You are on page 1of 12

Med Clin N Am 90 (2006) 825–836

Urinary Incontinence: Selected Current Concepts
Marget-Mary G. Wilson, MD, MRCPa,b,*
Division of Geriatric Medicine, St. Louis University Health Sciences Center, 1402 South Grand Boulevard, Room M238, St. Louis, MO 63104, USA b Geriatric Research, Education, and Clinical Center, Veterans’ Administration Medical Center, Jefferson Barracks Division, 1 Jefferson Barracks Drive, St. Louis, MO 63125, USA
a

Introduction Urinary incontinence (UI) in older adults is a potentially life-threatening problem. Potential consequences include significant functional decline, impaired quality of life, frailty, institutionalization, and death [1,2]. Reported prevalence for urinary incontinence ranges from 15% among relatively healthy community-dwelling older adults to 65% among frail older adults [3,4]. Available figures most likely underestimate the true prevalence of UI for several reasons, including patient embarrassment, low rates of clinical detection, and lack of awareness of effective treatment options [5]. Health care costs for UI exceed $20 billion annually [6]. Additionally, the lifetime medical cost of treating an older adult who has urinary incontinence approaches $60,000 [7]. Added costs arising from complications of UI, such as loss of wages, poor quality of life, depression, and loss of self-esteem, increase the financial burden of UI even further [6].

Pathophysiology of urinary incontinence in older adults Age-related changes in bladder function set the stage for UI (Fig. 1). These include an increased frequency of uninhibited detrusor contractions, impaired bladder contractility, abnormal detrusor relaxation patterns, and reduced bladder capacity. There is also an age-related increase in the volume of nocturnal urine production. In men, prostatic size increases, whereas

* Division of Geriatric Medicine, St. Louis University Health Sciences Center, 1402 South Grand Boulevard, Room M238, St. Louis, MO 63104. E-mail address: wilsonmg@slu.edu 0025-7125/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2006.06.005 medical.theclinics.com

826
Gender Anatomic Cultural Environmental Neurologic disease Childbirth Tissue disruption Pelvic surgery

WILSON

Constipation Occupation Obesity Surgery Advanced age Disease Dementia Drugs Debility Disease Environment Medications

Urinary Incontinence

Fig. 1. UI in the older adult: risk and predisposing factors.

urethral shortening and urethral sphincter weakening occur in women [8–11]. Aside from advancing age, other risk factors for UI include coexisting morbidity, cognitive dysfunction, functional impairment, gait abnormality, diuretic therapy, and obesity [3,12]. Female gender is an irreversible predisposing factor and mandates routine screening for UI in all women regardless of age. Anatomic genital abnormalities such as hypospadias, epispadias, and ambiguous genitalia may compromise continence. Coexisting illness, such as cerebrovascular disease, radical pelvic surgery, or autonomic neuropathy, may increase the risk for UI further [13,14]. Available data indicate that the occurrence of cerebrovascular disease doubles the risk for UI in the older woman. Obesity, frailty, and diabetes are strong predictors of the occurrence of UI Additionally, older adults are more likely to become incontinent following the onset of UI-promoting factors, such as constipation, obesity, and polyuria from uncontrolled hyperglycemia, hypercalcemia, or diuretic therapy [3,15,16]. Mechanistic classification of urinary incontinence UI can be categorized into five major groups: overactive bladder (OAB), stress incontinence, overflow incontinence, and functional incontinence; combinations of these categories constitute the fifth category, which is referred to as mixed incontinence. Symptoms of bladder hyperactivity and impaired contractility may coexist in patients who have diabetes mellitus. Likewise, benign prostatic enlargement can present with symptoms of bladder overactivity and urinary retention [17–19]. OAB occurs in one in four adults over the age of 65 years and accounts for 40% to 70% of all cases of UI in this cohort. Symptoms of OAB arise

