treatment is not known to improve prognosis Non-malignant causes of increased PSA PSA increases with age and with: \200 BPH \200 Pr ostatitis \200 Urinary tract infection \200 Rectal examination (up to 7 days) \200 Pr ostatic biopsy (6 weeks) \200 Urethral catheterization \200 Urethral instrumentation, e g cystoscopy \200 Vigorous exercise (48hrs) \200 Ejaculation (48hrs) (Figures in bracke ts are approximate durations of elevation.) Age-speci \201 c PSA values The following have been suggested as cut-off points to reduce unnecessary referral and investigation of patients with benign prostate disease. \200 50 \200\22359 years: (cid:116) 3.0microgram/L \200 60 \200\22369 years: (cid:116) 4.0microgr am/L \200 (cid:116) 70 years: (cid:116) 5.0microgram/L PSA reduces with some drug treatme nt (eg 5-A-reductase inhibitors; herbal remedies such as saw palmetto ( S. repens )), and m ay therefore reduce the thresholds given for referral. This page intentionally left blank 518 CHAPTER 19 Genitourinary medicine Prostatic cancer: treatment \200 Localized cancer \200\224 there are several treatment o ptions, including \200\230watchful waiting \200\231, hormonal treatment, radiotherapy, and surgery. Cure can often be achieved \200\230 Watchful waiting \200\231 \200\224 usually reserved for those with modest life expectancy (<10 years) and lower grade (Gleason score 2 \200\2236) localized tumors, where progression is rare within 10 years. Check PSA every 4 \200\2236 months. Start treatment (u sually hormonal) if symptoms, or if PSA rises Hormone treatment \200\224 there is doubt whether early hormone treatment improves outcome compared to \200\230watchful waiting \200\231 Radiotherapy \200\224 the most usual choice for high-grade localized tumors. Probably as effective as surgery, but better tolerated. Side effects include erectile dysfu nction, irritative urinary symptoms, and radiation proctitis Surgery \200\224 radical prostatectomy is a major procedure, usually indicated only for th ose with long life expectancy, high-grade tumors, and in good health. Major side effects ar e incontinence, impotence and hemorrhage Locally advanced disease without metastases \200\224 key treatments are radiotherapy (also discussed here) and/or androgen deprivation (also discussed here). The r elative bene \201 ts are unclear. Surgery probably offers no bene \201 t, other than TURP to relieve out \202 ow symptoms \200 Metastatic disease \200\224 androgen deprivation ( \200\230hormone treatment \200\231) is the linchpin of treatment. This can be achieved by castration (bilateral orchidectomy, usua lly under local anesthesia), but is usually chemical, largely for reasons of patient prefer ence. Treatment should not be delayed, even if there are no symptoms. Luteinizing hormone r eleasing hormone (LHRH) agonists are used commonly and are usually effective for 12 \200 \22318 months. If disease progresses despite LHRH agonists, patients occasionally respond t o antiandrogens. Surgery offers no bene \201 ts LHRH agonists (eg goserelin) \200\224 given as injections or implants, these cause initial (2 weeks) stimulation and then sustained depression of testosterone release. The initial i ncrease can cause tumor growth ( \200\230 \202 are \200\231) with adverse effects, eg urin ary out \202 ow obstruction, spinal cord compression, or bone pain. If anticipated, anti-a ndrogens may help. Continuous therapy is not needed: survival appears similar if therapy is stopped when PSA levels are normal and restarted when they rise Antiandrogens (eg bicalutamide, \202 utamide) \200\224 useful in inhibiting tumor \202 are after LHRH agonist initiation, in tumor refractory to LHRH agonists, if LHRH agonists are not tolerated or accepted (eg because of erectile dysfunction) or where oral drugs are preferred. There is no evidence that combined antiandrogens and LHRH agonists are helpful Side effects of LHRH agonists and antiandrogens include hot \202 ushes, erectile dysfunct ion, and gynaecomastia. PROSTATIC CANCER: TREATMENT 519 Late-stage prostate cancer Eventually, prostate cancer may become resistant (refractory) to hormone treatment, manifesting as a rising PSA and/or worsening symptoms whilst on treatme nt. Other treatments (eg oestrogens) may be tried, but are rarely very effective. Death fol lows, often in months. Common complications, usually in more advanced disease, include: Bone pain A major cause of reduced quality of life \200 Optimize oral analgesia: combinations of pa racetamol, opiates and NSAIDs are effective Local pain is helped by radiotherapy \200 Bisphosphonates or steroids may also help Pathological bone fracture Usually requires surgical \201 xation Acute urine retention Catheterize \200 Intensify anti-tumor treatment if appropriate (eg hormone treatment, radiotherapy) Consider TURP Post-renal renal failure \200\224 