排尿障礙治療中心版權所有 Geriatric Incontinence and Nocturnal polyuria Hann-Chorng Kuo...

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Geriatric Incontinence and Nocturnal polyuria

Hann-Chorng KuoDepartment of UrologyBuddhist Tzu Chi General Hospital


Lower urinary tract symptoms in geriatric population

LUTS are common in elderlyNocturia is the third most bothersome LUTS Prevalence of nocturia increases to 80% in patients aged over 80 yearsNocturia is one of the most common causes of disturbed sleep pattern


Prevalence of Male Urinary SymptomsAge group (years)Age group (years)

SymptomSymptom 40-4940-49 50-5950-59 60-6960-69 ≧ ≧70 years70 yearsNumberNumber 800 612 436 271Percentage reporting:Percentage reporting:

DribbleDribble 37 43 44 36HesitancyHesitancy 14 18 20 19IntermittencyIntermittency 18 25 29 32UrgencyUrgency 28 32 42 46Weak streamWeak stream 25 34 39 49Incomplete emptyingIncomplete emptying 16 17 23 23Urge incontinenceUrge incontinence - - - -

BurningBurning 5 6 4 7

Nocturia ≧ twice/nightNocturia ≧ twice/night 16 29 42 55Frequency > 2/hFrequency > 2/h 34 34 36 35


Prevalence of Female LUTSAge group (years)

Symptom 19-3919-39 40-5940-59 60-7960-79 ≧≧8080

NumberNumber 532 838 585 119

Percentage reporting:Percentage reporting:

Nocturia≧2/nightNocturia≧2/night 9 13 28 51

UrgencyUrgency 53 65 62 68

Urge incontinenceUrge incontinence 32 52 48 59HesitancyHesitancy 33 22 17 26Nocturnal enuresisNocturnal enuresis 4 6 4 17

Poor streamPoor stream 11 18 23 41

Incomplete voidIncomplete void 47 46 36 36


Bothersomeness of LUTS


Voiding Diary

Assessment of frequency, urgency, and nocturia in patients with LUTSRecord voided urine volume and total daily urine volumeCalculate nocturnal urine volumeInvestigate causes for frequency and polyuria


Hypersensitive bladder with small functional capacity

排尿記錄單排尿記錄單姓名：王進輝病歷號碼： U100009234日期（第一天） ˍ9ˍ 月 ˍ2ˍ 日日期（第二天） ˍ9ˍ月 ˍ3ˍ日日期（第三天） ˍ9ˍ 月 ˍ4ˍ 日

時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿

7-8 150 500 7-8 200 500 7-8 250 500

8-9 100 8-9 8-9

9-10 150 9-10 150 9-10 200

10-11 90 10-11 250 10-11 200

11-12 11-12 200 11-12

12-1 100 200 12-1 200 12-1 150 200

1-2 1-2 200 1-2

2-3 100 200 2-3 2-3 150

3-4 3-4 3-4 250

4-5 120 250 4-5 150 250 4-5

5-6 5-6 5-6 150

6-7 150 250 6-7 250 6-7 250

7-8 7-8 150 7-8

8-9 120 200 8-9 8-9

9-10 9-10 9-10 200 250

10-11 90 10-11 100 10-11

11-12 11-12 11-12 150

睡眠cc/次

100/2次睡眠cc/次

150/1次睡眠cc/次

200/2次


Normal functional capacity and nocturnal polyuria排尿記錄單排尿記錄單

姓名：施冠慨病歷號碼： U100016284 日期（第一天） ˍ8ˍ 月 ˍ29ˍ 日日期（第二天） ˍ8ˍ月 ˍ30ˍ日日期（第三天） ˍ8ˍ 月 ˍ31ˍ 日