URINARY INCONTINENCE

827

from involuntary contractions of the detrusor muscle at unusually low volumes of urine, resulting in a strong urge to pass urine. Clinically, OAB manifests with urgency, frequency, and nocturia, with or without urge incontinence [20]. People who have urge incontinence present with involuntary urine loss preceded by an urgent and compelling desire to void. Several physiologic mechanisms underlie detrusor muscle contraction. The major mechanism is cholinergic and is mediated through the effect of acetylcholine (Ach) on muscarinic bladder receptors. A second mechanism (purinergic) involves adenosine triphosphate- (ATP) mediated bladder contraction. A third non-neuronal mechanism probably exists, involving local uroepithelial Ach production and subsequent paracrine action on local muscarinic bladder. Available data indicate age-related compromise in cholinergic and purinergic bladder transmission. Purinergic transmission seems to play a greater role in bladder contraction with aging, suggesting disproportionate age-related compromise in cholinergic function. Available data also suggest an age-related compromise of non-neuronal uroepithelial Ach production [10,21]. Twenty-five percent of women who have UI present with symptoms of stress incontinence usually arising from anatomic or pathologic disruption of the angle between the bladder neck and the urethra. Causes of stress incontinence include vaginal childbirth and pelvic surgery, such as hysterectomy in women or prostate surgery in men. Generally, stress incontinence presents with involuntary urine loss associated with increases in intraabdominal pressure in the presence of a relatively incompetent urethral sphincter mechanism. In such patients, involuntary urine loss characteristically occurs when the patient laughs, coughs, or sneezes. In severe cases, UI may occur with a change in posture from supine or sitting to standing [22–24]. Overflow incontinence arises from bladder outlet obstruction that results in progressive bladder distension with a gradual increase in intravesical pressure until the mechanical outlet obstruction is overcome by sheer pressure. People who have overflow incontinence may complain of persistent trickling of urine in the presence of suprapubic distension or discomfort. In men, prostatic enlargement is the most common cause of overflow incontinence. Pelvic masses, such as uterine fibroids or cystoceles, may cause similar obstructive symptoms in women [25–27]. Functional incontinence refers to involuntary urine loss resulting from inability to gain prompt access to toileting facilities for reasons such as limited mobility, impaired cognition, lack of motivation, environmental barriers, or restricted access. This problem occurs commonly in frail elders who have dementia, cerebrovascular disease, Parkinson disease, or delirium. Altered mental status from narcotics, sedatives, or neuroleptic agents also may lead to functional UI [28,29]. Inappropriate use of physical or chemical restraints, poor vision, depression, reduced exercise tolerance, gait abnormality, or fear of falling are other causes of functional incontinence.

828

WILSON

Complications and consequences of urinary incontinence in elders Older adults who have urinary incontinence often experience embarrassment, loss of self-confidence, and poor self-esteem. Sixty percent develop depressive symptoms. Unpredictable episodes of UI may lead to withdrawal and social isolation. Limitation of physical activity in affected elders may compromise functional status and hasten progression to frailty. Intimate relationships may be avoided because of the fear of involuntary urine loss during sexual intercourse. Studies have shown an independent association between sexual dysfunction and urinary incontinence in older men [1,30–32]. Financially, UI can become burdensome. Protective garments and bedding often are not covered by insurance plans and are relatively expensive. Productivity of older adults in the workforce may be negatively affected by the threat of frequent and unpredictable episodes of incontinence. Likewise, the productivity of caregivers of patients who have UI may be compromised by their inability to cope with the demands of a relative who has urinary incontinence. Available data highlight UI as the most common cause of institutionalization of elders. Similarly, in long-term care facilities the resident who has urinary incontinence imposes an additional annual financial burden of approximately $5000 to total health care costs. [1,33]. In women aged over 65 years who have incontinence the incidence of falls and consequent fractures increases significantly. Approximately 20% to 40% of women who have UI will fall within 12 months and of these falls about 10% will result in fractures, usually of the hip. Available data show a strong association between UI, acute hospitalization, institutionalization, and death [34,35]. Thirty percent of women who have UI over the age of 65 years are likely to be hospitalized within 12 months. Older men are twice as likely to be hospitalized over a 12-month period. Of the myriad complications associated with UI, the most alarming is the independent association between UI and increased mortality [35].