determine site of obstruction by ultrasound: Prostatic obstruction: catheter, TURP, intensify anti-tumor treatment Ureteric obstruction: stenting or nephrostomy Spinal cord compression An emergency, as early decompression improves neurological outcome Con \201 rm with CT or MRI \200 Steroids, radiotherapy, or surgery help decompress the c ord 520 CHAPTER 19 Genitourinary medicine Postmenopausal vaginal bleeding De \201 ned as bleeding from the genital tract over 1 year after onset of menopausal amenorrhoea. The time criterion re \202 ects the fact that men- struation is often irregular and infrequent around menopause, and investi- gations for sin ister pathology are not then worthwhile. Most cases are secondary to benign pathology, but treatment of the few cases of cancer (lar gely endometrial) is far more effective if identi \201 ed early, so do not delay assessmen t. Malignancy is more likely if bleeding is signi \201 cant and recurrent \200\224 invest igate vigorously if no cause is apparent. Causes of post-menopausal vaginal bleeding In approximate order of frequency: Atrophic vaginitis In \202 ammation results as the thinner, less corni \201 ed epithelium is exposed to a more alkaline vaginal environment colonized by a broad microbial \202 or a Endometrial hyperplasia Secondary to: \200 Exogenous estrogen (eg HRT) \200 Unopposed e ndogenous estrogen (especially in older, obese women where peripheral conversion of steroid hormones to oestrogens by fat cells is higher) Benign tumor, eg cervical or endometrial polyps \200 Vaginal prolapse and ulceration Vagi nal infection Carcinoma \200 Endometrial \200 Cervical \200 Vulval \200 Vaginal \200 Ovarian Spurious Other relatively common causes of \200\230vaginal \200\231 bleeding are haematuria and rectal bleeding. Drugs causing endometrial disease (hyperplasia, polyps and cancer) include: \200 HRT (with cyclical replacement: investigate if bleed at unexpe cted times; for continuous estrogen and progestogen: investigate if irregular bleeding pers ists for > 12 months after treatment initiation) Tamoxifen (via a paradoxical endometrial estrogen-like effect) After hysterectomy bleeding is commonly due to atrophic vaginitis or overgrowth of post-surgical granulation tissue. POSTMENOPAUSAL VAGINAL BLEEDING 521 Assessment \200 History \200\224 assess the amount and frequency of bleeding, if necessa ry by discussing with carers. Consider other possible sources of blood, eg urinary, rectal. Take an accurate drug history. Examine \200\224 examine the genitalia, perineum, and rectum to exclude tumor, trauma, and bleeding from atrophic sites. Obesity or osteoarthritis may make examina tion dif \201 cult; the left or right lateral positions are usually more successful. Investigation \200\224 FBC to exclude severe anemia. Urine dipstick for haematuria is unlikely to be speci \201 c to blood of urinary tract origin, especially if bleeding is recurrent or ongoing. Further tests are usually guided by expert gynecological advice, but may include: \200 Ce rvical smear \200 Vaginal ultrasound to assess endometrial thickness (<5mm effectively excludes cancer and may prevent the need for more tests) \200 Hysteroscopy \200\224 can be done under local or general anesthetic \200 Dilatation and curettage \200 Consider i nvestigation of urinary and gastrointestinal tract (cystoscopy, sigmoidoscopy) Treatment Is directed to the underlying cause, eg: \200 Atrophic vaginitis : topical oest rogens (see b \200\230Hormone replacement therapy and the menopause \200\231, p.448). HRT : used if topical oestrogens fail. Review the balance of risks and bene \201 ts and consider stopping the drug. Consider change of preparation eg reducti on of estrogen dose, increase in progestogen dose Endometrial carcinoma : total abdominal hysterectomy and bilateral salpingo-oophorectomy and/or radiotherapy are the usual interventions. In those u n \201 t for surgery, progestogens (eg medroxyprogesterone) may control the tumor 522 CHAPTER 19 Genitourinary medicine Vaginal prolapse A prolapse is a protrusion into the vagina by a pelvic organ (bladder, bow el, or uterus) caused by: \200 Weakness of pelvic connective tissue and musculature due t o cumulative effects of childbirth trauma, ageing, and estrogen de \201 ciency Increased abdominal pressure, eg constipation, obesity, and coughing. Depending on which st ructures are weak, the following may be seen (Fig. 19.1): Cystocoele: the bladder protrudes through the anterior vaginal wall \200 Rectocoele: the rectum protrudes through the posterior vaginal wall \200 Enterocoele: herniation of perit oneum and small bowel (the pouch of Douglas), through the posterior vaginal wall Uterine prolapse: descent of the cervix and uterus down the vagina 1st degree: cervix lies within the vagina \200 2nd degree: cervix protrudes from the vagi na on