Academic journal article Care Management Journals

Urinary Incontinence Evaluation and the Utility of Pessaries in Older Women

Academic journal article Care Management Journals

Urinary Incontinence Evaluation and the Utility of Pessaries in Older Women

Article excerpt

Urinary incontinence and pelvic organ prolapse are common conditions affecting the elderly. A careful evaluation of urinary incontinence, including history and physical examination, will often determine the etiology of this condition. Vaginal pessaries are a safe and effective treatment for both urinary incontinence and pelvic organ prolapse. They should be considered a viable alternative to surgery especially in the elderly with complicated medical histories. This article reviews the etiology of urinary incontinence, offers a guide in the evaluation of the incontinent woman, and reviews the use of pessaries for the treatment of incontinence and pelvic organ prolapse.

Keywords: pessary; incontinence; pelvic organ prolapse

Pessaries have been used for thousands of years and are still a good option for selected elderly women with pelvic organ prolapse (Deger, Menzin, & Mikuta, 1993). Pelvic organ prolapse can lead to urinary incontinence, fecal incontinence, and sexual dysfunction. The use of pessaries can correct prolapse and its associated symptoms, leading to quality-of-life improvements. This conservative approach may help to avoid surgical or medical interventions with minimal morbidity, low cost, and no drug interactions or side effects. Despite its potential benefits, use of the pessary is an underutilized intervention, and it warrants increased attention, particularly in older patients.

EPIDEMIOLOGY OF PELVIC ORGAN PROLAPSE AND URINARY INCONTINENCE

With the aging of the population, pelvic organ prolapse and its associated symptoms are becoming increasingly prevalent (Olsen, Smith, Bergstrom, et al., 1997). Between 14% and 25% of the community-dwelling elderly suffer from urinary incontinence. The prevalence of urinary incontinence increases with age. About onethird of women over age 65 experience some urinary incontinence (Morley, 2004), as do 50% to 75% of nursing home patients (Tannenbaum & DuBeau, 2004). More than 1 in 10 women end up with pelvic floor dysfunction severe enough to warrant surgery for pelvic organ prolapse and stress urinary incontinence (Olsen, Smith, Bergstrom, et al., 2005). This represents about 300,000 inpatient surgeries and an estimated 400,000 outpatient surgeries in the United States each year. Approximately 30% of the surgeries need to be repeated (DeLancey, 2005).

Suboptimal management of urinary incontinence in the longterm care setting contributes to pressure ulcers, poor wound healing, and falls (Fantl, Newman, Colling, et al., 1996; Kron, Loy, Sturm, Nikolaus, & Becker, 2003; Schnelle et al., 1997). The use of indwelling Foley catheters to manage urinary incontinence increases the risk of recurrent urinary tract infections and sepsis (Warren et al., 1987). To address these problems, the 1987 Omnibus Budget Reconciliation Act mandated the documentation of continence status for all nursing home residents.

THE AGING PROCESS AND ITS EFFECT ON URINARY CONTINENCE

Aging changes that contribute to urinary incontinence in the elderly include functional disability, poor mobility, dementia, and neurologic diseases (Palmer, German, & Ouslander, 1991). A number of physiologic changes with age also contribute to symptoms of stress and urge incontinence (Keilman, 2005). Atrophic vaginitis and urethritis secondary to decreased estrogen production can result in a diminished urethral seal, contributing to stress incontinence. Symptoms of urge incontinence can result from the decreased bladder elasticity and capacity and spontaneous detrusor muscle contractions that are associated with aging. In addition, urine volume increases with age, due to decreased ability to concentrate urine.

RISK FACTORS FOR PELVIC FLOOR DYSFUNCTION

Many factors contribute to the risk of pelvic floor dysfunction. One of the strongest risk factors is increasing age. Another common etiology of pelvic organ prolapse is vaginal delivery, and increased parity correlates with increased prevalence. …

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