Clinical assessment of the older adult who has urinary incontinence Health care providers should screen all older adults at risk for UI because few patients volunteer this information as a presenting complaint. Delayed presentation is not unusual and patients may not complain until symptoms become severe [36,37]. Providers should ask about the volume of urine lost, strength of urinary stream, body posture in which urine loss is most likely to occur, number of pads used, and associated fecal incontinence. Quality of life and caregiver burden should also be assessed. Additional information should be sought regarding risk factors and predisposing factors. Patients should be asked about a coexisting history of diabetes mellitus, hypercalcemia, impaired cognition, functional disability, or impaired sensory perception. Medication history is critical because diuretics or hyperosmolar

URINARY INCONTINENCE

829

infusions may contribute to polyuria and precipitate UI. Additionally, anticholinergic medications can cause obstruction and consequent overflow incontinence. Narcotics, sedatives, and hypnotics may impair cognition or cloud consciousness, thereby precipitating functional incontinence. An accurate voiding diary facilitates quantification, classification, and characterization of UI. Short voiding diaries (48 or 72 hours) have been shown to be just as reliable and valid as traditional 7-day diaries and are perceived as less burdensome by patients [38,39]. Physical examination must include a complete neurologic, abdominal, urogenital, pelvic, and rectal examination. Both the anal and bulbocavernosus reflexes should be assessed. Urethral sphincteric response to the cough reflex should be evaluated during pelvic examination to enable exclusion of stress incontinence. People who have stress incontinence may lose urine during coughing, whereas patients who have intact perineal reflexes exhibit tightening of the anal sphincter during coughing. Bedside measurement of postvoid residual volumes is helpful in the clinical diagnosis of overflow incontinence attributable to bladder outlet obstruction. Postvoid bladder residual volumes greater than 150 mL in the older adult suggest inadequate bladder emptying. Postvoid residual volumes greater than 200 mL indicate urinary retention. Where available, noninvasive bladder ultrasound measurements of postvoid residual volumes are preferred over direct measurement using a urethral catheter to minimize the risk for complicating urinary tract infection [40,41].

Practical management strategies Comprehensive physical examination should yield preliminary information relating to postvoid residual volumes and urethral sphincter competence. Providers should be aware of specific indications that prompt referral for specialist urologic evaluation. These include urinary retention attributable to obstructive uropathy, hematuria, prostate disease, recent pelvic surgery, recurrent urinary tract infections, and stress incontinence. Most older patients who have functional UI or urge incontinence associated with overactive bladder can be managed effectively by geriatric or primary care providers. Although urodynamic studies are frequently requested, available data indicate that results of these tests are unlikely to alter management in a significant proportion of older adults. Urodynamic studies are likely to be most helpful in older patients being considered for surgical intervention or in whom the diagnosis remains unclear after a thorough history and physical examination [42,43]. Guidelines issued by the Agency for Health care Policy and Research recommend limitation of initial diagnostic workup to urinalysis and measurement of postvoid residual volumes. The American Medical Director Association’s (AMDA) guidelines for the management of UI are

830

WILSON

even more conservative, recommending urinalysis only in patients who have suspected urinary tract infection and new or worsening UI. AMDA guidelines recommend postvoid residual measurements only in men and in female patients at risk for retention because of coexistent neurologic disorders or diabetes mellitus [44,45]. Bedside cystometric studies are no longer recommended for evaluation of UI because of poor correlation with results of urodynamic studies. In addition, bedside cystometry results usually do not alter management initiated based exclusively on clinical criteria [46,47]. The increased risk for urinary tract infection associated with urethral catheterization is an additional disadvantage of bedside cystometry [48]. Nonpharmacologic management should be the first line of therapy in all cases. In the subset of patients who fail to respond, the addition of pharmacologic agents is a viable option [49,50]. The increased risk for adverse drug effects and interactions in older adults, however, mandates due caution with drug selection and dosing. Invasive procedures or definitive surgical intervention occasionally are warranted in older adults who can tolerate such procedures. Nonpharmacologic treatment Nonpharmacologic intervention strategies vary with the type of UI. In patients who have OAB the mainstay of nonpharmacologic management is behavior modification tailored to suit the individual patient. Mentally competent, functionally intact, and highly motivated people are good candidates for patient-dependent intervention, such as biofeedback therapy. Caregiver-dependent toileting protocols are more appropriate in dependent or cognitively impaired patients. Prompted voiding is a caregiver-dependent strategy that offers the patient a regular opportunity to toilet. The designated caregiver offers toileting assistance at scheduled intervals, usually starting with a short period of about 2 hours. Prompted voiding has the added advantage of providing the patient an opportunity for social interaction and positive reinforcement. Habit training is a more complex variant of this method in which people who have UI are encouraged to link voiding to specific activities, such as meals, drinks, or just before outings. Eventually, regular toileting becomes a habit and involuntary urine loss is preempted. In older adults who have severe cognitive impairment and are unable to respond to communication a simple timed toileting schedule may be more helpful. In such cases the caregiver toilets the patient consistently at predetermined intervals. Prompted voiding and habit training also are helpful in the management of older adults who have functional incontinence. Environmental assessment, and modification if indicated, is critical to the effective management of functional UI. Adaptive equipment and assistive appliances may help facilitate efficient toileting and reduce incontinent episodes. Rehabilitative exercises focusing on pelvic muscles and biofeedback therapy can be helpful in patients who have stress incontinence or mixed

