problem in older patients. Considerations are proposed to help identify the factors that contribute to incontinence in the individual patient, and patient-center approaches to managing bladder control disorders in older adults are reviewed.

Phillip P. Smith: deceased.

Authors would like to dedicate this chapter to the memory and legacy of our colleague, collaborator and friend Dr Phil Smith

Appendices

Appendix A

Fig a

Example of a Voiding Diary

Appendix B

Fig b

Example of a Bladder Diary

Appendix C: Office Cystometry Procedure and Interpretation

Procedure

• 1. Supplies at the ready: 14 or 16 Fr. Catheter. 500 ml of sterile water or saline. A Toomey syringe (or equivalent, with a catheter tip and at least 50 ml capacity). Clean gloves, tissues, lubricant. Kidney basin (to catch postvoid volume).

• 2. Explain the procedure and obtain verbal consent. This is same risk and discomfort as a straight catheterization to drain the bladder in a clinic examination room; therefore, consent process should follow institutional practice (verbal vs. written).

• 3. Have patient void the bladder as usual.

• 4. Patient undresses, waste down.

• 5. Gross contamination is cleansed from the urethral meatus. Antisepsis is not required and may irritate urethral outlet.

• 6. Operator wears clean exam gloves. The tip of a sterile 14 or 16 Fr catheter (latex, or silicon if allergic to latex) is lubricated with clinical lubricant, and the catheter is passed into the bladder. Collect and record the post void residual volume. Urine may be sent for culture or microscopic examination as needed.

• 7. Remove the plunger or bulb from the syringe and attach to the catheter.

• 8. Hold the syringe body about 15 cm (6 inches) above pubic symphasis and pour in about 50 ml of fluid, raise syringe as needed to observe fluid flowing into the bladder (syringe volume declines).

• 9. Ask the patient to report when they feel something in the bladder; the patient should be quiet (no conversation) to avoid increases in bladder pressure due to transmitted increases in intra-abdominal pressure.

• 10. When this is complete, refill the syringe and allow fluid inflow to start, but then lower syringe until fluid flow stops. If fluid backs up into the syringe, raise it until volume in syringe is stable. Estimate distance from top of fluid in syringe to pubic symphasis; this is the “low volume pressure” (i.e., if 15 cm above symphysis, “low volume pressure” is 15 cm of water).

• 11. Raise syringe about 5 cm above this level and continue to fill bladder, refilling the syringe as needed. Observe fluid level drop in the syringe as the bladder fills.

• 12. If column “bounces” (i.e., stops/starts, or even temporarily rises), and the patient is not talking/straining/valsalva’ing, “detrusor overactivity” (DO) can be suspected. Record volume and any accompanying reported sensations.

• 13. Repeat syringe filling until patient reports some desire to void. Raise/lower syringe to stabilize column height and measure height of fluid column above symphysis; this is “high volume pressure.” Record this pressure and the volume infused.

• 14. Remove catheter and ask patient to Valsalva and/or cough, observing meatus for any leakage (stand to the side and have a tissue positioned in case leakage happens).

Interpretation

• First sensation and voiding sensation assess patient’s awareness of bladder. In our experience, first sensation is typically around 50 ml, and voiding sensation at office cystometry is typically around 250–300 ml.

• Presence or absence of DO can help to understand the cause of incontinence and/or symptoms of urgency. Sensed DO may underlie urgency, whereas leakage may occur with either sensed or non-sensed DO.

• Calculate Compliance as difference between high and low volume divided by difference between high and low volume pressures (e.g., (250 ml – 50 ml)/(17 cm – 15 cm) = 100 ml/cm of water. Values below 40 should be concerning, and values below 20 should be considered for urologic referral.

• If no DO was observed but the patient leaks with Valsalva or cough at “high volume,” sphincteric insufficiency can be strongly suspected as a cause for incontinence. If DO was observed, this is not a safe assumption.