PENATALAKSANAAN MASALAH

INKONTINENSIA URIN
PADA LANJUT USIA
Putrawan I.B. Pt
Divisi Geriatri
Departemen Penyakit Dalam Fakultas Kedokteran Universitas Udayana
 Pendahuluan
Inkontinensia urin (IU): keluarnya sejumlah urin tanpa diinginkan atau ketidak
mampuan mengatur berkemih => masalah sosial dan /atau kesehatan.
 Jika seseorang keluar satu atau dua tetes urin ketika mereka tidak menginginkanya, pertimbangkan itu
inkontinensia

 diperkirakan mempengaruhi
sekitar 11-21% lansia di komunitas (studi di Italia)
 lebih dari 77% yang tinggal di rumah perawatan.

IU bukanlah sebagai bagian dari proses penuaan yang normal.

meningkatnya resiko ulkus dekubitus, kejadian jatuh, fraktur, ISK dan biaya
kesehatan tinggi (Liem CS, 2017).
 UI is not reported
because of...

Sesuatu yg memalukan
Kurang informasi
Dipercaya sebagai bagian menua
Petugas kesehatan tidak menanyakan
Dipercaya tdk ada penanganan yg efektif
What is Needed for Normal Bladder
Function?
1. Filling - Efficient and low pressure
2. Storage - Low pressure, with perfect continence
3. Emptying - Periodic complete urine expulsion, at low pressure,
when convenient
 Normal Bladder Function:
Bladder Filling
Sympathetic Parasympathetic
“On” “Off”

Bladder innervation
Sympathetic NorE
2,3 2,3 Ach
(Hypogastric nerve) Pelvic Nerve
Parasympathetic
(Pelvic Nerve) Detrusor
Somatic (Pudendal Voluntary
Nerve)

NorE
Hypogastric Nerve 1 Bladder Neck

Pudendal Nerve
Striated Sphincter
Normal Bladder Function:
Bladder Emptying
Sympathetic Parasympathetic
Parasympathetic
“Off” “On”
“On”

Ach
NorE 2,3 2,3 Pelvic Nerve

Detrusor
Voluntary
Detrusor Pelvic Nerve
NorE 2,3 2,3 Ach

Hypogastric
HypogastricNerve
NerveNorE
NorE 1
1 Bladder
BladderNeck
Neck

Pudendal Nerve
Striated Sphincter
 Voiding Dysfunction:
Functional Classification
• Classification:
• Failure to Store
Bladder Bladder
Pelvic Nerve
Outlet

• Failure to Empty
• Bladder
• Outlet
Bladder Neck
Striated Sphincter
Neurofisiologi Dasar Berkemih
• Disamping neuroanatomi kompleks dan refleks fisiologis untuk
mempertahankan kontinen, diperlukan
• Kognisi yang intak sangat penting untuk mempersepsikan sensasi penuhnya
kandung kemih dan kemampuan untuk menahan berkemih setelah sensasi
awal,
• Motivasi dan keinginan untuk mengeluarkan urin,
• Mobilitas dan koordinasi yang cukup untuk mencapai toilet dengan
keterampilan tangan untuk memanipulasi pakaian untuk proses berkemih
(Sakakibara R, 2008).
What is normal?
• daytime:
• frequency of no more than once every 2 hours

• nighttime:
• 1-2 voidings are considered normal
Age Related Changes
decreased bladder capacity (normal is 500-600 ml.,
older adult capacity may be 250 ml.)

increased residual urine

increased involuntary bladder contractions
decreased outlet resistance (females)

decreased ability to inhibit contractions

increased outlet resistance (males)
Forces that Affect the Pelvic Floor

Anatomical
Neurological Why would the female
In which ways do the anatomy increase incidence
nerves affect the pelvic of urinary incontinence?
floor?