URINARY INCONTINENCE

831

incontinence. In patients who have mixed incontinence a combination of pelvic floor exercises and bladder sphincter biofeedback therapy has been shown to result in a reduction in episodes of involuntary loss [51]. Pharmacologic therapy Detrusor muscle contraction depends on the action of Ach on bladder muscarinic receptors. Antimuscarinic drugs therefore are effective in the treatment of overactive bladder. Side effects, such as delirium, cognitive impairment, orthostatic hypotension, falls, and cardiac arrhythmias, mandate caution in the use of these agents in older adults. Data suggest that the newer, selective antimuscarinic agents may provide a safer alternative, although in older patients the occurrence of delirium, dry mouth, urinary retention, constipation, and blurring of vision are still troubling concerns. Five muscarinic receptor subtypes have been cloned (Fig. 2). M1, M4, and M5 receptor subtypes predominate in the nervous system, whereas M2 and M3 receptors predominate in smooth muscle. M2 and M3 receptors are the major cholinergic receptors in the bladder. M3 receptors mediate direct detrusor muscle contraction, whereas M2 receptors seem to play a role in inhibition of bladder relaxation and modulation of bladder contraction in pathologic conditions, such as denervation injury or spinal cord disease. Differences in receptor subtype distribution are particularly important when considering adverse events associated with antimuscarinic agents in older adults. Oxybutynin and tolterodine are the two most commonly used antimuscarinic agents in the treatment of OAB. Oxybutynin is a relatively nonselective antimuscarinic agent and acts primarily on M1, M2, and M3 receptor

M1: CNS, salivary glands, stomach M4: CNS, basal ganglia, striatum M5: CNS: substantia nigra, eye

M2: Bladder, heart, smooth muscle M3: Bladder, salivary glands, brain, bowel, smooth muscle

Fig. 2. Distribution of human muscarinic receptor subtypes.

832

WILSON

subtypes. Although oxybutynin has been shown to reduce episodes of UI by almost 50% in 60% to 80% of patients, there is a relatively high incidence of anticholinergic side effects, such as dry mouth, constipation, and blurred vision. Additionally, neurologic side effects, such as dizziness, cognitive dysfunction, and delirium, have been reported in several studies, rendering oxybutynin a poor choice for the geriatric patient. Tolterodine is a more selective antimuscarinic agent that affects predominantly M2 and M3 receptor subtypes. Although the efficacy of tolterodine is comparable to oxybutynin, the incidence of peripheral anticholinergic side effects, such as dry mouth, is much lower. Additionally, cognitive dysfunction related to tolterodine use occurs only rarely. Available data favor use of the extended-release formulations of tolterodine over the immediate release because of greater efficacy, higher tolerability, and higher adherence rates [52]. M3 selective inhibitors, darifenacin and solifenacin, are another effective pharmacologic treatment option for OAB. Adverse effects, such as constipation and blurred vision, in conjunction with the notable paucity of safety and tolerability data in older adults, preclude objective comment regarding prescription of these agents in geriatric practice [53,54]. Trospium has been in use in Europe over the past three decades but has only been approved recently by the Federal Drug Administration for the treatment of OAB. Unlike the M2 and M3 selective agents, which are lipophilic tertiary amines, trospium is a hydrophilic quaternary amine rendering the blood–brain barrier relatively impermeable to trospium, thereby reducing the risk for unwanted central nervous system side effects. Trospium is not metabolized by the cytochrome p450 system and therefore may be less prone to drug interactions. Limited data are available regarding the safety of these agents in the frail elder. Further studies in this area are needed [55–57]. Invasive procedures and surgical management Periurethral sphincter collagen injections and vaginal pessaries are reasonably effective options for older adults unable to tolerate surgery. Sacral neuromodulation involves surgical implantation of a ‘‘bladder pacemaker’’ in the patient’s hip attached to a lead wire that is threaded to a site within the sacral canal at the base of the spine. External programming results in delivery of a painless electrical stimulus to the sacral nerves, which regulate bladder function. This process allows patients to control urine storage and expulsion. For some patients who have stress or overflow incontinence, surgery may be the only effective treatment. Older men who have overflow incontinence because of obstructive uropathy from prostatic hypertrophy may respond to prostatectomy. Several operations have been developed for the treatment of stress incontinence. Prolene suburethral sling insertion is a relatively new technique, with a documented cure rate of greater than 80%. Surgical complications of this procedure include retropubic hematoma, urinary tract infections and fibrosis, pubic osteomyelitis, urinary fistula, and

