Special considerations in elderly individuals with urinary incontinence.

OBJECTIVES: To describe special considerations related to the etiology, evaluation, and treatment of urinary incontinence (UI) in the elderly. METHODS: The characteristics of UI in older patients are contrasted with those in younger patients. Recommended evaluations for elderly individuals are reviewed, and treatment issues are addressed. RESULTS: The etiology of UI is more complex in older than in younger patients, and a different clinical approach is required. Bladder overactivity is a common underlying component of UI in the elderly patient regardless of the complexity of the etiology. The most common voiding symptom in elderly patients is urgency with urge UI. The evaluation of the older patient with UI should include a symptom assessment, physical examination, review of the medical history (particularly with regard to previous surgeries), and assessments of social environment and functional status (which can have an impact on the type of treatment selected and the success of therapy). Urodynamic evaluations are particularly important because of the complexity of UI in this population. Treatment options include pharmacologic therapies, behavioral interventions, electrical stimulation, and combination therapies. The combination of surgical and nonsurgical therapies may be particularly important in the future. CONCLUSIONS: Control of bladder overactivity is the most significant long-term challenge in the management of UI in the elderly. Successful treatment can produce a marked improvement in the quality of life for these individuals.

Behavioral modification for institutionalized individuals with urinary incontinence.

OBJECTIVES: To review the evaluation of urinary incontinence (UI) in institutionalized individuals and to discuss the use of behavioral modification in this population. METHODS: The functional characteristics and patterns of incontinence typical of the institutionalized population are described to explain the rationale for the use of behavioral therapies. RESULTS: Both mental and physical status must be evaluated when considering behavioral therapies for UI in institutionalized patients. Institutionalized individuals often have significant functional impairment that prevents the use of behavioral therapies requiring extensive patient participation. Assessments of bladder function and the severity of UI are also important when planning therapy. In appropriate candidates, a prompted voiding program can be expected to reduce the severity of incontinence and improve the quality of life, even though normal bladder control is rarely achieved. Standardized protocols for the implementation of a prompted voiding program have been developed. CONCLUSIONS: Few treatment options for UI are feasible for use in institutionalized individuals. However, prompted voiding can reduce the severity of UI in most of these patients and will thereby improve the quality of life.

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association.

PURPOSE: The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures. RESULTS: The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings. CONCLUSIONS: The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Effects of subcutaneous bethanechol on bladder sensation during cystometry.

Bethanechol has been shown to produce a pharmacologic effect on the urinary bladder, although the clinical efficacy of this response is controversial. The measured response has been an increase in detrusor pressure, although sensory effects may occur also. In this study, 10 neurologically intact men had cystometry before subcutaneous administration of 5 mg bethanechol chloride and thirty minutes after bethanechol. The sensation of desire to void and the maximum cystometric capacity occurred at a higher intravesical pressure and a smaller bladder capacity following bethanechol. Subcutaneous bethanechol appears to alter the bladder pressure and capacity at which the perception of desire to void and the sensation of maximum fullness occurs.

Effects of serum acid phosphatase [correction of phosphate] elevation following transurethral prostatectomy on long-term mortality.

Studies of surgery for symptoms of bladder outlet obstruction in men suggest that a possible higher long-term mortality occurs in patients having transurethral prostatectomy compared with patients having an open prostatectomy. It is the purpose of this study to determine if intraoperative factors affect the long-term survival of patients having transurethral prostate resection for benign prostate hypertrophy. In 158 consecutive patients having transurethral prostatectomy for benign adenoma who were followed for eight years, 28 patients died during the follow-up period. In comparing those patients who are alive with those patients who have died, there was no significant difference at the time of surgery in intraoperative irrigant absorption as indicated by changes in serum sodium and there was no significant difference in the intraoperative absorption of prostate tissue substances as indicated by changes in serum acid phosphatase. The only factor in this study associated with long-term survival was age of the patient at the time of surgery with older patients having a higher long-term mortality. This study suggests that age of the patient rather than intraoperative factors is associated with long-term survival following transurethral prostatectomy.

Results of surgical management of Peyronie's disease.

Peyronie's disease is often managed surgically when medical management fails and sexual function is impaired due to residual curvature or loss of erectile function. In this study 63 patients were treated surgically, with 25 receiving a penile prosthesis, 25 undergoing a tunica vaginalis graft and 13 undergoing the Nesbit ellipse procedure. The long-term surgical outcome as determined by sexual function indicated that the penile prosthesis group remained the most sexually active, followed by the Nesbit ellipse group with the tunica vaginalis graft group being the least sexually active. Incision of curvature with placement of a penile prosthesis for the surgical management of Peyronie's disease remains an approach that has excellent long-term functional results.

Combined Raz urethral suspension and McGuire pubovaginal sling for treatment of complicated stress urinary incontinence.

