The selection of an agent depends on consideration of side
effects and cost, as well as comorbid conditions. Dosing
should be initiated at the lower end of the stated range for
each agent until symptoms are ameliorated, side effects are
encountered, or the upper end of the dosage range is
reached without discernible effect.
The use of calcium channel blockers such as nifedipine
and verapamil has been advocated by many clinicians but
must be considered investigational at this time. The
incontinent patient with angina or hypertension, however,
might best be treated with a calcium channel blocker,
which may also help the incontinence.
Reflex incontinence. Reflex incontinence is similar in
presentation to urge incontinence except that patients
receive no warning before voiding. This situation occurs
when the lower spinal micturition center is cut off from
brainstem and cortical centers and usually is seen in the
setting of severe spinal cord disease or injury. Because
there is no signal before voiding, behavioral management
and assistive devices are less effective. Pharmacologic
management is similar to that for urge incontinence but is
more problematic. Fortunately this pattern of incontinence
is rare in ambulatory geriatric populations.
Stress incontinence. Stress incontinence is a common
presenting pattern of urinary incontinence in women. It is
relatively uncommon in men, unless there has been
traumatic or surgical damage to the urinary sphincter.
Patients complain of intermittent leakage of small amounts
of urine associated with laughing, coughing, or lifting
heavy objects. The cause is usually related to the
postmenopausal decrease in estrogen with subsequent
atrophy and thinning of the urinary sphincter and pelvic
floor muscles. The bladder neck and sphincter, which are
normally located within the pelvis and are therefore
intraabdominal, can actually descend out of the pelvis. In
this situation transient increases in intraabdominal pressure,
rather than reinforcing the resting tone of the urinary
sphincter instead overwhelm it, resulting in the expulsion
of urine. Another variant of stress incontinence is
stress-induced detrusor instability, in which coughing,
laughing, lifting, or other maneuvers that produce a sudden
rise in intraabdominal pressure result in an uninhibited
contraction of the bladder. Several features distinguish this
condition from simple stress incontinence: the volume
leaked is moderate to large, nighttime incontinence is
more common, there may be a brief but detectable delay
LI Drugs used in the management of urge
incontinence
Oxybutynin: 2.5-5 mg tid
Propantheline: 15-30 mg tid
Imipramine: 25-50 mg tid*
Dicyclomine: 10-20 mg tid
*Should be begun at lower dosages (e.g., 10-25 mg qd) and gradually
titrated upward. Can cause serious cardiac conduction problems.
between the stress-inducing maneuver and the passage of
urine, and the patient may experience urgency.
The diagnosis of stress incontinence is based largely on
history and physical examination. Pelvic and rectal
examinations are indicated to detect evidence of estrogen
deficiency and to exclude anatomic problems such as
urethrocele or vesicocele, which might warrant surgical
intervention. During the examination the patient should be
asked to strain or cough, and the leakage of any urine
should be noted. The patient then can be asked to repeat
the maneuver after the examiner has inserted a finger in the
vagina and elevated the bladder neck by exerting gentle
pressure anteriorly. In a positive test, the leakage of urine
is corrected by the elevation of the bladder.
The management of stress incontinence depends on the
underlying cause, and the majority of patients respond to
conservative therapy. Weight loss is indicated in obese
patients and result in decreased pressure on the pelvic
floor. The patient should be taught Kegel exercises, which
involve isometric contraction of the pelvic sling muscles
and can increase the strength and resting tone of the
urinary sphincter. Estrogen therapy, either topical or
systemic, is sometimes effective, especially for women
with clinical evidence of estrogen deficiency such as
atrophic vaginitis and hot flashes. In patients who do not
respond to these therapies a trial of an adrenergic agent
such as pseudoephedrine, phenylpropanolamine, or imipramine
can be given (see the box below); however, the side
effects of these agents in the elderly can be considerable.
A variety of surgical procedures are available for
selected patients who fail medical management. When
surgery is not possible, a vaginal pessary or penile clamp
may restore continence.
The clinician should be aware of the existence of mixed
stress-urge incontinence, in which a sudden rise in
intraabdominal pressure triggers detrusor contractions.
The management is essentially the same as for urge
incontinence, although the diagnosis is frequently difficult
to make clinically. This is because the delay between the
stress and detrusor contraction may be extremely brief,
although the volume voided usually is larger than with
pure stress incontinence. Imipramine may be the drug of
choice in the treatment of stress-induced detrusor instability,
since it combines sympathomimetic effects on the
urinary sphincter and anticholinergic effects on the
detrusor.
Overflow incontinence. Overflow incontinence refers to
incontinence that occurs in the setting of abnormally high
a-Adrenergic agents used in the treatment
of stress incontinence
Pseudoephedrine: 15-30 mg tid
Phenylpropanolamine: 75 mg bid
Imipramine: 25-50 mg tid*
*Should be gradually titrated up to this dosage, starting with
10;25 mg qd.