7-8 300 7-8 300 7-8 300

8-9 300 8-9 100 300 8-9 300

9-10 9-10 300 9-10

10-11 300 10-11 10-11

11-12 100 300 11-12 100 11-12 200

12-1 300 12-1 300 12-1 500

1-2 1-2 100 1-2 100

2-3 200 2-3 2-3

3-4 300 3-4 3-4

4-5 4-5 4-5

5-6 5-6 5-6 300

6-7 200 300 6-7 300 6-7 100

7-8 7-8 200 100 7-8

8-9 100 8-9 8-9 100 300

9-10 9-10 9-10

10-11 10-11 10-11

11-12 11-12 11-12

睡眠cc/次

700, 600 500 ,150

4 次睡眠cc/次

500,400 2 次睡眠cc/次

200,900 350

3 次


Daytime frequency and Nocturnal polyuria排尿記錄單排尿記錄單

姓名：連信雄病歷號碼： U100036348日期（第一天） ˍ8ˍ 月 ˍ19ˍ 日日期（第二天） ˍ8ˍ月 ˍ20ˍ日日期（第三天） ˍ8ˍ 月 ˍ21ˍ 日


7-8 1000 7-8 100 1200 7-8 900

8-9 200 8-9 8-9 220

9-10 200 9-10 200 9-10 200 150

10-11 100 10-11 100 150 10-11

11-12 100 11-12 150 11-12 200

12-1 100 200 12-1 150 300 12-1 200

1-2 150 1-2 1-2

2-3 150 2-3 200 2-3 200 200

3-4 3-4 120 3-4

4-5 100 150 4-5 4-5 120

5-6 100 5-6 120 5-6

6-7 100 150 6-7 300 6-7 100 300

7-8 7-8 7-8 150

8-9 300 8-9 230 8-9 200

9-10 200 100 9-10 200 9-10 100 150

10-11 10-11 10-11 100

11-12 210 200 11-12 11-12

睡眠cc/次

300, 300 400

350 睡眠cc/次

400,480220

350 睡眠cc/次

400,400 440


Polydipsia, Nocturnal polyuria, Small functional capacity排尿記錄單排尿記錄單

姓名：李特民病歷號碼： B100338896日期（第一天） ˍ9ˍ 月 ˍ14ˍ 日日期（第二天） ˍ9ˍ月 ˍ15ˍ日日期（第三天） ˍ9ˍ 月 ˍ16ˍ 日


7-8 100,800 230 2 7-8 120,80,50 230 3 7-8 80,100,50 230 3

8-9 100,70,80 460 3 8-9 100,100,80 460 3 8-9 100,80,60 460 3

9-10 100,100 230 2 9-10 100,50 230 2 9-10 50,100 230 2

10-11 120,90 230 2 10-11 120,70 230 2 10-11 100,70 230 2

11-12 180,100120

230 3 11-12 100,80 230 2 11-12 80,100 230 2

12-1 150,80,100 230 3 12-1 180,100,80

230 3 12-1 80,100,120 230 3

1-2 100,110 230 2 1-2 180,100,80 230 2 1-2 80,100 230 2

2-3 100,120 230 2 2-3 100,150 230 2 2-3 100,120 230 2

3-4 80,100,80 230 3 3-4 100,80,50 230 3 3-4 80,100,60 230 3

4-5 100,80 230 2 4-5 80,90 230 2 4-5 90,100 230 2

5-6 80,120 230 2 5-6 150,80 230 2 5-6 80,120 230 2

6-7 100,80,100

460 3 6-7 80,120,50 460 3 6-7 100,80,60 230 3

7-8 100,100 230 2 7-8 100,80 230 2 7-8 100,80 230 2

8-9 80,100 230 2 8-9 100,120 230 2 8-9 60,120 230 2

9-10 100,50,150 460 4 9-10 150,120,80 460 3 9-10 100,80,120 460 3

10-11 10-11 10-11

11-12 11-12 11-12

睡眠cc/次

1400/7 次睡眠cc/次

1300/6 次睡眠cc/次

1300/6 次


Incontinence

Detruror instabilityUrethral incompetenceMixed detrusor instability and urethral incompetence (DHIC)Low bladder complianceDetrusor underactivity and overflowBladder outlet obstruction


