Take Test
Mr. J. is a 74-year-old white male who presents with complaints of urinary frequency, urgency, and nocturia of up to four times per night. He is well groomed, neatly dressed, and exudes the faint odor of urine.
He has had lower urinary tract symptoms for at least 4 years, which have progressively worsened. His symptoms consist of diurnal frequency of small amounts, nocturnal voiding of three to four times, slow-to-start urinary stream, and the feeling of incomplete emptying. He complains of daytime fatigue, often falling asleep as he watches television. Due to his urinary frequency and incontinence, he no longer plays golf or visits the library, both activities he had previously enjoyed. His medical history includes mild osteoarthritis. A review of systems is noncontributory. He takes no prescribed medications. He occasionally takes acetaminophen for minor arthritic pain. He also takes acetaminophen with diphenhydramine about once a week "to try to get some sleep."
The U.S. population is rapidly aging. According to the United States Census bureau projections, by the year 2030, almost 20% of the population will be over age 65, compared to 10% in 2000.1 Thoughts of aging can incur many feelings and fears. Some fears include the loss of independence, loss of cognition, loss of mobility, and loss of urinary continence. A widely held belief is that urinary incontinence (UI) is a natural consequence of aging. Although the risk factors for incontinence increase with age, aging itself does not cause incontinence.
UI remains an underreported, underdiagnosed, and, often, unmentioned problem.2 However, increased awareness of UI, due to recent pharmaceutical marketing, has opened the door for both patients and providers to discuss the condition more openly.
UI is often associated with women; however, it also affects men, especially elderly men. This article focuses on the most commonly occurring types of incontinence in the elderly male: overactive bladder (OAB) and urinary retention with overflow. These two conditions have very similar presentations but markedly different treatments. Identification of the underlying condition is essential prior to treatment initiation.
Definition
The two most commonly used UI definitions were proposed by the International Continence Society (ICS) and by the Urinary Incontinence Guidelines Panel. The ICS defines UI as, 'the complaint of any involuntary leakage of urine.'3 Other definitions include:
* The loss of urine at any time.
* Any UI in the previous 12 months.
* More than one episode of UI in a month.
* Two or more episodes of UI in a week.
Because UI prevalence and incidence have been studied using multiple definitions, a wide variation in statistics exists.4
Prevalence and Incidence
While the epidemiology of female UI has been widely studied, relatively little data exists regarding male UI prevalence and incidence. Stothers et al. estimate that UI prevalence among males older than 60 ranges from 13% to 17% and conclude that with age, the gap between male and female UI rates narrows considerably.5
Scope of Problem
UI has been referred to as the "last taboo," and the "silent epidemic." Urinary incontinence may be underreported because patients do not believe that anything can be done about it. Sometimes this is the belief of the provider as well.6
The UrEpik study7 examined the prevalence of male UI in four centers located in France, the United Kingdom, Korea, and Holland. Prevalence rates varied widely, ranging from 8% in Seoul, Korea, to 23% in Birmingham, United Kingdom. The authors speculated that these rates were not as disparate as they appeared but reflected cultural differences in reporting UI. The authors also concluded that males in the United Kingdom might be more willing to discuss UI than their counterparts in Korea. However, the authors noted that the difference in prevalence rates might be attributed to the intake of large volumes of tea and beer in the United Kingdom as compared to a lower intake of these beverages in the other studied countries. This was a large, multicenter study, and the authors were able to conclude that UI may be a relatively large problem in men. They also noted that UI is probably both underreported and undertreated.
Quality of life is deeply affected by UI. In one study, participants with overactive bladder and UI reported impairment on both the physical and mental scales of the Short-Form-36 questionnaire.8 UI continues to be one of the most common reasons for admission to a long-term care facility.10 There is also a significant financial burden associated with UI. The direct medical cost of UI in the United States was estimated to be $19.5 billion per year.10
Differential Diagnosis
Urinary incontinence is usually categorized by its type. Types include stress incontinence (also now known as activity-related incontinence), OAB (formerly know as urge incontinence), mixed stress-urge incontinence, reflex or neurogenic incontinence, and urinary retention with overflow (see Table: Revised UI Definitions").11
UI can also be related to a number of transient, correctable causes. It is important to rule out such causes. The acronym DIAPPERS12 is useful in the evaluation of the transient causes of UI. DIAPPERS stands for Delirium, Infection and/or bladder irritants, Atropic vaginitis/urethritis, Pharmaceutical causes, Psychological causes, Excessive urine production, Restricted mobility, and Stool impaction. Once transient causes are identified and corrected, symptoms may improve. At this point, the chronic incontinence can be evaluated.