standing/straining \200 3rd degree (procidentia): cervix lies outside the vagina Assessment Often asymptomatic. Most commonly there is a sensation of heaviness, fullness or bearing down, a palpable mass or a dull pelvic or back ache. Symptoms may be abolished by lying down. \200 Cystocoele may cause stress or over \202 ow urinary incontinence, urina ry tract infection, or bladder out \202 ow obstruction Rectocoele may cause fecal incontinence or dif \201 culty in defaecation \200\224 manual evacuation or digital reduction of the prolapse may be needed Enterocoel e causes pelvic fullness and discomfort \200 Third degree uterine prolapse may cause ulceration and bleeding, and bladder symptoms eg dif \201 culty in urinating Examination should include an abdominal and pelvic assessment (see b \200\230HOW TO Examine the older female genital system \200\231, p.509). Treatment This is dictated by symptoms, prolapse severity, the organs involved, general \201 tness, and patient preference. Urodynamic testing and imaging may be needed prior to t reatment. \200 Mild symptoms: topical estrogen cream and pelvic \202 oor exercises \200 Moderate or severe symptoms: pessary or surgery Surgery is now generally well tolerated and effective. Usually via a transvaginal approach, weakened structures of the pelvic \202 oor are strengthened and \201 xed in place. Hys terectomy is sometimes necessary. Pessaries \200\224 \201 tting of a pessary is indicated for reasons of patient preferenc e, when the risks of surgery are unfavorable, and as a temporary measure prior to surgery. They come in many shapes and sizes, but the most commonly used is the ring pessary. An estr ogen releasing ring pessary is available. Other shapes may be used, commonly for severe dis ease, but can be dif \201 cult to insert and remove. VAGINAL PROLAPSE 523 HOW TO Care for a vaginal pessary Every 4 \200\2236 months: \200 Remove and clean t he pessary \200 Examine the vagina for evidence of ulceration \200 Replace a damaged pe ssary \200 Reinsert if all is well Complications \200 If vaginal ulceration occurs, the pessary should be removed for several weeks, until complete healing has occurred. Local estrogen creams assist healing an d may prevent recurrent ulceration. Try a different shape or size of pessary Pessaries can embed in in \202 amed vaginal mucosa and become stuck. Topical oestrogens an d treatment of infection (eg Candida ) may reduce in \202 ammation and assist removal. If the pessary remains stuck, refer for specialist gynecological assessment 524 CHAPTER 19 Genitourinary medicine Prolapse: illustrations Fig. 19.1 shows the types of prolapse. Peritoneum Uterus Small bowel Bladder Large bowel Urethra Vagina (a) (b) (d) (c) (e) Peritoneum Area of prolapse Fig. 19.1 Types of prolapse: (a) normal pelvis, (b) uterine prolapse, (c) cystocele, (d) re ctocele, (e) enterocele. Reproduced with permission from Impey L, Obstetrics and Gynecology , Wiley- Blackwell Publishing, 1999. This page intentionally left blank 526 CHAPTER 19 Genitourinary medicine Vulval disorders Most non-malignant vulval disorders are worsened by local irritants (eg so ap, deodorant, perfume) and improve if avoided. Good perineal hygiene also helps, eg wiping front-to-back after urination or defecation, keeping the area dry and wearing loose- \201 tting non-synthetic clothing. Vulvitis Symptoms Itching, discharge, burning discomfort. Causes These include: \200 Candida ( \200\230thrush \200\231). The most common cause, esp ecially in diabetes and obesity. Vaginal infection almost always coexists Local dermatitis. Often exacerbated by soap and deodorants \200 Sexually transmitted path ogens. Uncommonly, eg chlamydia Treatment \200 Treat candidiasis with antifungal cream to the vulva (eg clotrimazole 1 % cream) and pessaries or cream inserted high into the vagina (eg clotrimazole 200mg pessary daily for 3 days). Single-dose pessaries (eg clotrimazole 5 00mg pessary once) are effective and may be better tolerated. Oral treatment is also effect ive, eg \202 uconazole 150mg once Treat irritant dermatitis by removing the cause and regular application of topical steroid cream (eg hydrocortisone 1 % ) for 7 \200\22314 days Recurrent candidal infection is common, especially in diabetes and in those receiving repea ted antibiotics. Consider longer-term treatment, eg weekly clotrimazole (500mg pessary) or \202 uconazole (100mg po) \200 If vulval itch persists without obvious cause consider s ystemic disease eg iron de \201 ciency, thyroid disorders. Use emollients and low potency topical steroid to break the itch-scratch-itch cycle. Antihistamines are not effective (see b \200\230Pruritus \200\231, p.596) Vulvodynia A chronic pain syndrome manifesting as burning, pain, or tenderness of the vulva . There are often psychological contributors. Infection, dermatitis, and epithelial