Pelvic Floor Hormonal

How does estrogen
affect the pelvic floor?
Mechanical
What is the impact of
pregnancy, constipation, Psychological
and/ or prostate enlargement ? How would one’s psychological
status impact incontinence?
Risk factors for UI
immobility/chronic degenerative disease
impaired cognition
medications
obesity
diuretics
fecal impaction, constipation
environmental barriers
diabetes
stroke
estrogen depletion
Each of these factors can increase one’s
smoking risk for experiencing urinary incontinence.
Often older adults experience more than one risk
factor at any given time.
Inkontinensia Urin Sementara
• Inkontinensia urin dengan onset baru, didefinisikan sebagai IU yang
durasinya empat bulan atau kurang
 Penyebab Inkontinensia Urin Sementara (DIAPPERS).
D- Delirium
I- Symptomatic urinary infection
A- Atrophic vaginitis
P- Pharmacological
P- Psychological
E- Excessive urine output
R- Restricted mobility
S- Stool impaction
Incontinence is a secondary feature and resolves once delirium
improve. Common causes of delirium include acute medical
conditions like stroke, infection, pain, fractures, medications, changes
in environment, recent surgery, etc.
Asymptomatic bacteriuria is common among the elderly and does not
cause UI.
Causes local irritability and contributes to UI
Anticholinergics, diuretics, antidepressants, antipsychotics,
sedatives/hypnotics, anti-Parkinson’s treatment, etc.
Depression.
Diabetes Insipidus, excess fluid intake, diuretics-incl alcohol and
caffeinated drinks, heart failure. Peripheral oedema.
Immobility due to restraint use, pain, lower limb arthritis, functional
decline.
 Inkontinensia Urin Menetap
IU yang terjadi dengan durasi > 4 mgg, umumnya
terdapat abnormalitas traktus urinarius bawah.
Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence
 Urge incontinence

Adanya keinginan tiba-tiba dan sangat kuat untuk kencing yang tidak bisa ditahan,
diikuti keluarnya urin yang tidak dapat ditahan.
 Jumlah urin yang keluar bisa sedikit atau banyak.
 memiliki sedikit waktu ke kamar mandi sebelum akhirnya “ngompol”.
• “I’m unable to make it to the bathroom on time.”

Disebabkan oleh overaktive detrusor muscle => exessive involuntary bladder

contractions yg mungkin diinisisi oleh:
• cancer (bladder / prostate)
• infection
• spinal or nerve damage

Sering didapatkan pd pasien

• diabetes, stroke, dementia, Parkinson’s disease, or
multiple sclerosis
 Stress incontinence
Keluarnya sejumlah kecil urin yang tidak terkontrol ketika melakukan
aktifitas yg meningkatkan tekanan intra abdomen
 batuk, tertawa, bersin, mengangkat obyek berat
Peningkatan tekanan perut > kemampuan menutupnya spingter urin.
Stress incontinence lazimnya terjadi pada perempuan
Disebabkan oleh pelvic muscular weakness
 Pregnancy
 Obesity
 Surgery
 Medications
 aging (lower estrogen levels)

Mixed Incontinence: kombinasi dari Urge incontinence dan Stress incontinence

Overflow incontinence
keluarnya sejumlah kecil urin yang tidak terkontrol, related to the
overdistention of the bladder, biasanya
 disebabkan oleh beberapa tipe hambatan atau oleh karena kontraksi yang lemah
dari otot kandung kemih
 Ketika aliran urin terhambat atau otot-otot kandung kemih tidak dapat
berkontraksi lebih lama, urin tertahan dalam kandung kemih (urinary retention)
dan kandung kemih overdistentin.
 Tekanan dalam kandung kemih akan terus meningkat sampai sejumlah kecil urin
menetes keluar. Peningkatan tekanan dalam kandung kemih juga bisa
mengakibatkan kerusakan ginjal
 DM, BPH, spinal or nerve damage
 Functional incontinence

• Keluarnya urin akibat ketidak mampuan (atau kadang karena

keengganan) untuk mencapai toilet dimana urinary tract is healthy

• Penyebab yang paling sering adalah

 Menurunya mobilitas (strok, artritis berat)

 Kondisi yang mempengaruhi mental (demensia Alzheimer).

 Orang menjadi sangat depresi ketika tidak mampu pergi ke toilet (psychogenic
incontinence)
 Evaluasi pada Inkontinensia Urin
Riwayat medis
Pemeriksaan fisik
Pemeriksaan lab (darah rutin, analisis urin dan kultur)
Post-Void Residual volume Urine (PVRU).
=>Tujuan utama evaluasi dasar:
 Identifikasi penyebab IU sementara (DIAPERS)
Identifikasi kondisi yang mungkin perlu evaluasi khusus / dirujuk ke urologis
atau urogynecologis.
Setelah penyebab sementara dan indikasi untuk evaluasi khusus / dirujuk bisa
diekslusi, tujuan ketiga: menentukan tipe IU
Physical Examination
General examination
Edema, Neurologic Abnormalities, Mobility,
Cognition, Dexterity
Abdominal examination
Assess for palpable or distended bladder
Pelvic exam - women, ?prolapse
DRE - men
Cough test - observe urine loss
Alur penatalaksanaan Inkontinensia Urin
Stress Incontinence:
Primary Care (Initial) Management
Risk Reduction
Weight loss
Smoking cessation
Topical Estrogen

