Voiding Disorders in Long-Term Care

Author Affiliations: Dr. Srulevich is a faculty member, Department of Medicine, in the Division of Geriatric Medicine, Crozer-Chester Medical Center, Upland, PA, and Clinical Assistant Professor of Medicine, Temple University School of Medicine, Philadelphia, PA; and Dr. Chopra is Professor of Medicine, Director of Education and Clinical Programs, New Jersey Institute for Successful Aging, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford, NJ.

Introduction

As many as half of all residents in long-term care (LTC) facilities suffer from some type of voiding disorder. A broad array of voiding symptoms such as incontinence, burning, frequency, sense of incomplete bladder emptying, and difficulty in initiating voiding affect the lower urinary tract. The primary focus of this article will be to review the pathophysiology and symptoms of common voiding dysfunctions in the LTC setting, understand how they relate to the underlying disease process, and effectively evaluate and manage acute and chronic conditions. Reasons for voiding dysfunction are often multifactorial and can be related to many overlapping comorbid conditions. Management and treatment options are tailored to relief of symptoms, reducing disease burden, and maintaining quality of life.

Pathophysiology of the Aging Lower Urinary Tract and Relation to Symptoms

The aging lower urinary tract undergoes physiologic changes that can result in increased urinary symptoms, such as urgency, frequency, and a sensation of incomplete emptying, which can manifest as urologic disorders. As aging occurs, overall bladder capacity is reduced and post-void residual volumes can become elevated.¹ Age-related morphologic changes in the bladder wall, consisting of a decreased ratio of the area density of smooth muscle to connective tissue, occur in both men and women.

In addition, detrusor contractility has been shown to decrease in an age-dependent manner.² An increase in lower urinary tract symptoms (LUTS) is thus age-related but not sex-specific.^3,4 In fact, while initially much lower in men, by the seventh decade the prevalence of urge urinary incontinence (UI) is about equal in both genders. Approximately half of all persons with symptoms of overactive bladder (OAB) suffer from detrusor overactivity.⁵ In contrast, voiding symptoms, such as the feeling of incomplete emptying or reduced urinary flow, are similar in both sexes until about age 50, when men demonstrate increased rates of voiding symptoms due to benign prostatic hyperplasia (BPH) and obstructive changes.⁵ In BPH, age-related prostatic enlargement may encroach upon the anatomic structures and cause obstruction of urine flow through the urethra.

Risk Factors for Voiding Dysfunction in the Geriatric Population

In both men and women, the causes of voiding dysfunction are diverse and can involve numerous organ systems. Acute symptoms always warrant further investigation, and reversible causes such as infection, obstruction, and medication side effects must be considered (Table I). If the symptoms are chronic, as is often the case in the LTC setting, the focus of management is to limit the impact of disease burden.

Epidemiological evidence in the geriatric population points to cognitive impairment, constipation, parity, medications, genitourinary surgery, obesity, and cardiovascular disease as risk factors for incontinence.^6,7 Gammack⁶ notes that in frail elderly persons, many of these conditions are already present and may be unmodifiable, so prevention should focus on reducing the impact of chronic disease on these related risk factors.

Older adults often take more medications, which can have deleterious effects on bladder control. Drugs with anticholinergic side effects can reduce bladder emptying and may cause urinary retention. The use of diuretics may complicate the management of incontinence. Dietary factors must also be considered in managing UI. For example, caffeine is a known bladder stimulant and should be reduced or eliminated for more effective management.

Cognitive status can impact voiding in several ways. In the early stages of dementia, continence strategies focus on simplifying the process. Wearing clothing that can be easily removed or using timed voiding may be of benefit. As dementia advances, the ability to respond appropriately to the voiding urge is lost, and behavioral management techniques such as scheduled voiding become even more important.⁶

Often, physicians attribute urinary difficulties to dementia. Gammack,⁶ however, cautions that it is only in the later stages of dementia that urinary problems may be attributed to cognitive defect alone. Therefore, new onset of UI in persons with mild dementia warrants further investigation of acute or transient causes. Immobility and environmental barriers also have been implicated as risk factors for UI.⁸

In a nursing home (NH) setting, predictors of incontinence after 1 year include male gender and impaired mobility.⁹ Jirovec¹⁰ implemented an ambulatory exercise program for NH residents with incontinence and found that over 8 weeks, daytime incontinence and endurance both improved. Such programs—while demonstrating efficacy—are difficult to implement as numerous administrative issues such as staffing and nurse aide-to-resident ratio also play an important role.