disorde rs (neoplastic and non-neoplastic) should be excluded. Refer for specialist assessment, and consider treating depression and empirical treatment with topical steroids or oestrogens. Non-neoplastic epithelial disorders Lichen sclerosus Common in middle aged and older women. Asymptomatic or else causes itching or soreness or dyspareunia. Seen as white or pink/purp le macules or papules resembling thin parchment paper and often in a \201 gure-of-eight d is- tribution around the vulva. Biopsy to exclude neoplasia. Treat with potent topical ster oids, tapering the potency and frequency as symptoms improve. Progression to carcinoma can occur. Long-term follow-up is sensible. VULVAL DISORDERS 527 Squamous hyperplasia Raised white keratinized lesions that may be very localized. Biopsy ma y be needed to exclude malignancy. Treat with medium potency topical steroids, tapering to a stop as symptoms improve. Other disorders For example, psoriasis and chronic dermatitis can usually be diagnosed clin ically, but biopsy permits more con \201 dent management. Malignant epithelial disorders Vulval cancer \200 Easily treated in its early stages and often preceded by a pre-malignant stage Late presentation is more common with age \200 Commonly asymptomatic and an incidental \201 nding, but may itch, discharge, bleed, or cause pain Appearance is variable \200\224 may be raised or ulcerated, or else appear as white or col ored macules. If in any doubt that a lesion may be malignant or pre-malignant, then refer f or biopsy Treatment depends on the size and invasiveness of the tumor, the presence or absence of met astases, and the condition of the patient Options include topical cytotoxic creams, resection under local anesthesia, wide local excision, or radical vulvectomy Extensive vulval surgery is relatively well tolerated in older people 2If any vulval lesion does not respond as expected to treatment, re-consider the possibility of malignancy. 528 CHAPTER 19 Genitourinary medicine Sexual function Studies show that most older people desire some sexual contact. However, th e frequency of sexual intercourse, both penetrative and non- penetrative, falls with age. T his decline is multifactorial, including: \200 Lack of partner, eg death of spouse \200 Physiological changes of ageing, eg decreased vaginal secretions, less sustained penile erections Physical comorbidity and medication, eg circulatory disease, B -blockers \200 Psychologic al comorbidity, eg low self-esteem, depression \200 Societal expectations and judgements \200 Lack of privacy, especially in institutional care The clinical response to a patient \200\231s report of sexual dysfunction involves addressing each of these factors in a supp ortive and understanding way. Erectile dysfunction Erection requires intact neurological, circulatory, hormonal, and psyc ho- logical processes. In older people, several factors more commonly con- tribute to erect ile dysfunction or impotence. A solely psychological cause is uncommon. Common contributors are drugs, vascular disease (arterial > venous) and neurological disease (stroke, autonomi c neuropathy, local surgery, eg prostatectomy) History Assess onset and progression, circumstances, and associated psycho- logical issues. Erectile dysfunction is common, yet is rarely asked about. Older men may volunteer the sym ptom, but many will accept it as part of \200\230normal ageing \200\231. Do not assume tha t an older man is not sexually active, and always warn about impotence as a potential side effect of relevant drugs. Drugs causing erectile dysfunction Along with vascular disease, drugs are the most common c ause in older people: \200 Antihypertensives (especially B -blockers and diuretics. ACE i nhibitors less so) \200 Alcohol \200 Antiandrogens, LHRH agonists, oestrogens, progestogens \200 Antidepressants (all classes, except trazodone) \200 Less commonly: cimetidine, spirono lactone Examination Of mental state (depression, anxiety). Presence of secondary sexual cha r- acteristics. Vascular disease. Genitourinary examination. Neurological examination to in clude perineal and perianal sensation. SEXUAL FUNCTION 529 Investigation Exclude systemic illness with FBC, U,C + E, and glucose. Diagnostic tests to determine an underlying cause of erectile dysfunction do not often alter management and are rarely performed. Hypogonadism is an uncommon cause of erectile dysfunction, so checking t estosterone level is not usually necessary. If libido (rather than erectile dysfunction) is the problem, then exclude hypogonadism by checking testosterone, LH, TSH, and prolactin. Treatment Where possible, stop incriminated drugs. Treat underlying disease, including anxi ety/depression. Recently developed drug treatments are highly effective. Phosphodiesterase type-5 inhibitors For example, sildena \201 l. Cause smooth muscle