Urinary incontinence is a debilitating problem that affects over 20 million people in the United States. Anatomical stress incontinence in women has an excellent continence outcome following urethral suspension procedures. However, intrinsic urethral incontinence has a high failure rate following urethral suspension procedures and is usually managed with a pubovaginal sling procedure. Eight patients with both anatomical and intrinsic urethral incontinence were managed with a combined urethral suspension procedure and pubovaginal sling procedure. Seven patients remain continent while one continues to have intrinsic urethral incontinence. The combined urethral suspension procedure and pubovaginal sling procedure appears to provide a treatment option for patients with coexisting anatomical and intrinsic urethral incontinence.

Urinary incontinence volume patterns in elderly inpatient men.

Urinary incontinence is a costly and debilitating disease of the aged. Although the most common clinical finding is detrusor hyperreflexia on filling cystometry, the role of this urodynamic abnormality in the etiology of incontinence is uncertain. The purpose of this study was to evaluate elderly patients who have cystometric detrusor hyperreflexia and to determine the incontinence volume characteristics of these patients during regular daily activities. Ten patients with detrusor hyperreflexia during filling cystometry and an incontinence volume level above 1 L per day were evaluated according to the volume of urine loss per incontinence episode during a ten-day measurement period. All patients studied were found to have an irregular urinary incontinence volume distribution with a wide range of involuntary urine loss per incontinence episode. An irregular pattern of incontinence volume was found in each patient which suggests that detrusor hyperreflexia is manifest as an irregular involuntary loss of urine during daily activities of elderly inpatients. This unstable bladder activity relative to the volume of urine loss appears to be an important factor in the pathophysiology of urinary incontinence in aged inpatients.

Pitfalls of urodynamic testing.

Urodynamic studies are one of the most useful clinical techniques available for the evaluation of lower urinary tract dysfunctions. Urodynamic data are of immense value in the diagnosis and treatment of many disorders of bladder and urethral function. However, there are problems of measurement that can limit the clinical applications of information obtained. First, the urologist should have a special interest in the neurophysiology of lower urinary tract disorders. Second, the standardized ICS concepts and terminology should be used in the descriptions of the findings. Third, the clinical value and limitations of each segment of the studies should be appreciated by the urologist. Fourth, careful attention should be given to the testing methodology and the calibration of the instruments. Finally, an investigative scientific approach should be taken to the interpretation of the data obtained.

Biofeedback therapy technique for treatment of urinary incontinence.

Biofeedback treatment of urinary incontinence is a management method that has low risk and therapeutic efficacy for selected patients. Biofeedback therapy techniques vary widely and have not been well described or standardized. A technique for biofeedback therapy is described that allows accurate signal monitoring and assures appropriate biofeedback to the patient. External anal sphincter electromyographic performance is presented to the patient as a color line graph with pitch variable audio feedback. The method has complete flexibility in providing biofeedback training according to patient performance level and is one that can be easily interpreted by patients who have voiding dysfunctions.

Incontinence management scale for elderly inpatient men.

For many elderly inpatients, urinary incontinence cannot be successfully treated and the management objective is identifying a suitable method for containment of urine loss. In elderly inpatient men, an external catheter is utilized in many cases for incontinence management. The role of the severity of incontinence and the use of an external catheter was investigated in 66 elderly inpatient men. Quantitative incontinence measurements showed incontinent patients having an external catheter had approximately 6.3 (SD = 2.5) episodes per day compared with 3.2 (SD = 2.0) episodes per day in the noncatheter incontinent patients. The clinical management method used in these patients was associated with the measured severity of incontinence.

Continence level following radical prostatectomy.

The relationship of the urethral anastomosis and postoperative continence following radical prostatectomy is uncertain. The objective of this study was to determine radiographically the functional level of continence following radical prostatectomy relative to the site of the intraoperative urethral anastomosis. In 8 patients having a radical prostatectomy, an intraoperative hemoclip was placed at the site of the urethral anastomosis and the postoperative functional level of continence was determined using a standing lateral cystogram. The functional level of continence was 9 mm (SD = 3.0) distal to the site of the urethral anastomosis. The level in the urethra that continence occurs may be a function of the intrinsic continence parameters of each individual patient.

Responses of detrusor smooth muscle to stretch and relaxation: in vitro study.

An in vitro model subjecting bladder muscle strips to continuous stretch relaxation evaluated-the properties of passive muscle length and tension. Tension generated as a strip was stretched or relaxed was found to be stretch-rate dependent. The primary influence of stretch rate on muscle tension is by alteration of muscle length; however, stretch and relaxation rates do influence the inherent smooth muscle properties of hysteresis, stress-relaxation, and adaptation. The characteristic filling curve to the point of bladder contraction seen clinically during cystometry in the neurologically intact subject can be reproduced in isolated bladder muscle strips. The bladder function of storage is a result of passive smooth muscle properties of muscle length and tension which can, however, be altered by superimposed neurologic influences.

Urinary incontinence volume measurement in elderly male inpatients.