URINARY INCONTINENCE

833

transient postoperative urinary retention. Late complications include dysuria, urinary retention, detrusor instability, genital prolapse, sexual disorders, chronic pain, chronic urinary tract infections, and complications related to the use of biomaterials, including screws, synthetic tape, and artificial urinary sphincter. Nevertheless, quality-of-life studies after surgery for stress incontinence in younger patients show consistent improvement. Data in older adults are lacking. Tension-free vaginal tape surgery is a highly effective and minimally invasive alternative for treating patients who have stress urinary incontinence. Surgical complications include bladder perforation, urinary retention, pelvic hematoma, suprapubic wound infection, persistent suprapubic discomfort, and intravaginal tape erosion [58–60].

Summary UI is highly prevalent in older adults and associated with excess comorbidity and increased mortality. Intensive screening and comprehensive clinical examination of all elders enables prompt detection, accurate classification, and appropriate treatment. OAB is the most common cause of persistent incontinence in the older adult. As with other types of UI, behavior modification is first-line treatment of OAB. Although antimuscarinic agents have been shown to be highly effective in the treatment of OAB, limited data are available regarding the safety and tolerability of these agents in older adults. Patients who fail to respond to noninvasive treatment or those in whom surgery may be appropriate should be referred to the urologist for evaluation and further management.

References
[1] Bradway C. Urinary incontinence among older women: measurement of the effect on healthrelated quality of life. J Gerontol Nurs 2003;29(7):13–9. [2] Johnson TM, Bernard SL, Kincade JE, et al. Urinary incontinence and risk of death among community-living elderly people: results from the National Survey on Self-Care and Aging. J Aging Health 2000;12(1):25–46. [3] Landi F, Cesari M, Russo A, et al. Potentially reversible risk factors and urinary incontinence in frail older people living in community. Age Ageing 2003;32(2):194–9. [4] Holroyd-Leduc JM, Mehta KM, Covinsky KE. Urinary incontinence and its association with death, nursing home admission, and functional decline. J Am Geriatr Soc 2004;52(5): 712–8. [5] Dugan E, Roberts CP, Cohen SJ, et al. Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians. J Am Geriatr Soc 2001;49(4):462–5. [6] Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology 2004;63(3):461–5. [7] Birnbaum H, Leong S, Kabra A. Lifetime medical costs for women: cardiovascular disease, diabetes, and stress urinary incontinence. Womens Health Issues 2003;13(6):204–13. [8] Klauser A, Frauscher F, Strasser H, et al. Age-related rhabdosphincter function in female urinary stress incontinence: assessment of intraurethral sonography. J Ultrasound Med 2004;23(5):631–7.