relax ation and increase blood \202 ow, they are easily used (take po before intercourse), effe ctive, and safe. Contraindications include patients on nitrates; exercise caution in those with coronary or cerebrovascular disease. Side effects are gastro- intestinal and vascular ( \202 ushing, headache). Alprostadil (prostaglandin E1) Is usually given as an intraurethral pellet, is absorbed loc ally and causes local smooth muscle relaxation, There is no signi \201 cant systemic absor p- tion, so systemic side effects are rare and vascular disease is not a con- traindication . Other options Include intracavernosal injections (the most effective treatment) and non- dr ug options such as vacuum devices (effective, but often discontinued due to discomfort). Hypersexuality \200 Sexually disinhibited behaviors may occur in people with dementia and frontal lobe pathology, eg stroke. It can present practical and ethical problems to the ca regiver. Assessment of the behaviors, the contexts in which they arise and any possible ris k is essential. Environmental modi \201 cation and carer education is needed. Medication m ay help (eg antipsychotics) but none are licensed A small proportion of patients with Parkinson \200\231s disease (particularly if treated wi th dopamine agonists) may develop impulse control disorders which can include hypersexualit y Further reading Series H , D gano P . ( 2005 ). Hypersexuality in dementia . Adv Psychiatr ic Treat 11 : 424 \200\223 31 . Goodson P . ( 2010 ). Sexual activity in middle to later l ife . BMJ 340 : 850 . 530 CHAPTER 19 Genitourinary medicine HIV in older people Prevalence \200 Increasing in the over-50s \200 UK study in 2010 in dicated that HIV infections diagnosed in the > 50s had more than doubled over 7 years Reasons for this include \200 Prolonged survival on antiretroviral therapy \200 Wider s cope of HIV testing \200 Increased transmission due to decreased awareness of HIV in olde r adults Risk factors \200 Broadly similar to younger group except less likely to be due to iv dru g use In men, the biggest risk factor is homosexual intercourse. US data looking at homosexual men > 50 reveals less frequent sexual activity, but still multiple pa rtners ( > 9 in the last 12 months for 25 % ) In older women, heterosexual intercourse is the biggest risk factor. They may be less likel y to use barrier contraception as there are no risks of conception. Also, age-related chang es to the female genital tract (eg atrophic vaginitis) may make transmission more likely Testing Delay in testing and diagnosis common (50 % of > 50s compared with 30 % of younger patients) because: \200 Clinicians are less likely to suspect HIV infection in older pati ents \200 Patients may mistake early symptoms for other age related disorders and not seek help 2It is important to take a sexual history and bear the diagnosis in mind as for younger pat ients, particularly if there is an opportunistic infection such as TB. Clinical features In older patients: \200 Mortality is higher, although this may relate t o delayed diagnosis \200\224 in one study, 75 % of those over 50 diagnosed with HIV/AIDS w ere dead within a year Antiretroviral therapy has equivalent ef \201 cacy as younger patients, improves survival and drug concordance may be better Comorbidity more common causing greater overall disability and possible problems with drug treatments There may be an increased risk of HIV-associated dementia, although studies are small Risk of cardiovascular disease is high \200\224 may be effect of the HIV or the antiretrov irals, plus accumulation of other risk factors (hypertension, smoking, high cholesterol, et c.) 531 Chapter 20 Incontinence Urinary incontinence: causes 532 Urinary incontinence: assessment 534 Urinary incontinence: management 536 Catheters 538 HOW TO Manage urinary incontinence without a catheter 539 HOW TO Treat catheter complications 540 Fecal incontinence: causes 542 Fecal incontinence: assessment 543 Fecal incontinence: manag ement 544 HOW TO Treat \200\230over \202 ow \200\231 fecal incontinence 545 532 CHAPTER 20 Incontinence Urinary incontinence: causes 2Incontinence has a major adverse impact on quality of life an d has signi \201 - cant associated morbidity (it may be the last straw leading to institut ion- alization). Even longstanding cases may be reversible so always explore continence iss ues even if everyone else is complacent. It is very common (around 30 % of elderly at home, 50 % in care homes) but is not a natural consequence of ageing. Most incontinence in older people is multifactorial, so think of al l the possible contributing factors and address each in turn. They can be divided as follow s: Age-related changes \200 Diminished total bladder capacity but increased residual volume \200 Diminished bladder contractile function \200 Increased frequency