Urinary incontinence is a debilitating disease in the elderly and is a leading cause of nursing home placement for aged patients in our society. Accurate measurement of urinary incontinence in elderly inpatients is necessary to determine the severity of the disease and to evaluate the efficacy of any treatment methods being investigated. The technique required for evaluation of elderly chronic care inpatients is different from methods that can be used in patients who do not have the ambulatory and cortical impairment that is common among chronic care inpatients. Since chronic care nursing staff involvement is necessary for accurate measurement and recording of incontinence episodes, a procedure for measurement must be well defined and clearly outlined in a sequence that can be followed easily. This study provides a method of incontinence volume assessment for elderly inpatients that can be performed by inpatient nursing staff to provide accurate incontinence volume measurements. Quantitative urinary incontinence volume measurements were done over ten days in 42 elderly men. Urinary incontinence presented as a significant problem in these patients over a wide range of both frequency and volume of urinary incontinence episodes. The volume measurement technique described allowed the nursing staff to identify, measure, and record incontinence severity over a wide range of frequency and volume while monitoring multiple patients simultaneously.

Synergist Erection System: clinical experience.

The Synergist Erection System (SES) was tested over a six-month period in 44 impotent patients with an organic etiology. The device was successfully used by 73 percent. The duration of erection for 75 percent of the patients was as long as they wanted to wear the device. The frequency of use was once a week for 47 percent. The quality of erection was rated satisfactory by 63 percent of the patients and 78 percent of the couples rated satisfactory intercourse. It appears the SES option is a valid one with high success and satisfaction rating at least on a short-term basis. In addition, it offers prophylactic protection.

Follow up outcome of intracavernous papaverine.

One of the more significant recent therapeutic developments in the treatment of male impotence has been intracavernous pharmacotherapy using penis self-injection technique. The intracavernous pharmacotherapy of impotence results in a relatively normal erection in most cases with minimal alteration of the anatomy, physiology, and psychosocial factor of impotence. However, early treatment success of the patient does not assure long-term success. The objective of this study was to determine the long-term utilization outcome of intracavernous pharmacotherapy in the management of impotence. Of 103 enrolled in the study, 50 patients (49%) were actively using the injection treatment method after 18 months. There were no significant difference in mean age of those patients who discontinued from those who continued to use intracavernous therapy. Of the 53 patients (51%) who discontinued intracavernous therapy, 33 patients (62%) were unsatisfied with the results, nine patients (17%) were unsatisfied with the methodology, eight patients (15%) developed penile complications, and three patients (6%) had improvement of sexual function. Thirty-four (69%) of those who discontinued therapy elected an alternative form of therapy and 16 patients (30%) were not interested in any further treatment. While it is difficult to assess the many factors involved in the outcome of therapy for impotence, the assessment of long-term intracavernous therapy utilization provides a relatively low risk means for clinical evaluation of the therapeutic value of pharmacotherapy for the individual as well as a clinical indication of the sexual function needs of the patient.

Central actions of bethanechol on the urinary bladder in dogs.

Bethanechol has been used to promote bladder emptying although the clinical efficacy of bethanechol remains uncertain. Both laboratory and clinical observations suggest that the pharmacologic actions of bethanechol are dependent to some extent on intact reflex mechanisms of the bladder. The objective of this study was to determine the effects of central nervous system administration of bethanechol on reflex detrusor contractions. Twelve isolated cross perfusion studies of the central nervous system in dogs were done to determine the cystometric response to central bethanechol administration. Central bethanechol resulted in reflex bladder contractions, decreased cystometric volume, increased maximum intravesical pressure, and increased periurethral EMG activity. This study demonstrated a central nervous system site of pharmacologic activity of bethanechol.

Effects of intravenous infusion of human prostate tissue substances in dogs.

Symptoms of postresection syndromes following transurethral prostatectomy have been associated with a transient increase in serum acid phosphatase due to intraoperative absorption of prostate tissue substances. Factors associated with postoperative syndromes include intraoperative absorption of irrigant solution, intraoperative blood loss, and intraoperative absorption of prostate tissue substance. An animal model was used in this study to determine the isolated physiologic effects of intravenous infusion of a saline prostate tissue extract using an infusion schedule comparable to that of transurethral prostate resection. Twenty-four animals received either normal saline infusion (control) or saline prostate tissue extract infusion (experimental). The experimental group showed a significant decrease in fibrinogen, platelet count, white blood count, activated clotting time, and plasma volume. These results suggest that the isolated effects of intravascular absorption of prostate tissue substances are due to disseminated intravascular coagulation, most likely resulting from tissue thromboplastin and activation of plasminogen.

Serial incontinence assessment in elderly inpatient men.

Urinary incontinence is a major problem for elderly chronic care patients. As a consequence, a high level of nursing care is required for patient management. Because incontinence rehabilitation programs are usually implemented during the day shift, the incidence of incontinence according to time of day has major implications regarding patient management. Although treatment is usually based on severity, assessment of incontinence severity in elderly chronic care inpatients is difficult. In this study, a telemetric incontinence detection system was developed to identify incontinence episodes. An absorbent pad exchange technique was used for incontinence volume measurement. The study group, 66 chronic care inpatient men over 65 years old, were subject to incontinence measurements over 10 days during all nursing shifts using the telemetric incontinence detection system. The results showed a significantly high incidence of incontinence episodes during the evening nursing shift. The volume of involuntary urine loss was significantly higher during the night nursing shift. Thus, the highest level of incontinence severity occurred during the time of day when nursing staff on chronic care units is usually the lowest.