Detrusr overactivity in elderly

Unknown etiologyIncreased incidence with ageMay relate with poor cortical perfusionBladder outlet obstruction in men and women should be consideredUrethral relaxation in womenFrequency urgency and/or urge incontinence


Detrusor Overactivity & Pseudodyssynergia after Stroke


Detrusor overactivity in senile dementia


Detrusor instability & BPH

Asymptomatic BPH may result in detrusor changes with ageingA low Qmax is frequently encountered in the elderlyPatients may have frequency urgency but not difficult urinationSmall functional capacity in BPH


BPH with Detrusor overactivity


Low Bladder Compliance and Low contractility


Poor cortical perfusion & Detrusor overactivity

Senile dementiaMultiple strokesPost-intracranial hemorrhageChronic illness in systemic disease and increased incidence of incontinenceSchizophrenia and cortical dysfunction


Low detrusor contractility and low urethral resistance


Geriatric Incontinence

Poor cortical perfusionSequale of previous strokeParkinson’s diseaseBenign prostatic obstructionWeak urethral striated sphincterLoss of cortical arousal of bladder fullness


Detrusor overactivity in woman with ISD


Dysfuncional voiding with Detrusor overactivity


Postprostatectomy incontinence

Detrusor overactivity not relieved after TURPIntrinsic sphincteric insufficiencyNewly developed detrusor overactivity Poor cortical function with ageingUrinary tract infection in non-ISD postprostatectomy menNeurological lesions


Postprostatectomy incontinence due to urethral incompetence


Detrusor overactivity in Post-TURP patient


Transient incontinence (Diappers)

DeliriumInfectionAtrophic vaginitisPsychological disordersPharmacological effectsExcessive urine outputRestricted motilityStool impaction


Management of Geriatric Incontinence

Medical treatment: anticholinergics (Ditropan, Detrustol, Tofranil, etc.)On diaper or external applianceOn Foley catheter or cystostomyIntravesical resiniferatoxin therapyDetrusor injection of botulinum toxinSurgical treatment


Anticholinergics

Effectively reduced intravesical pressure and contractilityIncreased postvoid residual urine and possible urinary retentionIncreased risk of UTI and upper tract deteriorationAdverse effects of dry mouth, constipation, blurred vision, weakness


Diaper and external appliance

Suitable for patients with detrusor overactivity and low urethral resistanceNot indicated in patients with low detrusor contractility and large PVRPerineal eczema and cutaneous infection including candidiasisPrepuce erosion and urethral injuryFrequent change of diaper and external appliance is needed


Urethral Foley catheterization or Suprapubic cystostomy

Active hydrationRegular change of catheterAcidic solution irrigation of bladderIntermittent antibiotics for turbid urine or hematuriaPrevention of genital tract infection in men, such as vasectomyPrevent fecal soiling in women


Intravesical resiniferatoxin therapy

10-7M RTX bladder instillation Effective in spinal cord lesion induced detrusor hyperreflexiaLess effective in non-traumatic neurogenic detrusor overactivityMay be effective in detrusor overactivity due to bladder outlet obstructionLow detrusor contractility may occur after high concentrations RTX instillation


Intravesical RTX therapy for DI


Botulinum A toxin Detrusor injection

Effectively reduced detrusor overactivity and detrusor contractility via blocking Ach releaseLarge residual urine may occur after 300 U botulinum toxin (Botox) injectionPeriodic injection is neededNot clinical applicable so far


Response of Botulinum A toxin Detrusor injection in DH


Nocturia

A result of excessive amount of urine production at nightNoctural polyuria >35% daily urineAbnormal lower urinary tract functionA combination of two etiologies