of uninhibited bl adder contractions \200 Reduced ability to postpone voiding \200 Excretion of \202 ui d later in the day with less concentrated night-time urine Atrophy of vagina and urethra in females \200 Loss of pelvic \202 oor and urethral sphi ncter musculature \200 Hypertrophy of the prostate in males Comorbidity \200 Diminished mobility \200\224 may have an urge to urinate then not be ab le to get to the toilet in time Prescribed medications affect lower urinary tract, conscious state (eg sedatives) or abilit y to get promptly to the toilet (eg antihypertensives causing postural drop) \200 Increas ed constipation \200 Impaired cognition \200\224 a continent person needs to be able to recognize that they need to urinate, locate and reach a toilet, then undress in time to pas s urine in the right place. Confusion can cause inappropriate micturition (initially failur e to \201 nd an appropriate receptacle, then in later dementia they may be unaware altoge ther of urination). There may also be interference with UMN input into continence pathways Reversible factors \200 UTI (see b \200\230Urinary tract infection \200\231, p.621) \200 Delirium \200 Drugs eg diuretics cause polyuria, anticholinergics such as tricyclic s cause retention, sedatives can reduce awareness or mobility \200 Constipation \200\224 m ay cause voiding dif \201 culty and increased residual volumes in both sexes Polyuria (eg poorly controlled diabetes, hypercalcaemia, oedema resorption at night can cau se nocturnal polyuria, psychogenic polydipsia) Urethral irritability (eg atrophic vaginitis, candida infection) \200 Prolapse (women) \200 Bladder stones and tumors URINARY INCONTINENCE: CAUSES 533 Irreversible (but treatable) factors \200 In males, prostatic hypertrophy or carcinoma ca uses out \202 ow obstruction, an unstable bladder or \200\230over \202 ow \200\231 incon tinence \200 Overactive bladder syndrome (symptom diagnosis)/detrusor overactivity (urodynamic diagnosis) \200\224 spontaneous contractions of the bladder muscl e causes urgency and frequency incontinence In females, outlet incompetence (stress incontinence) \200\224 usually due to pelvic muscl e and ligament laxity (which supports the urethra) following childbirth \200\224 any rise in intra-abdominal pressure causes small leaks eg with cough, hoisting Mixed symptoms \200\224 suggesting the presence of both overactivity and stress incontinence Fistula (connection between the bladder and vagina) can occur after pelvic malignancy and irradiation, causing constant wetness Environmental factors \200 Being bed bound and reliant on assistance with toileting makes continence a challenge. Whilst nurses will endeavor to promptly attend to a request for toi leting, there is an inevitable delay In males with reduced mobility, a lack of manual dexterity and/or small penile size can make the use of bottles a challenge In hospitals, the toilet may be further away than at home, or dif \201 cult to \201 nd. In addition, the acute illness may mean that mobilizing is dif \201 cult \200 At home, a ccess to a toilet may become harder with reducing mobility (eg if there is only an upstairs toilet) 534 CHAPTER 20 Incontinence Urinary incontinence: assessment Much is made in the literature of the different symptoms i n different diag- nostic groups. \200 Urgency symptoms Frequent ( > 8 times per day) and/ or precipitant voiding \200\224 strong urge, and decreased time to reach the toilet. If in continence occurs this is termed wet overactive bladder (OAB). Urge alone whilst maintainin g continence is dry OAB and may be a precursor to the wet form. Nocturnal incontinence comm on. Urge symptoms are commonly due to detrusor muscle overactivity where the residual volum e small, but can also occur in obstruction Stress symptoms Small volume leaks during coughing, laughing, lifting, walking and other ex ercise. Often coexist with urge symptoms in women Obstructive symptoms in men include decreased force of urinary stream, hesitancy, and intermittent \202 ow Older patients are often unable to give precise descriptions and the dif- ferent symptom co mplexes can overlap. Even where a \200\230pure \200\231 symptom complex exists you may get the diagnosis wrong, eg prostatic out \202 ow symptoms where incontinence is actually det rusor overactivity or symp- toms of urgency as a presentation for retention with over \202 ow. Additional factors such as reduced mobility, dexterity, and cognition also interact to produce the syndrome of incontinence. A more pragmatic approach is often required. Take a history \200\224 a bladder or voiding diary can help, especially if you are relying on carers for information. Ask questions such as: \200 \200\230Do you know when you need to go to pass urine? \200\231 \200 \200\230Do you get much time between getting the urge and when the urine