URINARY INCONTINENCE IN THE ELDERLY FEMALE
- Mon, 10/12/09 - 10:08am
- 0 Comments
- 6475 reads
Pages 41 - 45
Alex Gomelsky, MD
Urinary incontinence is a common condition in the rapidly aging U.S. population. The incidence and prevalence of incontinence is increasing in the elderly, in no small part due to the greater recognition of its signs and symptoms and the subsequent negative impact on quality of life. Elderly women are different from their younger counterparts, due not only to several physiologic changes in the urinary tract, but also to concomitant morbidity and polypharmacy. While the elderly have the same treatment options as younger women, they may experience a greater incidence of adverse events due to urologic and nonurologic factors. The objective of this review is to elucidate the unique changes in the elderly population and summarize the treatment options. (Annals of Long-Term Care: Clinical Care and Aging 2009;17:41-45)
In 2003, a panel convened by the International Continence Society (ICS) defined the signs, symptoms, urodynamic observations, and conditions associated with lower urinary tract symptoms (LUTS) and urodynamic studies.1 The symptoms of LUTS were categorized into several distinct types of incontinence. Stress urinary incontinence (SUI) refers to involuntary leakage on effort, exertion, or other increases in intra-abdominal pressure.1 Urge urinary incontinence (UUI) is involuntary leakage accompanied or immediately preceded by urgency, while mixed urinary incontinence (MUI) refers to incontinence with symptoms of both SUI and UUI.1
Several emerging trends are germane to a discussion of incontinence in the elderly woman. First, the population is aging. A report by the U.S. Census Bureau noted that, while the total U.S. population has increased twofold in the past century, the population of Americans age 60 years and older increased tenfold to 35 million in the year 2000.2 Additionally, the number of Americans over age 80 is expected to increase by nearly 70% from 2000 to 2030. Second, incontinence is an increasingly common problem in the aging population. An analysis of more than 3100 responses to a medical questionnaire showed that the estimated incidence of incontinence increased steadily with age, especially through ages 25-29 and 45-49.3 By the age of 59 years, 30% and 18% of individuals were estimated to have had one or more episodes of incontinence in general and incontinence as defined by the ICS, respectively.
The prevalence of different types of incontinence is also considerable. A U.S. national telephone survey using a clinically validated interview of 5204 adults revealed that the prevalence of UUI in women increased with age from 2.0% to 19%, with a marked increase after 44 years of age.4 The prevalence of SUI has been reported to be as high as 40% in women after age 70, with one-third of these women classifying their incontinence as severe.5,6
Additionally, the most common type of incontinence may change with age. Once the prevalence rates of different types of incontinence were stratified by frequency and age, 55% of women under 60 years of age were found to have pure SUI, while 20% and 25% had UUI and MUI, respectively. In comparison, SUI accounted for only 30% of incontinence cases in the over-60-year-old female, while UUI and MUI each accounted for 35% of cases.7
Incontinence may also make a significant impact on a woman’s quality of life (QoL).
1. Abrams P, Cardozo L, Fall M, et al; Standardisation Sub-Committee of the International Continence Society. The standardisation of terminology in lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Urology 2003;61(1):37-49.
2. Hobbs F, Stoops N. Demographic Trends in the 20th Century. Washington, DC: United States Census Bureau, Census 2000 Special Reports, Series CENSR-4. United States Government Printing Office. Issued 2002. http://www.census.gov/prod/2002pubs/censr-4.pdf. Accessed August 26, 2009.
3. Elving LB, Foldspang A, Lam GW, Mommsen S. Descriptive epidemiology of urinary incontinence in 3100 women age 30-59. Scand J Urol Nephrol Suppl 1989;125:37-43.
4. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003;20(6):327-336. Published Online: November 15, 2002.
5. McGrother C, Resnick M, Yalla SV, et al. Epidemiology and etiology of urinary incontinence in the elderly. World J Urol 1998;16(suppl 1):S3-S9.
6. Hunskaar S, Burgio K, Diokno A, et al. Epidemiology and natural history of urinary incontinence in women. Urology 2003;62(4 suppl 1):16-23.
7. Thom D. Variation in estimates of urinary incontinence prevalence in the community: Effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc 1998;46(4):473-480.
8. Johnson TM 2nd, Kincade JE, Bernard SL, et al. The association of urinary incontinence with poor self-rated health. J Am Geriatr Soc 1998;46(6):778-779.
9. Frick AC, Huang AJ, Van den Eeden SK, et al. Mixed urinary incontinence: Greater impact on quality of life. J Urol 2009;182(2):596-600. Published Online: June 17, 2009.
10. Elbadawi A, Yalla SV, Resnick NM. Structural basis of geriatric voiding dysfunction. II. Aging detrusor: Normal versus impaired contractility. J Urol 1993;150(5 Pt 2):1657-1667.
11. Elbadawi A, Yalla SV, Resnick NM. Structural basis of geriatric voiding dysfunction. III. Detrusor overactivity. J Urol 1993;150(5 Pt 2):1668-1680.
12. Forsberg JG. A morphologist’s approach to the vagina—age-related changes and estrogen sensitivity. Maturitas 1995;22(suppl):S7-S15.
13. Perucchini D, DeLancey JO, Ashton-Miller JA, et al. Age effects on urethral striated muscle. I. Changes in number and diameter of striated muscle fibers in the ventral urethra. Am J Obstet Gynecol 2002;186(3):351-355.