Patient Assessment
Assessment should begin with a thorough medical and surgical history. Patient history should include questions about presenting symptoms. In addressing a topic as sensitive as UI, it is important to put the patient at ease so he will feel comfortable discussing such intimate issues with a healthcare provider.
Patients often need an explanation of the difference between urgency and actual leakage. Questions should be asked in a nonjudgmental, nonthreatening manner to elicit the most honest response from the patient, who may not see himself as "incontinent." Asking a question such as, "Do you ever lose water/urine unintentionally?" is useful in obtaining accurate information from the patient.
Questioning the patient about his most bothersome symptoms may be very helpful. A bladder diary, kept for 2 to 3 days is essential in the identification of bladder patterns. The bladder diary should include information such as time and amount voided, and associated symptoms such as urgency, pain, straining, or postvoid dribbling. Any activity associated with leakage, such as sneezing, coughing, laughing, position change, or any sudden urgency should also be recorded. Fluid intake, including type and amount, should be recorded. Lastly, a record of bowel movements is helpful in evaluating the impact of constipation on the bladder. This information should include frequency, stool consistency, volume, and whether straining is involved.
Next, a thorough medical and surgical history should be obtained. Special attention should be paid to conditions that can contribute to UI, such as Parkinson's disease, history of stroke, benign prostatic hyperplasia (BPH), diabetes mellitus, multiple sclerosis, spinal cord injuries or surgeries, urinary tract carcinomas or injuries, and previous radiation therapy. The patient should be asked about previous surgeries, especially back or urinary tract surgeries. Medication usage should be reviewed, including over-the-counter medications, herbal formulations, and prescription medications. There are a number of medications that can affect continence (see Table: "Medications Affecting Detrusor Function").13 Any history of urinary tract infection, prostatitis, and treatment for each should be included in the patient history. Lastly, prostate-specific antigen (PSA) should be reviewed, if available.
A PSA should be ordered on patients with at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management or those for whom the PSA measurement may change the management of their voiding symptoms.14 A urinalysis with a culture should be performed.
The physical examination should begin with a complete genitourinary examination. This would consist of a thorough examination of the genital area, including the glans penis, the foreskin if present, and the perineum. Evidence of dermatitis or fungal rash should be noted. A rectal examination should be performed to evaluate rectal tone. This is done by inserting a gloved finger into the patient's rectum and placing the other hand on the patient's abdomen and asking the patient to try to pull your finger "upward as if trying not to pass gas." A normal finding would be a circumferential contraction of several seconds without use of abdominal muscles. This examination may be uncomfortable for most men but men with high pelvic tone will experience a heightened sense of discomfort. During the rectal examination, the rectal vault should be assessed for retained stool. Lastly, a prostate examination should be performed.
A focused abdominal examination does not take long and can yield valuable information. The abdomen should be percussed in the lower quadrants, following the path of the colon for retained stool. If the patient has a history of constipation and dullness is percussed in the descending or sigmoid colon area, it is likely that there is retained stool that could be interfering with bladder function.
If a bladder scanner is available, a bladder scan should be performed. If a bladder scanner is not available, the bladder area should also be percussed, assessing for dullness. The patient should then void with the amount measured. A postvoid residual (PVR) is an important measurement to determine if the patient is retaining urine. A PVR can be obtained either through a follow-up bladder scan or by in and out catheterization. This should be done within a few moments of voiding.
 | Table. Medications Affecting Detrusor Function |
 | Table. Lower Urinary Tract Assessment |
There is considerable controversy regarding the value of the PVR, and there is relatively little agreement about a numerical value. However, if the initial PVR is greater than 500 mL, the patient is thought to have urinary retention with the need for follow up. In the assessment of PVR, consideration should be given to patient symptoms and the amount of residual urine compared to the total bladder capacity. For example, in the case of a volume voided of 150 mL and a PVR of 175 mL, the total bladder capacity would be 325 mL and the PVR would be greater than 25% of the total bladder capacity. This would be more reason for concern than residual urine of 175 mL and a voided volume of 350 mL. In the elderly male, the treatment of PVR is very dependent on symptoms.15
Inclusionary information should be obtained through the patient history (see Table: "Lower Urinary Tract Assessment"), from the bladder diary, and/or from the BPH Symptom Index (see Table: "BPH Symptom Index Questionnaire.").16
Patient Findings
Once the patient history and physical examination have been obtained, it is time to assess and process this information and make some recommendations. Let us return to our patient.
Mr. J.'s bladder diary provided documentation of the scenario that he described. He voids frequently during the day, every 1 to 2.5 hours. A nightly pattern of awakening as often as 3 to 5 times to void is documented. Voided volumes are never more that 200 mL and frequently only 50 mL.