comes? \200\231 \200\230Do you sometimes leak urine when you cough or run? \200\231 Examination \200\224 include vaginal, rectal, and neurological examination \200 Exclude a signi \201 cant residual volume See Box 20.1 \200 Investigations \200\224 urinalysis and midstream urine (MSU) , general screening blood tests, cytology and cystoscopy if haema turia. Urodynamics can be helpful if patient \200\231s incontinence cannot be explained or they are not responding to treatment and essential if surgical intervention is contemplated URINARY INCONTINENCE: ASSESSMENT 535 Box 20.1 Residual volume Normal young people have only a few mL of urine post-micturition but normal elderly can hav e up to 100mL. Causes of raised residual volume include: Prostatic hypertrophy, carcinoma \200 Urethral stricture \200 Bladder diverticulum \200 Large urinary cystocele and other pelvic organ prolapsed (females) \200 Hypocontrac tile detrusor \200 Neurological disease eg Multiple sclerosis, Parkinson \200\231s diseas e, spinal cord disease, disc herniation Bladder tumor \200 Drugs eg tricyclic antidepressants, anticholinergics Acute retention i s usually painful but can present atypically with delirium, renal failure etc. Chronic bladder distention is usually painless, presenting with infection, abdominal disten sion/mass or incontinence (continuous dribbling due to over \202 ow or urge incontinence d ue to detrusor instability). Persistently elevated residual volume increases the risk of infection. If pressure is eleva ted this can cause dilation of the urinary tract and eventually hydronephrosis and renal failure. Residual volume can easily be estimated using a simple ultrasound bladder scan or a diagnostic (in/out) catheterization. Bladder diaries It is helpful to ask patients and/or carers to complete a bladder diary to aid assessment. This should include the timing and volume of all urine voided along with de tails of any symptoms and episodes of incontinence. An example is shown in Table 20.1 . Analysis of this will allow correct assessment of: 24-hr urine volume \200 Number and severity of incontinence episodes \200 Maximum and m inimum voided volume \200 Diurnal variation Table 20.1 Bladder diary Date Time Voided volume Symptoms Incontinence episodes and cause 536 CHAPTER 20 Incontinence Urinary incontinence: management \200 Depends on cause so try to make a diagnosis \201 rst. \200 Incontinence is multifactorial in most elderly so combining treatments may be n ecessary eg a man with obstructive prostatic symptoms and detrusor hyperactivity may bene \201 t from an A -blocker and an anti- muscarinic (eg tolterodine) (Table 20.2 ). Table 20.2 Management of urinary incontinence Treatment Indication Notes Overactive bladder syndrome/detrusor over activity Bladder retraining (gradually increasing time between voiding) Dementia Decreases likelihood of incontinence episodes Regular toileting (taking to toilet every 2 \200\2234hr) Overactive bladder syndrome Pelvic \202 oor exercises Stress incontinence Effect wears off when exercises stop May precipitate urinary retention \200\224 monitor carefully Bladder stabilizing drugs Overactive bladder syndrome/detrusor overactivity Tolterodine 2mg bd \200\2234mg od Side effects of dry mouth, constipation, postural hypotension may limit effectiveness. Solifenacin 5 \200\22310mg od Trospium chloride 20mg bd Titrate dose up slowly. Use for 6 weeks before maximal effect. Oxybutynin 2.5mg bd \200\2235mg tds Refer for urodynamics to prior to surgery Surgery For stress incontinence \200\224 tension-free vaginal tape (TVT) is promising new procedur e \200\224 female Colposuspension \200\224 gold standard operation \200\224 male For out \202 ow tract obstruction TURP Slow onset of action Anti-androgens For prostatic hyperplasia Improves \202 ow and obstructive symptoms Decreased libido/impotence Finasteride 5mg od A -blockers Doxazosin 1mg \200\2234mg od Tamsulosin 400micrograms od Titrate dose slowly \200\224 watch for hypotension (especially postural) and syncope/falls Smooth muscle relaxant for BPH \200\224 improves \202 ow and obstructive symptoms Useful for co-treatment of hypertension URINARY INCONTINENCE: MANAGEMENT 537 Table 20.2 (Contd.) Treatment Indication Notes Sometimes helps reduce large residual volumes and decrease UTI Double micturition (ask patient to repeat voiding) Surprisingly well tolerated in \200\230 \202 exible \200\231 elderly Intermittent catheterization Atonic/hypotonic bladder \200\224 removing residual volumes daily can aid continence and r educe renal damage and infection. Also used to dilate stenotic urethras Useful for nocturnal frequency Main troublesome side effect is dilutional hyponatraemia \200\224 unlicensed for > 65s in the UK Synthetic vasopressin either oral or intranasal Caution in patients with comorbid conditions, likely to be exacerbated 