834

WILSON

[9] Yoshida M, Miyamae K, Iwashita H, et al. Management of detrusor dysfunction in the elderly: changes in acetylcholine and adenosine triphosphate release during aging. Urology 2004;63(3, Suppl 1):17–23. [10] Lluel P, Deplanne V, Heudes D, et al. Age-related changes in urethrovesical coordination in male rats: relationship with bladder instability? Am J Physiol Regul Integr Comp Physiol 2003;284(5):R1287–95. [11] Patel MD, Coshall C, Rudd AG, et al. Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes. J Am Geriatr Soc 2002;50(4): 700–6. [12] Zunzunegui Pastor MV, Rodriguez-Laso A, Garcia de Yebenes MJ, et al. [Prevalence of urinary incontinence and linked factors in men and women over 65]. Aten Primaria 2003;32(6): 337–42. [13] McLoughlin MA, Chew DJ. Diagnosis and surgical management of ectopic ureters. Clin Tech Small Anim Pract 2000;15(1):17–24. [14] Allen L, Rodjani A, Kelly J, et al. Female epispadias: are we missing the diagnosis? BJU Int 2004;94(4):613–5. [15] Klausner AP, Vapnek JM. Urinary incontinence in the geriatric population. Mt Sinai J Med 2003;70(1):54–61. [16] Ouslander JG. Intractable incontinence in the elderly. BJU Int 2000;85(Suppl 3):72–8. [17] Johnson TM, Ouslander JG. Urinary incontinence in the older man. Med Clin North Am 1999;83(5):1247–66. [18] Nasr SZ, Ouslander JG. Urinary incontinence in the elderly: causes and treatment options. Drugs Aging 1998;12(5):349–60. [19] Ouslander JG, Schnelle JF. Incontinence in the nursing home. Ann Intern Med 1995;122(6): 438–49. [20] Tubaro A. Defining overactive bladder: epidemiology and burden of disease. Urology 2004; 64(6, Suppl 1):2–6. [21] Wuest M, Morgenstern K, Graf EM, et al. Cholinergic and purinergic responses in isolated human detrusor in relation to age. J Urol 2005;173(6):2182–9. [22] Jackson RA, Vittinghoff E, Kanaya AM, et al. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstet Gynecol 2004;104(2): 301–7. [23] Molander U, Sundh V, Steen B. Urinary incontinence and related symptoms in older men and women studied longitudinally between 70 and 97 years of age: a population study. Arch Gerontol Geriatr 2002;35(3):237–44. [24] van der Vaart CH, van der Bom JG, de Leeuw JR, et al. The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. BJOG 2002;109(2): 149–54. [25] Borrie MJ, Campbell K, Arcese ZA, et al. Urinary retention in patients in a geriatric rehabilitation unit: prevalence, risk factors, and validity of bladder scan evaluation. Rehabil Nurs 2001;26(5):187–91. [26] Chapple CR. Lower urinary tract symptoms suggestive of benign prostatic obstruction: triumph: design and implementation. Eur Urol 2001;39(Suppl 3):31–6. [27] Grosshans C, Passadori Y, Peter B. Urinary retention in the elderly: a study of 100 hospitalized patients. J Am Geriatr Soc 1993;41(6):633–8. [28] Chadwick V. Assessment of functional incontinence in disabled living centres. Nurs Times 2005;101(2):65–7. [29] Vickerman J. Thorough assessment of functional incontinence. Nurs Times 2002;98(28): 58–9. [30] Hogan DB. Revisiting the O complex: urinary incontinence, delirium and polypharmacy in elderly patients. CMAJ 1997;157(8):1071–7. [31] Johansson C, Hellstrom L, Ekelund P, et al. Urinary incontinence: a minor risk factor for hip fractures in elderly women. Maturitas 1996;25(1):21–8.