Your physical examination reveals a voided volume of 175 mL and a PVR of 250 mL. It takes at least 35 seconds for Mr. J. to begin to void and his stream is hesitant and ebbs and flows. He does state that he feels as though he has not emptied his bladder completely, as the bladder scan confirms. He also states that this is a typical voiding pattern. He states that there is urgency associated with his voiding and frequently, before he can make it to the bathroom, he has lost some urine into his underclothing.
 | Table. BPH Symptom Index Questionnaire |
To begin to assess Mr. J.'s condition, review the data and your physical findings, including the PVR. Mr. J.'s PVR is highly suggestive of an obstructive process. It is more than 25% of his bladder capacity. However, there are a number of measures that can be undertaken to make Mr. J. feel immediately more comfortable.
Management of Correctable Conditions
D-Delirium. There is no evidence of delirium with Mr. J.
I-Irritants. Mr. J.'s bladder and fluid diary reveal an intake high in caffeinated beverages. He drinks 5 to 8 cups of coffee per day. Suggest to Mr. J. that he cut down on coffee and substitute water for some of the coffee. Suggest that he drink an extra bottle of water between breakfast and lunch, and between lunch and dinner. It is more "doable" to many patients to add two 16-ounce bottles of water twice a day rather than "increase your fluid intake to 8 glasses a day."
A-Atrophic vaginitis/urethritis: Not applicable.
P-Pharmacologic. Review medications to see if any contribute to incontinence or retention. Mr. J.'s medications include acetaminophen with diphenhydramine, which he takes occasionally. The diphenhydramine can contribute to urinary retention. It should be suggested to Mr. J. that he avoid this medication altogether.
P-Psychological. Assess for depression leading to incontinence (depression is common among elderly widowers). There are a number of screening tools available for depression in the elderly. Two such scales are the Geriatric Depression scale17 and the Hamilton Depression Rating Scale.18 Mr. J.'s assessment reveals no depression.
E-Excessive urine production. Assess for undiagnosed diabetes mellitus. Mr. J.'s fasting blood glucose is 90mg/dL, which is not suggestive of diabetes. He takes no diuretics.
R-Restricted mobility. Assess gait and clothing problems. Mr. J. does not have major mobility problems. He is able to ambulate without the use of an assistive device. His clothing is a khaki pant with a belt and a polo shirt tucked into the pants. He wears boxer shorts and has no problem with dexterity. He is able to manipulate his clothing in 45 seconds.
S-Stool impaction. Chronic constipation and impaction can have a profound effect on the bladder. Mr. J. states that he has had a lifelong problem with constipation. He moves his bowels about every 2 to 4 days with a fair amount of straining. On rectal examination, there is hard, stool palpable in his rectal vault. He uses prune juice when he feels that he has become too constipated. He did not realize that this could be contributing to his continence problem. A bowel cleanout program was suggested with oral bisacodyl (Dulcolax) tablets and a Fleet's enema the following day. After this he will begin a regular regimen of increased fiber, fluid, and moderate exercise.
Differential Diagnosis
Differential diagnosis includes prostate cancer, BPH, urinary retention with overflow, and OAB. Due to his high residual volume, Mr. J. was referred to a urologist and was diagnosed with BPH. Cancer was ruled out via a normal PSA and physical examination. The final diagnosis was chronic urinary retention due to BPH and OAB.
The pathophysiology of OAB remains poorly understood. The neurogenic theory proposes that damaged nerve pathways may impact the ability to suppress bladder contractions.19 Damage can occur due to a number of conditions including: brain tumor, stroke, and multiple sclerosis. The myogenic theory applies to patients with an obstructed bladder outlet.20 This theory proposes that the changes that occur in the smooth muscle cells of the bladder as a result of distention cause partial denervation of the bladder. This results in "micromovements" and the sensation of OAB. More research is needed to determine the exact pathology of OAB.
Treatment
Dutasteride (Avodart) and doxazosin (Cardura) were prescribed. These medications are often prescribed together to allow the 5-alpha-reductase inhibitor to take effect, which can be up to a 3-month period, while treating symptoms with the Alpha1-blocker. It is also possible to use a muscarinic receptor antagonist in conjunction with an Alpha1-blocker (see Table: "UI Pharmacologic Therapy"). This combination of drugs would not have been used together several years ago due to concern that the antimuscarinic would exacerbate the urinary retention in a man with BPH. However, recent research has shown that these medications can be safely used together in patients with both urge incontinence and bladder outlet obstruction.21 It is well known that OAB can exist in the elderly male without bladder outlet obstruction; however, it is also known that bladder outlet obstruction can exacerbate or even cause an OAB.