Behavioral techniques:
Kegel exercises
• Designed to strengthen pelvic floor muscles
• Initial treatment for stress incontinence
• Also helpful for urge incontinence
Stress Incontinence:
When to Refer?
• If incontinence causes decrease in quality of life
• Failed previous SUI treatment
• Failed Kegel exercises
Stress Incontinence:
Other Treatment Options
• Pelvic Floor Biofeedback
• Pessary
• Intra-vaginal insert to reduce prolapse and support the
urethra
• Urethral Bulking Agents: (collagen, etc.)
• Minimally invasive
• Less durable than surgery
• Surgery
• Urethral sling – Effective and durable
Stress Incontinence Surgery:
Does it Work?
 Success: 80-85%
 Not all bladder/women the same
 30% of women will have improvements in
OAB symtpoms
 Retention: 2-3%
OAB/Urge Incontinence: Primary
(Initial) Treatment

• Most cases of OAB can be diagnosed and

treated by primary health care providers.

• Treat OAB and urge incontinence the same.

• Treat for 6-8 weeks and reassess

• Consider voiding diary (frequency volume chart

for 3 days)
Overactive Bladder:
Treatment Options
• Behavioral therapy
• Medication (Anti-cholinergics, B3 Agonists)
• Combined therapy1
• Minimally invasive therapy
• Surgery

1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

Overactive Bladder Treatment:
Behavioral Therapy
• Patients should implement the
following program at home:
• Regular pelvic floor muscle exercises
• Specified voiding schedule aimed at avoiding
emergencies
• Reduce fluid intake to 1.5 litres per day
• Avoid caffeine and alcohol
 Overactive Bladder Treatment:
Anti-cholinergic Medications
First line treatments:
• Oxybutynin generic oxy 2.5 to 5mg TID-QID
• Tolterodine IR Detrol 1 or 2mg BID
• Tolterodine ER Detrol LA 2 or 4mg OD
• Oxybutynin ER Ditropan XL to 30mg OD
• Oxybutynin TDS Oxytrol 3.9mg OD (2-wk)
• Oxybutynin ER Uromax 10 or 15mg OD
• Darifenacin Enablex 7.5 or 15mg OD
• Toviaz Toviaz
• Solifenacin Vesicare 5 or 10mg OD
• Trospium Trosec 20mg BID

Other
• Myrbetriq Mirabegron 25-50mg OD
Anti-Cholinergic Medications and Glaucoma
• What do you do?
• Okay, if open angle glaucoma
• May be okay for closed angle glaucoma if treated.
• If not sure, ask for the ophthalmologist “okay”, not
the urologist
 When should you refer to a
urologist?
1. Uncertain diagnosis/no clear treatment plan
2. Unsuccessful therapy for OAB – after 2-3 meds?
3. Neurological disease
4. Stress incontinence concurrently
5. Hematuria without infection
6. Persistent symptoms of poor bladder emptying
7. History of previous radical pelvic or anti-incontinence
surgery
What to include in the referral?
• Urinalysis & Urine Culture
• Previous urologic/pelvic surgery
• Type of incontinence (UUI, SUI, Mixed)
• Attempted treatments
• ? Voiding diary
 OAB/UUI: Key clinical points

• Educate and reassure the patient

• No anti-cholinergic better than another
• Efficacy and side effects vary from individual to
individual
• OK to try different medications
• Realistic expectations – not a cure
• Be careful in geriatric patients
• Trosec 20 mg daily or bid, Detrol 2mg or 4mg, Enablex,
Vesicare
Overflow Incontinence:
Key Points
• Overflow incontinence: Leakage of urine due to
chronic urinary retention
 Usually related to bladder outlet obstruction
 BPH or Urethral Stricture
 May also be related to a weak or “hypotonic”
bladder
• Treatment:
• Relief of urinary obstruction
• If due to a weak bladder - self-catherization
Management of UI
is a team effort
Must involve:
 the client
 family
 caregiver(s)
 nursing
 primary care provider
 dietician
 PT/OT/RT/SLP
 management
 Obat-Obatan yang Berkontribusi Terhadap Inkontinensia Urin
Drugs Adult Dose Comments
I) Drugs with predominantly anticholinergic or antimuscarinic effects
Darifenacin 7.5-15 mg/d Selective for M3 muscarinic receptors in bladder with fewer cognitive side
effects
Fesoterodine 4-8 mg/d Active metabolite is identical to active metabolite of tolterodine

Oxybutynine 2.5-5 mg Long acting and transdermal preparation preferred

5-30 mg/d
10% topical gel daily
Solifenacin 5-10 mg/d Some selectivity for bladder M3 muscarinic receptors