URINARY INCONTINENCE

835

[32] Saltvedt I, Mo ES, Fayers P, et al. Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit: a prospective randomized trial. J Am Geriatr Soc 2002;50(5):792–8. [33] Miner PB Jr. Economic and personal impact of fecal and urinary incontinence. Gastroenterology 2004;126(1, Suppl 1):S8–13. [34] Yust-Katz S, Katz-Leurer M, Katz L, et al. Characteristics and outcomes of ninth and tenth decade patients hospitalized in a sub-acute geriatric hospital. Isr Med Assoc J 2005;7(10): 635–8. [35] Baztan JJ, Arias E, Gonzalez N, et al. New-onset urinary incontinence and rehabilitation outcomes in frail older patients. Age Ageing 2005;34(2):172–5. [36] Rodriguez LV, Blander DS, Dorey F, et al. Discrepancy in patient and physician perception of patient’s quality of life related to urinary symptoms. Urology 2003;62(1):49–53. [37] Resnick NM, Beckett LA, Branch LG, et al. Short-term variability of self report of incontinence in older persons. J Am Geriatr Soc 1994;42(2):202–7. [38] Ku JH, Jeong IG, Lim DJ, et al. Voiding diary for the evaluation of urinary incontinence and lower urinary tract symptoms: prospective assessment of patient compliance and burden. Neurourol Urodyn 2004;23(4):331–5. [39] Nygaard I, Holcomb R. Reproducibility of the seven-day voiding diary in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(1):15–7. [40] Lehman CA, Owen SV. Bladder scanner accuracy during everyday use on an acute rehabilitation unit. SCI Nurs 2001;18(2):87–92. [41] Sullivan MP, Yalla SV. Detrusor contractility and compliance characteristics in adult male patients with obstructive and nonobstructive voiding dysfunction. J Urol 1996;155(6): 1995–2000. [42] Lovatsis D, Drutz HP, Wilson D, et al. Utilization of preoperative urodynamic studies by Canadian gynaecologists. J Obstet Gynaecol Can 2002;24(4):315–9. [43] Thompson PK, Duff DS, Thayer PS. Stress incontinence in women under 50: does urodynamics improve surgical outcome? Int Urogynecol J Pelvic Floor Dysfunct 2000;11(5): 285–9. [44] Resnick B, Quinn C, Baxter S. Testing the feasibility of implementation of clinical practice guidelines in long-term care facilities. J Am Med Dir Assoc 2004;5(1):1–8. [45] AMDA. AMDA (American Medical Directors Association) issues how-to guide for protocols on long-term care resident assessment. LTC Regul Risk Liabil Advis 2000;8(25): 7–8. [46] Byun SS, Kim HH, Lee E, et al. Accuracy of bladder volume determinations by ultrasonography: are they accurate over entire bladder volume range? Urology 2003;62(4): 656–60. [47] Resnick NM, Brandeis GH, Baumann MM, et al. Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution. Neurourol Urodyn 1996;15(6): 599–613. [48] Ouslander JG, Greengold B, Chen S. Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study. J Urol 1987;138(5):1191–5. [49] Ouslander JG, Maloney C, Grasela TH, et al. Implementation of a nursing home urinary incontinence management program with and without tolterodine. J Am Med Dir Assoc 2001; 2(5):207–14. [50] Goode PS. Behavioral and drug therapy for urinary incontinence. Urology 2004;63 (3, Suppl 1):58–64. [51] Teunissen TA, de Jonge A, van Weel C, et al. Treating urinary incontinence in the elderly– conservative therapies that work: a systematic review. J Fam Pract 2004;53(1):25–30, 32. [52] Rovner ES, Wein AJ. Once-daily, extended-release formulations of antimuscarinic agents in the treatment of overactive bladder: a review. Eur Urol 2002;41(1):6–14. [53] Jimenez Cidre MA. [Urinary incontinence: anticholinergic treatment]. Rev Med Univ Navarra 2004;48(4):37–42.

836

WILSON

[54] Robinson D, Cardozo L. The emerging role of solifenacin in the treatment of overactive bladder. Expert Opin Investig Drugs 2004;13(10):1339–48. [55] Scheife R, Takeda M. Central nervous system safety of anticholinergic drugs for the treatment of overactive bladder in the elderly. Clin Ther 2005;27(2):144–53. [56] Gaines KK. Trospium chloride (Sanctura)dnew to the US for overactive bladder. Urol Nurs 2005;25(1):64–5, 52. [57] Rovner ES. Trospium chloride in the management of overactive bladder. Drugs 2004;64(21): 2433–46. [58] Abouassaly R, Steinberg JR, Lemieux M, et al. Complications of tension-free vaginal tape surgery: a multi-institutional review. BJU Int 2004;94(1):110–3. [59] Ayoub N, Chartier-Kastler E, Robain G, et al. [Functional consequences and complications of surgery for female stress urinary incontinence]. Prog Urol 2004;14(3):360–73. [60] Krissi H, Borkovski T, Feldberg D, et al. [Complications of surgery for stress incontinence in women]. Harefuah 2004;143(7):516–9, 548.