The Evaluation of the Elderly Incontinent Patient / הגישה לחולה המרטיב

There are many uncertainties concerning the elderly incontinent patient. There is no validated approach nor a concensus regarding the extent of evaluation or the subtype of patient who should undergo specific testing. Practically, incontinence can be divided into two groups: 1) Transient incontinence, which may account for as much as a third of the community elderly population. 2) Established incontinence with the following categories: a) the bladder contracts when it should not (detrusor hyperactivity – DH); b) fails to contract when or as well as it should (detrusor underactivity); c) the outlet resistance is low when it should be high; d) the outlet resistance is high when it should be low. Recently, a new entity was described in which, in spite of the detrusor hyperactivity, the bladder contracted slowly and inefficiently, leaving the bulk of its content behind. This, without any increased outlet resistance. It was termed as Detrusor Hyperreflexia with Impaired Contractility (DHIC). It seems that DHIC is the single, most common cause in institutionalized elderly patients. This entity may mimic most of the other causes of urinary tract dysfunction and explain many of the therapeutic failures, including inappropriate surgery for obstruction and stress incontinence. Further, it was found that, contrary to the expected still nearly 40% of the institutionalized patients has other causes of incontinence than DH. The men mostly suffered from obstruction, while in women stress incontinence prevailed. Another surprising result of these studies showed that there was no statistically significant association between DH and Dementia. The most important factors which influenced – apart from the lower urinary tract – the incontinence, were two functional disabilities, ability to transfer and to dress independently and four medical conditions: Parkinson's, dementia, stroke, and diabetes. These findings justify a comprehensive approach to the older incontinent individual. It is important to note that meticulous clinical evaluation alone without urodynamics may have a diagnostic accuracy of 83%, while the therapeutic accuracy may reach 91%.