Il paziente con incontinenza urinaria: attualità in tema di diagnosi e opzioni terapeutiche

Prof. Massimo Porena Dept. of Urology and Andrology, University of Perugia

We are speaking on…

1) Epidemiology and classification;

2) Pathophisiology;

3) Clinical picture;

4) Diagnosis;

5) Treatment

Epidemiology and classification

Lower urinary tract dysfunction is

one of the most prevalent disorders in

the elderly, especially in the

oldest old patient

The oldest old, defined

variously as those aged 80 or 85 years or

older,

are now the fastest growing sector of

the population worldwide

In United Kigdom: 2-3 millions of incontinente patients

In USA: 10-12 millions of incontinent patients

In Italy: at least 3 millions of incontinent patients

But the real prevalence is under- extimated

PREVALENCE OF UI in the general population:

Years 1990-2000 (ICI 2009)

Costs: highly impressive in both Europe and

USA

• 1990: USA -> than 10 billiondollars

• Social problem largely neglected

(ICI 2009)

• Known incontinent patients for the Social Health

Ministery are fewer than continent patients in community

houses

• Prevalence of UI increases with increasing age and it is

higher in females than in males

(Garcia-Perez et al., Int Urogynecol J. 2012)

Epidemiology data

Urinary incontinence (UI) occurs in 17- 55% of oldest old

patients living in community.

Medically, it predisposes individuals to:

- perineal rashes;

- pressure ulcers;

- falls;

- insertion of an indwelling catheter;

- urosepsis and death.

Psychosocially, it is associated with stigmatization, anxiety, depression, cessation of

intimacy and institutionalization.

(Christine M. Ruby et Al. J Am Geriatr Soc. 2010)

Urinary incontinence classification (ICI 2009)

Definitions

Stress UI: due to sphincteric incompetence

Urge UI: due to

detrusor overactivity

Mixed UI: coexistence

of the two conditions

Age category (years)

No incontinence (%)

Any incontinence (%)

Types of urinary incontinence

Stess only (%)

Urge only (%)

Mixed (%)

< 35 72.2 27.8 16.7 0 11.1

35<45 57.3 42.7 25.3 5.3 12

45<55 59.6 40.4 17.5 4.4 18.4

55<65 59.6 40.4 14.7 5.1 20.6

65<75 57.8 42.2 11.7 10.9 19.5

>= 75 45.5 54.5 12.1 24.2 18.2

Prevalence of different types of urinary incontinence over the previous month based on 10 year age group

(Roslin Botlero et Al., Maturitas 2009)

UI and both urge and stress incontinence are

positively related to falls.

The larger the volume of urine lost, the greater the risk of falls.

Falls are associated with:

-the presence of urinary symptoms,

-physical limitations

- poorer quality of life in respondents with UI.

(Foley AL et al., Neurology International 2012)

Pathophisiology

Nervous control of the micturition reflex

The frontal cortex is now recognized as an important centre for

micturition. Damage to the prefrontal cortex, medial

superior/middle frontal gyro, anterior cingulated cortex and

supplemental motor area have been shown to result in marked

lower urinary tract dysfunction in humans.

Detrusor Overactivity (DO) and the clinical picture represented

by overactive bladder (OAB), is the major underlying

pathophysiology of “vascular brain” incontinence

(Ryuji Sakakibara et al., Neurology International 2012)

Concomitant white matter changes are likely to

contribute to detrusor overactivity (DO)

White matter disease can cause UI and in some patients this may be the initial

manifestation.

Functional imaging studies have shown that anterior lesions, especially of the deep white matter of the frontal lobe, more often result in incontinence.

Other neurological conditions may also manifest with incontinence:

- Alzheimer’s disease (DO: 40%);

- Parkinson’s disease (DO: 45- 93%);

- Dementia with Lewy bodies (DO: 71%);

- Progressive supranuclear palsy (DO: 67%).

UI in patients with dementia: an unknown problem

Only few data about prevalence of incontinence in people with

cognitive impairment or dementia

It ranges from 1.1% in a general community population to 38% in those receiving home care services.

(Drennan et al., Neurourol Urodyn 2012)

Urological problems are an important cause for

incontinence in the elderly

Detrusor overactivity (DO) may occur in men with benign prostatic

enlargement

In 25- 93%, DO is reported to remain unchanged after

prostatectomy, the figures increasing with age

The incidence of Benign Prostatic Hyperplasia (BPH)

significantly increases with men’s age:

• 31-40 years: 8% of histological evidence of BPH

• 51-60 years: 50%

• 61-70 years: 70%

• 81-90 years: 90%

(Mc Vary, Am J Manag Care 2006)

Detrusor overactivity after BOO: the role of NGF

• After bladder outlet obstruction, C afferent sensitive bladder fibers

initiate a usually inactive, involuntary spinal reflex and increase

production of NGF which decreases the C-fiber threshold

• NGF activates p75 and TrkA receptors on the afferent fibers to initiate

or enhance micturition reflex

NGF

binding

Hypothesis on NGF activity into the bladder wall:

Mechanical stretch of urothelium and smooth muscle

NGF production

Increase of excitability of bladder afferent fibres

Increased excitability of dorsal rooth ganglia and enhanced micturition reflex

Clinical picture

•External genitalia and urethral meatus

•Evidence of congenital malformation

•Abdominal palpation: bladder distension??