bladder volumes and incomplete emptying. The most
common underlying conditions are mechanical outlet
obstruction (usually benign prostatic hypertrophy in men)
and neurologic lesions. The PVR is by definition high, and
patients report constant or frequent dribbling, which may
be exacerbated by stress, and decreased force of urinary
stream. Patients also may report the sensation of incomplete
bladder emptying and the need to strain to void.
Physical findings may include a palpable bladder or
suprapubic dullness to percussion in addition to any
underlying neurologic deficits. Prostate size as determined
by DRE correlates very poorly with the presence of outlet
obstruction.
The performance of urodynamics is particularly important
in suspected overflow incontinence. Cystoscopy is
necessary to determine the presence and site of a
mechanical obstruction. Management includes relief of
mechanical obstruction followed by intermittent catheterization
until the bladder regains contractility. If the
bladder does not regain contractility, continued catheterization
may be necessary. Management also may include
the use of cholinergic agents to increase bladder contractility
and a-adrenergic blockers to decrease resting
sphincter tone. When employed, pharmacologic agents are
rarely of long-term utility.
Functional incontinence. Functional i~continence refers
to incontinence that occurs because an individual has lost
the capacity to move to an appropriate place to void in a
timely manner. This definition incorporates both individuals
with normally functioning urinary tracts and those with
impaired function. An obvious example would be a patient
who is hospitalized with a hip fracture and is placed in
traction with an intravenous infusion. The patient is likely
to become incontinent unless supplied with aids such as a
bedside urinal or bedpan, prompt assistance from hospital
staff, and aggressive restorative services such as physical
and occupational therapy. Although usually less overt,
global functional problems such as visual and auditory
impairment, mobility problems, and deconditioning are
frequently contributory factors in both transient and
established incontinence. Identification and management
of these functional difficulties are essential.
Use of assistive devices
As previously discussed, the use of assistive devices such
as a bedside commode or urinal can be an indispensable
part of the management plan, particularly for a patient with
a component of nocturnal urge incontinence. In the
daytime a regular toileting schedule (based on the patient's
incontinence chart) can preempt inadequate warning time
before voiding and can be effective even in patients with
moderate cognitive impairment. Patients should modify
their fluid intake so that most of it takes place at times
when appropriate facilities are nearby. Avoiding fluid
intake in the evening may reduce nocturia and incontinence.
The judicious use of adult incontinence briefs can
provide substantial independence and prevent homeboundedness,
functional decline, and institutionalization.
Overuse can lead to skin maceration and breakdown, along
with urinary and vaginal infections. The use of an
indwelling or suprapubic Foley catheter should be reserved
for instances when all other approaches have failed
or are unacceptable to the patient. For those with
hypocontractile bladders and retention as a cause of their
incontinence, intermittent self-catheterization is a preferred
method with a lower infection rate.
Given the potential complications and loss of dignity,
the use of Foley catheters and adult incontinence garments
in acutely ill patients with transient incontinence is rarely
appropriate, since the risk usually outweighs the benefit.
Such management should not be invoked for the Convenience
of the hospital or nursing home staff alone.

PRESSURE SORES

The pressure sore is one of the most difficult management
problems encountered in elderly patients and is always
best dealt with by prevention rather than cure. Recent
advances have improved our understanding of the epidemiology,
pathophysiology, and principles of management
oUhis condition. Surveys of general hospitals indicate that
from 3% to 11 % of hospitalized patients bring pressure
sores into the hospital and that between I and 5% of newly
admitted patients develop pressure sores during hospitalization.
The mortality associated with pressure sores in
some studies leads to a fourfold increased risk of dying in
those patients coming from nursing home environments.
The elderly are most likely to develop this condition. Risk
factors for the development of pressure sores have been
identified for hospitalized patients and include fecal
incontinence, fractures, and hypoalbuminemia. Nursing
instruments such as the Norton Scale have been developed
to predict which patients are at greatest risk for the
development of decubitus ulcers and therefore require
assiduous attention to ameliorating those risks and treating
underlying disease.
Pressure sores occur over bony prominences with 65%
being found in the pelvic area and 30% on the lower
extremities. Four critical factors have been proposed to
explain the pathophysiology of decubiti: pressure, shearing
forces, friction, and moisture. Prolonged direct
pressure above 32 mmHg produces tissue anoxia with
subsequent necrosis of epidermis and superficial dermis.
When supine, 70 mmHg of pressure may be generated at
sacrum, and 45 mmHg is generated at the heels. It is not
surprising, then, that pressure sores may arise in less than
an hour of total immobility.
In addition, the elderly have less subcutaneous fat and
therefore less "cushioning" as well as a higher likelihood
of diseases that reduce cutaneous blood flow, such as
congestive heart failure, atherosclerosis and dehydration.
Shearing forces result from the relative displacement of
tissues and occur, for example, when the head of the bed
is raised and the torso slides down. In this case the skin is
fixed to the sheets but the subcutaneous tissue is stretched,
resulting in angulated blood vessels and thrombosis in the
underlying dermis.
Friction results when two surfaces in contact move
across each other, as when a patient is dragged across a
sheet. Moisture results from fecal and urinary incontinence,
drainage from tubes, food, and sweat leading to
skin maceration and breakdown.
The differential diagnosis of the pressure sore is made
substantially by location of the lesion. Early ischiorectal
abscesses, vasculitis, deep mycosis, and necrotic maJig