Definition of Assessing NocturiaVariable Definition

Nocturnal urine volume (NUV)Nightly voided volume plus first morning

Functional bladder capacity (FBC)

Largest single recorded voided volume from 24 h voiding diary

Nocturia index (NI) NUV/FBC

Actual number of nightly voids (ANV)

Recorded from voiding diary

Predicted number of nightly voids (PNV)

NI-1 (rounded to next highest integer if this is not a whole number)

Nocturnal bladder capacity index (NBCI)

ANV-PNV: if PNV>ANV then NBCI=0

Nocturnal polyuria index (NPI) NUV/24-h total voided volume:Normal<35%


Voiding Diary Analysis of Nocturia

MalesMales

(N=65)(N=65)FemalesFemales

(n=129)(n=129)BPHBPH

(n=15)(n=15)UIUI

(n=8)(n=8)SUISUI

(n=25)(n=25)DIDI

(n=52)(n=52)

NP (n=13)NP (n=13) 5% (3) 8% (10) 0% (0) 25% (2) 16% (4) 13% (7)

NDO NDO (n=111)(n=111)

48% (3) 62% (80) 33% (5) 25% (2) 56% (14) 54% (28)

Mixed Mixed (n=70)(n=70)

48% (31) 30% (39) 67% (10) 50% (4) 28% (7) 33% (17)

NP/Mxd (n=8NP/Mxd (n=83)3) 52% (34) 38% (49) 67% (10) 75% (6) 44% (11) 46% (24)

Poly (n=45)Poly (n=45) 34% (22) 18% (23) 27% (4) 13% (1) 8% (2) 14% (7)


Causes of Nocturnal PolyuriaCause Underlying cause

Poor sleep patternPoor sleep pattern Mental or physical ill healthMental or physical ill health

LUT dysfunctionLUT dysfunction Incomplete voiding Incomplete voiding

BOOBOO

Detrusor under-activityDetrusor under-activityBladder overactivityBladder overactivityBladder hypersensitivityBladder hypersensitivity

Excessive fluid outputExcessive fluid output Primary polydipsiaPrimary polydipsiaDrugs; diuretics, alcohol, caffeineDrugs; diuretics, alcohol, caffeine

Circadian changes to arginine vasopresCircadian changes to arginine vasopressin secretionsin secretionDiabetes insipidus, melitusDiabetes insipidus, melitusHypercalcaemiaHypercalcaemia


Homeostatic Controls of Urine OutputIntravascular volume and pressure (e.g. heart failure; diuretics; oedema; hypoalbuminaemia)Renal perfusion (e.g. hypertension; chronic renal failure)

Serum osmolality (e.g. diabetes mellitus; diabetes insipidus)Thirst mechanism and responsiveness

Excessive fluid intake (e.g. psychogenic; caffeine; alcohol)

Ability to access fluids (e.g. sedation; ADL status)

Levels of circulating hormones and end organ responsiveness

Renin (posture; fluid status; drugs)Aldosterone (hypertension; heart failure)

Angiotensin Ⅱ(diuretics; ACE inhibitors)CatecholaminesAtrial natriuretic peptide (ANP)(heart failure)Arginine vasopressin (AVP) (neurogenic DI; nephrogenic DI)Ageing brain losing its circadian rhythm


Desmopressin

The circardian rhythm of vasopressin was lost in the elderly with nocturnal polyuriaAtrial natriureteric peptide in the elderly was higher during night timeUse of arginine vasopressin analogue patients with nocturnal enuresis and nocturnal polyuria become dry


Etiologies of Nocturia

Detrusor instabilityHypersensitive bladderBladder outlet obstructionNocturnal polyuriaSmall bladder capacity


Impact of Nocturia on the Elderly

Elderly patients are likely to be exposed to serious health risksNocturia causes fatigue due to sleep deprivationIncrease chance of traumatic injury through falling from 10 to 21% with >2 voids per night