•Stress test and Valsalva manoeuvre (sphincteric

incompetence)

DRE: locally advanced prostatic cancer can produce OAB-like symptoms

BPH with idiopathic detrusor overactivity:

54% incidence of intravescical protrusion of prostate

(Tong, Urol Int 2005)

Physical examination in men

Symptoms assessment in men

• Bladder diary: estimate of bladder capacity and

frequency, urgency and urge incontinence

• Pad test: quantify severity of incontinence

• AUA-7

• IPSS Assessment of subjective

symptoms

• ICS-BPH

• DAN-PSS-1

Physical examination in females

UI is not a disease but it is the sign

of a disease

To evaluate

the aspect of genitalia

Presence of urogenital

prolapse

Detection of urinary

incontinence under stress

manouvres

Urinary incontinence and urogenital prolapse

Presence of high

degree of

urogenital

prolapse can

mask the sign of

urinary

incontinence

Diagnosis

Non invasive investigations

• Urinalysis

• Urine cytology, (haematuria and history of smoking)

• IPSS

• PSA

• Uroflowmetry

• Post void residual volume (ultrasonography)

Urodynamics (ICI 2009)

• It is not necessary in men with BOO without incontinence

and in women with clear stress incontinence

• Men suffering from BOO with incontinence should

receive a complete urodynamic study, even if the

evidence that urodynamics improves outcome is limited

(Grade of recommendation C)

• In elderly that suffer from neurological diseases

urodynamic test is mandatory in order to finalize the

diagnosis and to plan the optimal treatment

Cystometry Pressure-Flow study

The degree of bladder compliance loss and incidence of obstruction increase

with age, as reflected in decrease bladder capacity, decrease urine voided

volume and increased of DO, along with noticeably impaired detrusor

contractility

Pressure flow study

Urodynamic characteristics in the elderly

-Qmax (ml/s) declines significantly with age;

-Significant decrease of cystometric capacity and bladder compliance

-Increased incidence of Detrusor Oveactivity

-Higher incidence of infravesical obstruction;

Treatment

One potentially modifiable risk factor for UI in elderly is

medication use

It has been observed that the risk is increased by:

estrogens, alpha blockers, diuretics and drugs affecting the central nervous system (benzodiazepines, antidepressants, antipsychotics and opioids).

…UI is most often associated with dementia and both conditions originate from the same underlying disorder:

96% of subjects with dementia and UI seem to be also dependent in getting to the toilet and the combination of dementia and locomotor problems has been extimated to be 13 times more common among incontinent than continent individuals.

(Ryuji Sakakibara et Al, IJU 2008)

UI: special conditions

Pharmacologic intervention

ANTIMUSCARINIC therapy:

represents the most common treatment for patients with OAB including oxybutynin, tolterodine, trospium chloride, solifenacin, darifenacin and

fesoterodine. While efficacy has been demonstrated in adult populations,

few studies have been reported specifically in the oldest old population.

If they cross the blood- brain barrier they reach the CNS and block

cholinergic receptors, particularly M1 in the cerebral cortex or M4 in the

basal ganglia. To a much lesser extent, tolterodine and propiverine also

affect cognitive function.

ADVERSE EVENTS: are frequent such as dry mouth, the likelihood of

detrimental central nervous system (CNS) effects including cognitive

impairment and sleep disturbances and the potential for harmful interactions

with existing pharmacotherapy.

Behavioral suggestions and rehabilitation

Behavioral intervention should always include patient

education:

Timed voiding in infrequent voiders or in patients with prior central nervous system injury, decreased fluid consumption in those with polydypsia or night-

time fluid intake, caffeine modification;

Biofeedback pelvic floor muscle retraining can be used to relax any contributory pelvic floor muscle spasm and to educate patients on

manipulation of bladder inhibitory reflexes;

Pelvic floor rehabilitations: Kegel exercises, functional electrical stimulation

(very useful to reduce DO), FCK.

Surgical interventions

Surgery can be used to treat benign outlet obstruction and stress

incontinence in older patients, when conservative methods and medications

have failed or are not appropriate.

Recently the use of botulinum A toxin intravesical injections has been

introduced to treat refractory detrusor overactivity in both neurogenic and

idiopathic conditions

TVT TOT

Sling

ACT

Our clinical research…

Aim of Research: proposal for a new organizational model for the

provision and distribution of garrisons for urinary incontinence that is

able to reduce costs and increase the level of user satisfaction

OMS ICUD E ICS have recently emphasized the need for a

multidisciplinary approach to the problem;

MMG, specialists (urologist, geriatrician, neurologist, gynecologist,

pediatrician) and medical personnel;

MMG is the first referent and often is the first set out the diagnosis and

therapy.

The concession of the pads is

effected often by the MMG on the

bases of only anamnestic datum without intervention on the

diagnosis and/or treatment that

finally could solve the problem;

To guarantee the proper use of

clinical resources;

ANALYSIS

Our study evaluates the mortality and morbidity through an indicator defined as QALY

137

Group A: 43

SUI grade II-III

Group B: 57

SUI grade I-II

Group C: 37

UUI

MUS PFME DRUG

Solifenacin 5 mg/die

RESULTS

Diagnosis and treatment of urinary incontinence: benefit in terms of Qol and costs as regards the use of sanitary towel

Surgical or rehabilitative approach determines an improvement of Qol and a cost reduction;

Medical therapy is a cost-effective intervention and determines an improvement of Qol;

…However, there are costs to be faced…

Future prospects?

Change of costs?

Thank you for your attention!