Urinary Incontinence

Urinary incontinence, defined as any involuntary leakage of urine,¹¹ is not a “normal” part of aging but is a common condition in many elderly persons. Furthermore, it is estimated that more than 50% of NH residents are incontinent of urine.¹² When considering UI in the LTC setting, one often thinks of frail elderly individuals, who often reside in NH and other LTC settings such as residential care homes and personal care homes. Exisiting literature about UI in the LTC setting is largely limited to NH data, and there has been little research in other settings such as assisted living and personal care facilities.¹²

Four Classifications of UI

In general, problems related to incontinence can be divided into problems of storage and emptying. Storage problems occur due to dysfunction of the bladder or urethra. Likewise, impaired emptying also results primarily from bladder and urethral causes. However, in many instances, the cause of UI is idiopathic. For descriptive purposes, UI is generally divided into four categories (Table II). No single type of UI is exclusive, and mixed etiologies are often present, particularly in the LTC setting.

Stress UI Stress UI occurs because of failure of the urethral sphincter to remain closed during bladder filling or periods of exertion. An increase in intra-abdominal pressure, which occurs with coughing, sneezing, or laughing, can overcome urethral closure pressure and cause leakage. This is usually due to weakened pelvic floor muscles in women. In men, this condition results from trauma sustained by prostate surgery (radical prostatectomy, transurethral resection of the prostate). After radical prostatectomy, most men experience temporary periods of UI to various degrees, but about 20% remain incontinent 18-25 months afterwards.⁵

Urge UI Urge UI is involuntary leakage of urine accompanied by or immediately preceded by a strong urge to void.⁵ Urge UI is caused by an overactive detrusor and is often referred to as one of the symptoms associated with OAB, which often includes frequency and nocturia. Detrusor overactivity is either neurogenic or myogenic in origin.⁵ It is often difficult to separate out these two underlying processes, which may occur simultaneously. Common causes of detrusor instability include the loss of cortical inhibition of the voiding reflex, such as can occur in stroke, dementia, or Parkinson’s disease.

Overflow UI Overflow UI refers to leakage that occurs when an inability to empty the bladder results in overdistension. This type of UI, often termed continuous, results from either a lack of detrusor contractility or outflow obstruction. The hallmark of overflow UI is high post-void residuals.⁵ Men with overflow UI often have BPH or strictures, and present with hesitancy, weak stream, and a sense of incomplete emptying. In both men and women, detrusor hypotonicity may be related to diabetes or anticholinergic medications. Causes of overflow UI can include diabetes, pelvic trauma, pelvic surgery, injuries to the spinal cord, multiple sclerosis, or polio.

Functional UI Functional UI, which is very common in LTC settings, is not directly due to disorders of the lower urinary tract, but rather results from cognitive, psychological, or physical disability. Conditions such as depression, dementia, macular degeneration, decreased physical function resulting from stroke, and shortness of breath from end-stage heart failure can all decrease the functional ability of older adults to toilet appropriately.⁶

Management of Urinary Incontinence

Behavioral modification should always be encouraged as a part of any comprehensive management strategy for voiding dysfunction, particularly in light of frail elderly persons predisposing to medication side effects.

One behavioral change often utilized in more cognitively intact individuals is encouraging them to reduce fluid intake at night and avoid such bladder stimulants as caffeine. Bladder training techniques such as scheduled voiding may also be implemented, especially in the cognitively impaired population. Pelvic floor exercises, also known as Kegel exercises, are especially useful for stress incontinence in women without pelvic prolapse,² but they also may be prescribed for men who experience stress UI after prostate surgery. Removing physical barriers to toileting (eg, proximity to facilities) and encouraging the use of handrails must also be addressed, and may help manage symptoms of OAB. Caregiver interventions such as prompting or assisting patients with regular voiding intervals can greatly improve urge and overflow UI with both cognitively intact and impaired individuals.

Pharmacologic treatment of urgency and urge UI (Table III) utilizes the antispasmotic properties of receptor-specific anticholinergic agents such as oxybutynin or tolterodine. Newer agents include trospium and two other agents, solifenacin and darifenacin, which target antagonizing acetylcholine at muscarinic receptors. Long-acting formulations and more receptor-selective forms of the drugs are preferred in the geriatric population because they tend to cause fewer anticholinergic side effects¹⁴; however, this may be hampered by LTC facility agreements with participating pharmacies, as well as by insurance issues.