Obstruction of the bladder can cause a decrease in control and contraction strength, hypertrophy of the bladder wall, and create an increased risk for incomplete emptying.22 Therefore, it is extremely important for the clinician to differentiate between these conditions. Bladder outlet obstruction, as in the case of BPH, requires a referral to the urologist or the urologic nurse practitioner to rule out malignancy and evaluate for surgical intervention. Multiple medical and surgical interventions are now available that can greatly improve quality of life for these patients. OAB without bladder outlet obstruction can often be treated by behavioral interventions alone.
Conclusion
Mr. J. is not alone. There are many elderly men quietly enduring continence issues, believing that frequency, urgency, and incontinence is an inevitable part of aging. Advanced practice nurses can play a significant role in discovering continence problems. A thorough physical assessment and evaluation can differentiate between conditions that should be evaluated by a physician or urologic nurse practitioner and transient conditions that can be treated by behavioral measures. Referral to a urologic specialist should be considered whenever a malignancy should be ruled out, when there is not the expected response to prescribed medications, when there is a high PVR with symptomology, when surgical intervention is needed for BPH, or in cases of complicated urinary tract infections. However, in the case of OAB without complications or uncomplicated BPH, the advanced practice primary care nurse can be instrumental in implementing behavioral changes and medical management that can improve continence, thereby improving quality of life.
REFERENCES
1. He W, Sengupta M, Velkoff V, DeBarros K. 65+ in the United States: 2005. Available at: http://www.census.gov/prod/2006pubs/p23-209.pdf. Accessed July 22, 2007. [Context Link]
2. Boyle P, Robertson C, Mazzetta C, et al. The prevalence of urinary incontinence in community-dwelling married women: a matter of definition. BJU Int. 2004;94(9):1291-1295. [Context Link]
3. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology. 2003;61(1):37-49. [Context Link]
4. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet. 2003;82(3):327-338. [Context Link]
5. Stothers L, Thom D, Calhoun E. Urologic diseases in America project: urinary incontinence in males-demographics and economic burden. J Urol. 2005;173(4):1302-1308. [Context Link]
6. Morley, J. Urinary incontinence and the community-dwelling elder: a practical approach to diagnosis and management for the primary care geriatrician. Clinics in Geriatric Medicine. 2004;20:427-435. [Context Link]
7. Boyle P, Robertson C, Mazzetta C et al. The prevalence of male urinary incontinence in four centres: the UREPIK study. British Journal of Urology. 2003;92(9):943-947. [Context Link]
8. Stewar, WF, Van Rooyen JB, Cundiff GW et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327-336. [Context Link]
9. Nuotio M, Tammela TL, Luukkaala T, et al. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol A Biol Sci Med Sci. 2003;58(8):756-762.
10. Hu TW, Wagner T, Bentkover J, Leblanc K et al. Costs of urinary incontinence and overactive bladder in the United States: A comparative study. Urology. 2004;63(3):461-465 [Context Link]
11. Doughty D, Crestodina L. Introductory Concepts. In: Doughty D, ed. Urinary and fecal incontinence: current management concepts. 3rd ed. St. Louis, MO: Mosby; 2006;1-20. [Context Link]
12. Resnick NM. Geriatric incontinence. Urol Clin North Am. 1996;23(1):55-74. [Context Link]
13. Ouslander JG, Dutcher JA. Overactive bladder: assessment and nonpharmacological interventions. Consult Pharm. 2003;18(suppl B):Table 2:17. [Context Link]
14. AUA Practice Guidelines. AUA Guideline on management of benign prostatic hyperplasia. J Urol.2003;170:530. [Context Link]
15. AUA Practice Guidelines. AUA Guideline on management of benign prostatic hyperplasia. J Urol. 170:530.2003 [Context Link]
16. AUA BPH Symptom Index Questionnaire Available at: http://godot.urol.uic.edu/~web/ASIS.html . Accessed July 22, 2007 [Context Link]
17. Beers M, ed. Depression. Table 33-4. In: Merck Manual of Geriatrics. 3rd ed. 2006. [Context Link]
18. Beers M, ed. Depression. Table 33-4. In: Merck Manual of Geriatrics. 3rd ed. 2006. [Context Link]
19. Wein A, Rackley R. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. J Urol. 2006;March:175:S5-S10. [Context Link]
20. Wein A, Rackley R. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. J Urol. 2006;March:175:S5-S10. [Context Link]
21. Lee JY, Kim HW, Lee SJ, et al. Comparison of doxazosin with or without tolterodine in men with symptomatic bladder outlet obstruction and an overactive bladder. BJU Int. 2004;94(6):817-820. [Context Link]
22. Burnett A, Wein A. Benign prostatic hyperplasia in primary care: what you need to know. J Urol.2006;175 819-824. [Context Link]