Side Effects of Desmopressin

HyponatremiaWater retentionSide effects can be eliminated after discontinuing medicationFederal law cautions against its use in patients over 65 years


Effects of Urodynamics on Therapeutic Effects of Desmopressin

Patients with small bladder capacity and detrusor instability might not benefit from desmopressin if no nocturnal polyuriaChildren with NE have been noted to be cured after DDAVP therapyCan the bladder learn to hold more urine and reduce nocturnal voiding frequency


Materials and Methods

Patients with severe nocturia refractory to previous treatmentAll patients had > 3/N nocturia and nocturnal urine volume > 35% daily voided volumeUrodynamic pressure flow study, patients with BOO or residual urine >100mL were excluded


Desmopressin Treatment

A one week entry testA 3-day voiding diary was recorded and nocturnal urine amount was calculatedA nocturnal urine sample taken for U/A and specific gravity testSerum BUN, Cr, Na, K were measuredPatients with both nocturnal frequency and polyuria were enrolled


Therapeutic Effects of Desmopressin in NocturnalPolyuria

BaselineBaseline PosttreatmentPosttreatmentP ValueP Value

(Paired t (Paired t Test)Test)

Nocturnal frequency Nocturnal frequency (time/night)(time/night)

5.20 ± 1.16 2.24 ± 1.12 <0.0001

Nocturnal urine volume (mNocturnal urine volume (mL)L) 955.6 ± 255.9 255.8 ± 210.5 <0.0001

Quality of lifeQuality of life 4.47 ± 1.07 1.05 ± 0.91 <0.0001Urine specific gravityUrine specific gravity 1.012 ± 0.007 1.016 ± 0.005 0.011Serum Sodiun (mEq/L)Serum Sodiun (mEq/L) 139.5 ± 4.34 139.7 ± 3.84 0.761Serum Potassium (mEq/L)Serum Potassium (mEq/L) 4.46 ± 0.35 4.31 ± 0.44 0.022


Effects of Bladder Capacity after Desmopressin Therapy

Baseline cystometric capacit

y (mL)

Pretreatment nocturnal bladder ca

pacity (mL)

Post-treatment nocturnal bladder ca

pacity (mL)P Value*

Good effect Good effect (n=20)(n=20)

235.0 ± 102.5 185.6 ± 39.3 260.2 ± 106.9 0.006

Failed (n=8)Failed (n=8) 262.9 ± 108.9 162.7 ± 88.0 200.0 ± 134.3 0.216

P valueP value 0.501 0.353 0.226

Nocturnal bladder capacity = mean nocturnal urine amount/ mean nocturnal frequency.*Comparing prectreatment and post-treatment findings.


Changes of Nocturnal Frequency after Desmopressin Therapy

Baseline urodynamic Results

Return to Baseline

Improved over

Baseline

Same as Post-

treatmentP Value

With DI (15) 2 7 6 >0.1

Without DI (10) 4 6 0

BC ≦250mL (17)

1 10 6 <0.05

BC > 250mL 5 3 0

Total (25) 6 (24%) 13 (52%) 6 (24%)

KEY: DI = detrusor instability; BC= bladder capacity.


Common Causes of Low Nocturnal Bladder Capacity

Infravesical obstructionIdiopathic nocturnal DINeurogenic bladder dysfunctionCystitis (Bacterial, interstitial, TB, radiation)Cancer of bladder, prostate, urethraLearned voiding dysfunctionAnxiety disordersPharmacological: xanthines (theophylline, caffeine), beta-blockersBladder or lower ureteral calculi


Combnation therapy for geriatric Nocturnal polyuria and Nocturia

Combined anticholinergics and DDAVP for detrusor overactivity and nocturnal polyuria for DI & NPCombined alpha-blocker and DDAVP for BOO and NPCombined alpha-blocker and anti-cholinergics and DDAVP for BOO & DI & NP

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