Urinary retention must always be ruled out, however, as the administration of anticholinergics may exacerbate this condition, no matter how receptor-specific the agent may be. Interventions for persons with atonic bladder may include patient self-catheterization if cognitive status and physical ability are intact. Indwelling urethral catheters should be avoided if possible due to a high rate of bacteriuria and risk of urinary tract infection (UTI). Men with outlet resistance from enlarged prostate resulting in bothersome symptoms and incontinence may need intermittent catheterization or surgical relief. Urologic referral is appropriate for poorly managed symptoms.

Urinary Retention

Urinary retention is defined as the inability to voluntarily void. It can be acute or chronic. In the acute setting, retention is sudden, often painful, and the bladder cannot empty despite being full.¹⁶ If retention is of chronic nature, it may not involve pain and is primarily associated with increased residual urine.¹⁷ Acute retention is most often associated with obstruction but may also be caused by infection, inflammation, medications, neurologic disease, or trauma. In older persons, several underlying factors may interact to precipitate acute urinary retention. There may be underlying disease with respect to documented outflow obstruction from BPH in men, sequelae from previous stroke in both men and women, or recent use of anesthesia for hip fracture, which can often lower the threshold for retention, especially if new medications are added in the LTC setting.

Causes of Urinary Retention

There are various classification systems for the causes of urinary retention, but in general they are obstructive, infectious/inflammatory, pharmacologic, neurologic, and other (Table IV). Obstructive causes include outflow obstruction from mechanical factors (eg, stricture, mass, kidney stone, volume of the prostate) or dynamic factors (eg, smooth muscle tone within the prostate). Another classification includes intrinsic (eg, prostatic enlargement, stricture, stone formation) or extrinsic (eg, uterine or gastrointestinal mass causing compression) etiologies.

The most common cause in men is BPH. In women, retention can be due to organ prolapse, pelvic mass, or uterine fibroids. Infectious and inflammatory causes include prostatitis and urethritis, resulting from UTI in both women and men in LTC settings. Medications are commonly implicated with urinary retention. Any medication with anticholinergic propreties—often prescribed in LTC settings for managing such common conditions as OAB and irritable bowel syndrome—are always suspect. In addition, antihistamines, tricyclic antidepressants, and muscle relaxants can also cause acute or exacerbate chronic retention.

Of note, nonsteroidal anti-inflammatory drugs (NSAIDs) have also been implicated in urinary retention due to the inhibition of prostaglandin-mediated detrusor muscle contraction.¹⁸ Postoperative complications can cause urinary disorders. For example, as many as 78% of persons who have had hip arthroplasty will develop urinary retention,¹⁵ and it is felt that pain, instrumentation, and pharmacologic agents (particularly narcotics) all play a role. Narcotics, often employed for reducing pain in the postoperative period, can reduce detrusor contractility and muscle tone in the bladder neck.¹⁵ They may also cause constipation, which, if bad enough, can precipitate urinary retention. Table V provides a list of pharmacologic agents associated with urinary retention. Other causes include neurologic factors such as stroke, which can result in detrusor hyporeflexia. In addition, persons with diabetes and diabetic peripheral neuropathy can experience bladderdysfunction.¹⁵

Approach and Management of Urinary Retention

In men, a common presentation for urinary retention is BPH. If there has been no retention in the past, LUTS are present by history and commonly include frequency, urgency, nocturia, and hesitancy. Care should be taken to see if the individual has undergone recent surgery, if any new medication was started, or if other precipitating factors such as constipation or UTI are present. Additionally, evidence of delirium, which is often the only presenting sign in the frail elderly person with dementia, should be carefully assessed. Iatrogenic causes—chiefly, medication side effects—are often implicated in the LTC setting, making medication review of paramount importance.

As mentioned previously, many medications utilized in LTC to treat chronic conditions may play a role in causing urinary retention. The physical exam should include percussion of the bladder and assessment for suprapubic tenderness A bladder scan, preferable to catheterization because it is noninvasive and can avoid potential complications, should be performed when possible to assess residuals. A urinalysis should also be obtained due to the occurrence of retention with pain and urethritis associated with UTI.

Acute urinary retention in both men and women requires decompression of the bladder through catheterization. If catheterization is not successful, immediate referral to a urologist or to the emergency room is appropriate. Often, however, in LTC these are chronic issues, and individuals may have BPH or chronic urinary retention, so the focus in management is to prevent further exacerbations by close monitoring of voiding, periodic medication review, and close communication with urological consultants when problems persist.