Tolterodine 2-4 mg/d Limited aility to cross blood brain barrier

Trospium 20 mg twice daily Less likely to cross blood brain barrier
II) Estrogen (for women)
Cream, esterdiol local vaginal preparations ring,
III) Serotonin and noradranaline reuptake inhibitors
Duloxetine 20-80 mg/d improvement in stress UI.
IV) Alpha adrenergic antagonists (for men)
Alfuzosin 10 mg/d Postural hypotension serious side effect
Doxazosin 1-8 mg/d
1-5 mg/d Also used for post traumatic stress disorder in men
Prazosin (nonselective)

Silodosin 4-8 mg/

Tamsulosin 0.4-0.8 mg/d
Terazosin 1-10 mg/d HS
V) 5 alpha reductase inhibitors (for men)
Dutasteride 0.5 mg/d
Finasteride 5 mg/d
 Simpulan
• Inkontinensia urin sering terjadi pada lansia => menurunya kualitas hidup,
morbiditas dan biaya yang tinggi.
• Skrining IU hendaknya dilakuan secara aktif pada lansia
• Anamnesis, px fisik dan urinalisis sudah cukup untuk memulai penanganan.
• Terapi bertahap dari terapi behavioural dan medikasi ke pendekatan yang lebih
invasive.
• Terapi behavioural (bladder training dan latihan otot pelvis) umumnya efektif untuk
menurunkan IU tipt urge dan stress, terapi dengan antimuskarinik untuk IU urge memiiki
efikasi serupa dan pilihan obat hendaknya dipandu dengan antisipasi efek-efek sampingnya.
• Penyebab IU sering multifactor dan sering disertai demensia, sehingga pilihan
terapinya terbatas, baik nonfarmakologi maupun farmakologi.
• Mempertahankan tidak ngompol secara sosial dengan kualitas hidup sebagai
luaran utama hendaknya menjadi tujuan, dari pada tidak ngompol secara total.
Approach to Urinary Incontinence
Peripheral Nerves in Micturition
 Perbandingan Antara Kemih pada Lansia dan Dewasa
Normal Bladder Aging Bladder

Filling & Storage Voiding Filling & Storage Voiding

Bladder Filling Detrusor contraction Increased bladder Increased outlet
excitability obstruction

Detruser relaxation Sphincter relaxed Reduced outflow Decreases

resistence contractility

Sphincter contracted Smooth urine flow - Palpable bladder

Continent Normal Urge Continuous dribbling
micturition in an incontinence
appropriate Stress
environment. incontinence
 Inkontinensia Urin berdasar penyebab dari traktus urinarius bawah dan neurologis
Causes Detrusor over- Stress incontinence Bladder outlet Detrusor underactivity
activity obstruction
Lower urinary Cystitis-infection/ Pelvic floor weakness- BPH, bladder neck Post-surgical
tract chemical, bladder multiparity, obesity, dysfunction, complications TURP,
stone, tumour. surgical procedures. posterior urethral hip op, hysterectomy.
High urethral resistance. Post TURP in men. valves, iatrogenic- Pelvic organ prolapses,
postop. severe atrophic
vaginitis.
Anticholinergic drugs.

Neurological DM neuropathy, spinal Pudendal nerve injury, Uncoordinated Multiple sclerosis, PD,
causes cord lesions, sacral spinal cord. sphincter activity- DM, dementia, sacral
Parkinson’s disease, Spinal cord injury. neuropathy, stroke.
MSA, stroke, dementia.
Neurogenic Bladder:
Definition
• Failure of bladder function with loss of
innervation
• Normal bladder:
• Holds 350-500mL
• Senses fullness
• Low pressure
• Empties >80% efficiency
Neurogenic Bladder:
Classification
• Innervation:
• Parasympathetic (S2-4) – empties bladder
(bladder contracts, sphincter relaxes)
• Sympathetic (T10-L2) – fills bladder (bladder
relaxes, sphincter contracts)
• Classification:
• Upper motor neuron (lumbar and higher)
• Lower motor neuron (sacral and lower)
Neurogenic Bladder
• Upper motor lesion:
• Detrsuor overactivity – Above pons
• Detrusor overactivity & discoordinated sphincter –
Spinal cord (thoracic & lumbar)

• Treatment
• Lower bladder pressure – Anticholinergics
• Empty bladder – Intermittent self catheterization
• Augment bladder (surgery) if high pressures persist
Neurogenic Bladder

• Lower motor lesion (sacral or lower):

• Detrusor atony/areflexia
• Treat with Clean Intermittent catheterization
Neurogenic Bladder:
Autonomic Dysreflexia
• Autonomic dysreflexia
• Massive sympathetic release in response to
stimulation below spinal cord lesion
• Hypertension, headaches, bradycardia, flushing
above
• THIS IS A POTENTIALLY LIFE THREATENING EVENT
• Treat with alpha-blockers, sublingual nifedipine