URINARY DISTURBANCE MANAGEMENT IN ELDERLY

URINARY INCONTINENCE IN ELDERLYDr dr RA Tuty Kuswardhani SpPD KGer; MARS RS PTN UNUD BALIDivisi Geriatri SMF llmu Penyakit Dalam FK UNUD

Mrs. L,80 yo; explains that, on the night of the falls and gets fracture, she woke up to urinate around midnight, and the broke her shoulder. The conversation reminded Mrs. L that she experienced frequent nocturnal urination during the hospitalization and on several occasions was unable to get to the toilet on time and become incontine she develops urinary urgency as soon as the key goes into the lock. She has occasionally experienced leakage when sneezing, standing, or coughing but this most commonly occurs when she is trying to hold her urine during one of her urgent episodes. Still, she did not view her urinary pattern as a big problem until her recent hospitalization.Mrs. L visited her gynecologist 1 year ago. She has no cystocele, rectocele, or uterine prolapse. She denies dysuria, fever, or constipation.

QuestionWhat factors contributed to the patients urinary incontinence?How should her problem be approached? What non pharmacologic approaches could be of benefit to this patient?

CASE2

3UI - unconsencius not wanted to induce social and problem hygiene

(International Continence Society, 2002)

Definition of UI

@ Data Geriatry SANGLAH Hospital Denpasar : UI FEMALE IN 60-85 YO (2011) Prevalens 21 % @ USA prevalens: 47% post menopause (2012)

Prevalence Urinary Incontinence5CLINICAL IMPLICATION UIClinical significant : health physic and emosional Incontinence Urine stress, depression ,limitation function sex, risk falls mortality

Embarrassment Contributes to Rationalization of Condition as not worth medical attentionEmbarassementDirtySign of old ageSmellNot worth disturbing the DoctorDisgustChild-likeAstellas Market Research : Branding Science 20067Type of Urinary Incontinence (Peet et al ; 2005):Rule out of Transient CausesD eliriumI nfectionA trophyP harmaceuticalsP sychologicE ndocrine or excess urine outputR estricted mobilityS tool impaction9

Normal Bladder Over active BladderOverflow BladderStress Bladder

Neurogenic BladderImages Of Bladder Condition in Normal and Four Types of Urinary Incontinence10SKIN: Urinary Incontinence : iritation, mechanic ,fraillty, infection Dermatitis Perineum/ Incontinence Dermatitis Infection 1 - 2 organisme: Tinea and Candida Albicans

HealthyUnHealthy

UI AND SKIN INFECTIONIncontinens Urin in MANBPH : Gland prostat >

> 60 YO: 60% > 90 %: 80 YO, LUTS and BPH

SIGN : Obstruction, < path urinary urgency ; .> urinary at night; incontinence

Gambar tetep yang lama12UI IN FEMALEMenopause estrogen in menopause women caused in supportive: tissue, thinning of urethral and vaginal epitel, vascularisation of urethral submucosa, cellular Estrogen defisiensi is an important ethiology of lower urinary tract disease including urge symptoms(frequency, nocturia, urgency, incontinence urge)

The role of Receptor Estrogen is IMPORTANT in mechanism on Stress Urinary Incontinence

Assesment : History and Physical :Pertanyaan : Apakah anda mengompol / BAK atau BAB tanpa disadari ?0tidak pernah1,0kadang-kadang kehilangan kontrol berkemih/menggunakan alat bantu untuk berkemih & BAB2,5kehilangan kontrol berkemih sedikitnya sekali dalam sebulan4,0kehilangan kontrol berkemih sedikitnya 2 kali sebulan/kadang-kadang kehilangan kontrol BAB5,0kehilangan kontrol BAB sedikitnya sekali dalam sebulan5,5kehilangan kontrol berkemih sedikitnya sekali dalam seminggu6,5kehilangan kontrol BAB sedikitnya 2 kali sebulan8,0kehilangan kontrol BAB sedikitnya sekali seminggu/kehilangan kontrol berkemih sedikitnya sekali setiap hari10kehilangan kontrol BAB sedikitnya sekali sehari10,5tidak bisa mengontrol fungsi berkemih sama sekali11,5tidak bisa mengontrol BAB sama sekaliTotal SkorIncontinence Scanning Incontinence classified : 0 : No Incontinence 1 2,5 : Mild Incontinence 4,0 6,5 : Moderate Incontinence 8 : Severe Incontinence(Johnston B, UCSF. 2009)DIAGNOSIS 14UI DAILY CARD

Warning TimeThe time between the onset of urgency and or incontinence

Significant to patients since it represents the time they have to find a bathroom and avoid possible incontinence

16RD slide

Warning time potential to be one of most useful measures but difficulty in definition when the start the clock at which sensation

Affected by external factorsUsing the Urgency Perception Score (UPS) with a Patient in PracticeThe Urgency Perception Scale (UPS)Describes the ability of a patient to hold urine and finish tasks before going to the toilet

Cardozo L et al BJU Int 2005; 95:591-59617PHYSICALABDOMEN : peritonitis, FLUID, mass

Rectum : impaksion, sphincter tonus, sensasi perineal, prostat

Man: skin perineum

Female: prolapsus utery

Atrophy organ: pelvis, mass , muscle

Volume urine : test cough

VOLUME PVRURINALYSIS

EVALUATION18THERAPY type functional in man Condom CateterFemale tampon , pampers Technic Toileting Bladder TrainingKaegel Exercise 1.NON PHARMACOLOGYINTERVENTION Kaegel exerciseMenemukan MUSCLE yang tepat Menahan otot yang digunakan Jika merasakan perasaan tertarik maka siap latihan pelvicJangan lakukan pada otot lain pada waktu bersamaan atau menahan nafas Hanya tekan otot pelvic, tarik otot pelvic dan tahan selama 3 detik Kemudian rileks selama 3 detik, Ulangi jangan berlebihan, Latihan sampai 3 X -10 X

THERAPY NON PHARMACOLOGY agonist cholinergic , inhibitor alpha adrenergic,anti muscarinic

BetaneCol

PrazosinAgonis cholinergicDosis 10 25 mg/oral 6 8 hrs in elderly SE: UlCus PeptiCum, hYpotensi on OF Postural

Inhibitor alpha adrenergicDosis 1 mg/oral 8 12 hrs hypotenti on posturalOxybutinin Antimuscarinic effect relaxationMetabolite in Reseptor M antagonist muscarinic selective receptor M1, M3, M4 Dosis :2,5 5 mg/oral, 24 x perday, patch 3 mg,9 mg/ day syrup 5mg / 15ml, transdermal gel 3%, 9%

SolifenacineSolifenacin Succinate receptor antagonist cholinergic Dosis : 510 mg/oral /12 x per day CKD & hepar IMPAIRMENT NO recommendation for dosis > 5mg / day 2. THERAPY PHARMACOLOGY

Name21Name agonist cholinergic , inhibitor alfa adrenergic, anti muscarinicTolterodineAntagonis kompetitif anti muscarinik selective dosis 2 mg/ day Tolterodine : frecuension urine tolerance >, withdrawl