14. Perucchini D, DeLancey JO, Ashton-Miller JA, et al. Age effects on urethral striated muscle. II. Anatomic location of muscle loss. Am J Obstet Gynecol 2002;186(3): 356-360.
15. Strasser H, Tiefenthaler M, Steinlechner M, et al. Age dependent apoptosis and loss of rhabdosphincter cells. J Urol 2000;164(5):1781-1785.
16. Verelst M, Maltau JM, Ørbo A. Computerised morphometric study of the paraurethral tissue in young and elderly women. Neurourol Urodyn 2002;21(6):529-533.
17. Carlile A, Davies I, Rigby A, Brocklehurst JC. Age changes in the human female urethra: A morphometric study. J Urol 1988;139(3):532-535.
18. Resnick NM, Yalla SV. Geriatric incontinence and voiding dysfunction. In: Wein AJ, Kavoussi LR, Novick AC, et al, eds. Campbell-Walsh Urology. Philadelphia, PA: Saunders Elsevier; 2005:2305-2321.
19. Diokno AC, Wells TJ, Brink CA. Urinary incontinence in elderly women: Urodynamic evaluation. J Am Geriatr Soc 1987;35(10):940-946.
20. Resnick NM, Yalla SV. Detrusor hyperactivity with impaired contractile function. An unrecognized but common cause of incontinence in elderly patients. JAMA 1987;257(22):3076-3081.
21. Resnick NM, Yalla SV, Laurino E. The pathophysiology of urinary incontinence among institutionalized elderly persons. N Engl J Med 1989;320(1):1-7.
22. DuBeau EC. The aging urinary tract. J Urol 2006;175(3 pt 2):S11-S15.
23. Resnick NM. Noninvasive diagnosis of the patient with complex incontinence. Gerontology 1990;36(suppl 2):8-18.
24. Lavelle JP, Karram M, Chu FM, et al. Management of incontinence for family practice physicians. Am J Med 2006;119(3 suppl 1):37S-40S.
25. Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med 2005;165(7):808-813.
26. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: Does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000;48(7):721-725.
27. Burgio KL Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: A randomized controlled trial. JAMA 1998;280(23):1995-2000.
28. Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc 2000;48(4):370-374.
29. Rotzoll S. Pelvic floor muscle training for urinary incontinence. Which training method is the most effective for people over 60 years [article in German]? Pflege Z 2008;61(11):610-615.
30. Zinkgraf K, Quinn AO, Ketterhagen D, et al. Percutaneous tibial nerve stimulation for treatment of overactive bladder and urinary retention in an elderly population. Urol Nurs 2009;29(1):30-34.
31. Abrams P, Andersson KE, Buccafusco JJ, et al. Muscarinic receptors: Their distribution and function in body systems, and the implications for treating overactive bladder. Br J Pharmacol 2006;148(5):565-578. Published Online: June 5, 2006.
32. Scarpero HM, Dmochowski RR. Muscarinic receptors: What we know. Curr Urol Rep 2003;4(6):421-428.
33. Ikeda K, Kobayashi S, Suzuki M, et al. M(3) receptor antagonism by the novel antimuscarinic agent solifenacin in the urinary bladder and salivary gland. Naunyn Schmiedebergs Arch Pharmacol 2002;366(2):97-103. Published Online: June 14, 2002.
34. Wagg A, Wyndaele JJ, Sieber P. Efficacy and tolerability of solifenacin in elderly subjects with overactive bladder syndrome: A pooled analysis. Am J Geriatr Pharmacother 2006;4(1):14-24.
35. Katz IR, Sands LP, Bilker W, et al. Identification of medications that cause cognitive impairment in older people: The case of oxybutynin chloride. J Am Geriatr Soc 1998;46(1):8-13.
36. Lipton RB, Kolodner K, Wesnes K. Assessment of cognitive function of the elderly population: Effects of darifenacin. J Urol 2005;173(2):493-498.
37. Oliphant SS, Wang L, Bunker CH, Lowder JL. Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004. Am J Obstet Gynecol 2009; 200(5):521.e1-e6.
38. Anger JT, Weinberg AE, Albo ME, et al. Trends in surgical management of stress urinary incontinence among female Medicare beneficiaries. Urology 2009;74(2):283-287. Published Online: June 7, 2009.
39. Richter HE, Goode PS, Brubaker L, et al. Two-year outcomes after surgery for stress urinary incontinence in older compared with younger women. Obstet Gynecol 2008;112(3):621-629.
40. Sharp VJ, Bradley CS, Kreder KJ. Incontinence surgery in the older woman. Curr Opin Urol 2006;16(4):224-228.
41. Campeau L, Tu LM, Lemieux MC, et al. A muticenter, prospective, randomized clinical trial comparing tension-free vaginal tape surgery and no treatment for the management of stress urinary incontinence in elderly women. Neurourol Urodyn 2007;26(7):990-994.
42. Lo TS, Huang HJ, Chang CL, et al. Use of intravenous anesthesia for tension-free vaginal tape therapy in elderly women with genuine stress incontinence. Urology 2002;59(3):349-353.
43. Anger JT, Litwin MS, Wang O, et al. Complications of sling surgery among female Medicare beneficiaries. Obstet Gynecol 2007;109(3):707-714.
44. Anger JT, Litwin MS, Wang O, et al. The effect of age on outcomes of sling surgery for urinary incontinence. J Am Geriatr Soc 2007;55(12):1927-1931.