In acute retention, the placement of a catheter is important to relieve rising bladder pressures and pain. The optimal time to keep a catheter placed is unknown, and 70% of men will have recurrent urinary retention within 1 week if the bladder is simply drained.¹⁵ The use of chronic indwelling catheters should be avoided when possible due to the development of UTIs. In a prospective study of NH residents, catheter use was independently associated with increased mortality.¹⁹ However, in many LTC residents, some who have been followed by urologic consultants, indwelling catheters are still employed because of therapeutic failure of medication and previous catheterization. It must be emphasized that even if a person has an indwelling catheter due to chronic urinary retention, ultrasound should still be considered, as the catheter may become dislodged or displaced; high residuals may alert providers of the need to adjust the catheter.

Benign Prostatic Hyperplasia

In BPH, an increase in prostate gland volume has been shown to be associated with future LUTS and progression to acute urinary retention.²⁰ Although a history of retention may point to BPH, many men may have had no retention in the past, so a careful review of symptoms should always be considered. One of the most serious complications of BPH is acute outflow obstruction and resulting urinary retention. Therefore, the primary preventive goal in men who have BPH is the relief of outflow obstruction.

Treatment of BPH

The mainstay of treatment remains alpha-adrenergic blockade. Alpha blockers work by allowing relaxation of smooth muscle fibers and decreasing outlet resistance in the prostate and bladder neck.²⁰ They can be nonselective (terazosin, doxazosin, prazosin) or selective (tamsulosin, alfuzosin). In general, the nonselective agents tend to be less expensive but their effects are often more systemic, while the selective agents tend to have fewer side effects, so their selection may be more appropriate in LTC residents. The primary adverse events related to this drug class include nasal congestion, orthostatic hypotension, and dizziness, due to the ubiquitous presence of alpha receptors in the entire vascular system.

Treatment with alpha blockers has not been shown to reduce the overall long-term risk of acute urinary retention or BPH-related surgery,²¹ although statistically significant improvement in symptom scores as compared to placebo have been reported.²² Another class of drugs, the 5-alpha-reductase inhibitors (finasteride, dutasteride), are most effective for men who have demonstrable prostatic enlargement.²³ These agents work by inhibiting 5-alpha-reductase, which is implicated in the growth of the prostate gland. A combination of alpha blockers and 5-alpha-reductase inhibitors is often effective in reducing or even eliminating LUTS associated with BPH.

For men who continue to have significant symptoms, repeated UTIs, or increased renal insufficiency related to BPH, surgical management and referral to a urologist may be appropriate. If catheterization becomes necessary due to urinary retention, recent studies demonstrate that men with BPH have a greater chance of successful void trial if they are treated with alpha-adrenergic blockers (alfuzosin, tamsulosin) started at the time of catherization.¹⁵ Elderly men in LTC facilities can still have retention despite being on optimal medical therapy, and urologic consultation would be appropriate. Selective alpha blockers are preferred over nonselective agents because of a potentially lower side-effect profile, although these still can occur.

Conclusion

As the population ages, more people will be experiencing UI and other voiding disorders, with many of those residing in LTC settings. While the overwhelming majority of research has been done in the NH setting, existing data in other LTC facilities (eg, assisted living, personal care homes) are sorely lacking. Many types of disorders can be managed with behavioral and/or pharmacologic modalities. Avoiding bladder stimulants and using bladder training techniques such as scheduled voiding may also be of benefit. Potentially reversible causes of new-onset UI must always be explored, and the role of pharmacologic side effects in contributing to or exacerbating this condition in the LTC setting cannot be overstated.

Before considering pharmacotherapy, clinicians must obtain a careful history of symptoms in order to choose the most appropriate intervention. Behavioral therapy can be very useful in urgency associated with incontinence in both men and women. If behavioral therapy does not help, pharmacologic therapy may help symptoms associated with urgency and OAB; an anticholinergic agent may be appropriate if no evidence of urinary retention exists. In men with BPH, treatment goals aim to avoid obstruction, and alpha-adrenergic blockade is the mainstay of therapy. Stress and overflow UI are difficult to treat pharmacologically and may warrant a consultation with a urologist. The treatment for functional UI relies heavily upon behavioral modification and preventing physical disability. While these therapeutic approaches may not be curative, their potential impact in preventing morbidity and improving quality of life is significant.

The authors report no relevant financial relationships.