538 CHAPTER 20 Incontinence Catheters A catheter is indicated for: \200 Symptomatic urinary retention \200 Obstruct ed out \202 ow associated with deteriorating renal function or hydronephrosis Acute renal failure for accurate urine output monitoring \200 Intensive care settings \200 Sacral pressure sores with incontinence \200 Where other methods of bladder managem ent cause undue distress to a frail older person Occasionally to facilitate discharge home by reducing care needs (especially overnight) whe re non-catheter options have failed 2 A catheter is NOT usually indicated for: \200 Immobility \200\224 even from stroke \200 Heart failure \200\224 just because you are giving furosemide \200 Monitoring \202 uid balance in a continent patient \200 Convenience of nursing \200\224 at home or in hospital \200 Asymptomatic chronic retention \200\224 refer to urology for assessment Catheter selection \200 Long-term catheters should be either silicone, Silastic, or silve r- impregnated (expensive but reportedly fewer blockages and infections) Catheter size should be as small as practical \200 Catheters should be changed at least e very 3 months \200 Consider the use of a catheter valve (like a beer keg tap) rather than a drainage bag If duration is likely to be more than a year, consider suprapubic placement to preserve urethral sphincter function CATHETERS 539 HOW TO Manage urinary incontinence without a catheter In spite of correct diagnosis, investigation and treatment of reversible causes there will still be patients who will be permanently or intermit- tently incontinent of urine. 2 An in dwelling catheter is not always the best solution. They have been shown to increase morbidi ty (infection, stones, urethral erosion) and even mortality. Suggesting that catheters are removed is one of a geriatrician \200\231s most important job s in post-acute care. If in doubt involve a specialist continence nurse/team. Other options for continence management include: Environmental modi \201 cations : urinals/commodes by the bed, easy access clothing, etc. can minimize or prevent accidents Regular or individualized toileting programs : this can be very successful in patients with dementia but is labor intensive Pad and pants : can be very effective but is quite labor intensive for very immobile patients A drainage sheath or condom catheter (Conveen is a manufacturer) for men: like a cathete r but held onto the penis with a plastic sheath like a condom. Particularly useful for isol ated nocturnal incontinence as it can be removed by day. Main problem is displacement and l eakage which can be a problem with small or unusually shaped penises Intermittent catheterization : for those with obstruction or atonic bladders. Consider in a gile, cognitively intact patients. Can be supported by district nursing services 540 CHAPTER 20 Incontinence HOW TO Treat catheter complications Blocked catheters \200 Consider possibility of stones, infection, sediment, encrustation, constipation or bladder tumor Renew catheter and change if necessary \200 Maintain good \202 uid intake \200 Cathet er maintenance solution can be used for short periods \200 Blockage due to sediment can b e prevented with regular saline bladder washouts Catheter encrustation occurs with Proteus infection; acidic irrigations instilled into the bladder may dissolve these (eg Suby G ) \200\230Bypassing \200\231 \200 Catheters can irritate bladder causing contractions \200\224 resulting leak of urine past catheter can render them useless and occasionally cau ses very painful spasms This is particularly common where detrusor overactivity was cause of incontinence Can be induced or aggravated by infection \200 Exclude catheter blockage (presents with i dentical spasms and leaks) \200 If no residual volume, reduce catheter diameter/balloon s ize \200 Antimuscarinic drugs can sometimes help \200 Longer-term catheters can cause u rethral sphincter incompetence, so urine will leak continuously. This may be temporarily he lped by passing a larger gauge catheter but is a dif \201 cult problem to manage \200\224 avoid by using suprapubic catheters earlier Catheter infections \200 All catheters become colonized after a few days, all catheter ur ine will dipstick positive, and most catheter specimens of urine will grow bacteria 2This alone is not an indication for antibiotics \200 Bad smelling, dark colored, and clo udy urine is more commonly due to dehydration and is not an indication for antibiotics per se There are now some trials of cranberry juice/capsules that suggest there is a minor effect on reducing recurrent infections Only treat clinically signi \201 cant infections (fever, malaise, delirium, pain, abnormal in \202 ammatory markers, etc.) or you will just promote resistant organism s If you believe a catheter is a source of signi \201 cant infection: