Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence
Introduction
Urinary incontinence is common among the elderly. In some cases it may be due to acute causes such as a urinary infection or a recent stroke and is potentially transient. In others it may become established. This paper is concerned with established incontinence. The International Continence Society has defined four types of urinary incontinence—urge, genuine stress, reflex and overflow [7]. Urge incontinence, which is associated with overactive bladder function, is frequently observed in elderly patients. It represents a failure of voluntary control of the voiding reflex. Overactive bladder function may be of two different types—phasic detrusor instability or uninhibited overactive bladder [3]. Typically, during urodynamic testing of the uninhibited overactive bladder, there is no sensation of bladder filling nor any phasic bladder (detrusor) activity until, at a certain bladder volume, an involuntary detrusor contraction develops and urine leakage occurs. Among the elderly, if bladder function is overactive, it is frequently of the uninhibited overactive bladder type and is believed to be associated with cortical abnormalities [3]. Human and experimental observations have indicated some of the pathways and cerebral areas involved in voiding [8], but knowledge at levels above the pons and hypothalamus is incomplete. Recent positron emission tomography (PET) experiments [1]have shown that cerebral areas involved in normal voiding appear to be located predominantly on the right side, including areas in the right anterior cingulate gyrus and right inferior frontal gyrus.
We have examined brain and bladder function among incontinent geriatric patients undergoing rehabilitation in a tertiary centre. About half were demented according to conventional criteria. The hypothesis was that poor voluntary control of the bladder (urge incontinence) would be associated with particular aspects of cognitive impairment and with dysfunction of specific regions of the brain.
Section snippets
Materials and methods
A total of 128 patients were referred for incontinence, after elimination of possible causes of transient incontinence. Patients who were bedridden, had an indwelling catheter, or had overt infrapontine neuropathy or multiple sclerosis, were excluded. After obtaining written informed consent from the patient and a close relative if necessary, a history and a physical examination including simple neurological testing were performed. Patients with findings suggestive of peripheral neuropathy that
Results
A total of 128 incontinent patients, 76 women and 52 men were examined. The median age was 79 years and the median MMSE score was 23/30. Thus, approximately half had a score below 24/30, the conventional criterion for dementia. A total of 20 patients had a clinical diagnosis of possible primary degenerative dementia and eight had a diagnosis of possible multi-infarct dementia.Of the 27 continent patients, 17 women and ten men underwent SPECT scans and cognitive testing with the MMSE. Their
Discussion
Among incontinent geriatric patients, genuine urge incontinence is the most common urodynamic type and is frequently accompanied by reduced sensation of bladder filling. The underlying abnormality is the uninhibited overactive bladder, representing inability to voluntarily control the voiding reflex. This type of incontinence is associated with more severe urine loss than other types.
Genuine urge incontinence is associated with overall impairment of cognitive function, but the strongest
Acknowledgements
This work was supported by a grant from the Alberta Heritage Foundation for Medical Research and was made possible by the unstinting help of many colleagues. I am particularly grateful to Gloria Harrison R.N., Dr Peter McCracken and Dr Sandy McEwan.
References (9)
- et al.
‘Mini-mental state’: A practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975) - et al.
A PET study on brain control of micturition in humans
Brain
(1997) - et al.
Subtypes of overactive bladder in old age
Age Ageing
(1993) - et al.
Characteristics of urinary incontinence in elderly patients studied by 24-hour monitoring and urodynamic testing
Age Ageing
(1992)
Cited by (75)
Genitourinary
2020, Brain Injury Medicine: Board ReviewNew Frontiers of Basic Science Research in Neurogenic Lower Urinary Tract Dysfunction
2017, Urologic Clinics of North AmericaCitation Excerpt :In CI, the neurologic dysfunction is caused by a focal brain damage due to ischemia and/or hemorrhage. When the brain damage is located in a small area in the right frontal region of cerebrum, which is involved in the control of micturition, it may predominantly result in bladder overactivity and urgency urinary incontinence.1,35,36 A rat model of CI produced by occlusion of the middle cerebral artery with a flamed 4-0 monofilament nylon inserted into the internal carotid artery has been shown to exhibit bladder overactivity as evidenced by reduced bladder capacity during awake cystometry.37
Functional Brain Imaging and the Neural Basis for Voiding Dysfunction in Older Adults
2015, Clinics in Geriatric MedicineCitation Excerpt :Despite poor spatial resolution, the study showed, in a group of older men and women (mean age, 79 years), that a particularly severe form of incontinence (urge urinary incontinence [UUI] with reduced bladder-filling sensation) was associated with reduced perfusion of the frontal lobes. A further association between incontinence and impaired cognition confirmed that a brain factor contributed to severe geriatric incontinence,47 presumably reflecting a white or gray matter defect in a region critical to both bladder control and aspects of cognition. The modern era of brain imaging of bladder control began in 1997 when Blok and colleagues48 published their landmark PET studies of filling and voiding in normal men and women.48,49
Affective symptoms and the overactive bladder - A systematic review
2015, Journal of Psychosomatic ResearchCitation Excerpt :The ACC is part of a neural stress-network, which is involved in (social) pain aspects [76,77]. Single photon emission computed tomography (SPECT) of older patients with UI showed hypo-perfusion in the regions of the prefrontal cortex [78]. Similar hypo-perfusion in the ACC and the prefrontal cortex was also seen in patients with major depressive disorder [79].
Sexual dysfunction in patients with epilepsy
2015, Handbook of Clinical NeurologyCitation Excerpt :In patients with stroke and brain tumors, incontinence correlated with right-hemisphere lesions (Maurice-Williams, 1974; Kuroiwa et al., 1987). In geriatric patients, urge incontinence with reduced bladder filling sensation was associated with hypoperfusion of the right frontal regions on interictal single-photon emission computed tomography (SPECT) (Griffiths, 1998). Concerning the specific brain areas responsible for the generation of ictal urinary urge, the involvement of the insular cortex is proposed.
Functional imaging of structures involved in neural control of the lower urinary tract
2015, Handbook of Clinical NeurologyCitation Excerpt :This is evident in Table 7.1, where insular and lPFC activations are reported predominantly on the right, regardless of whether the subjects were men or women (and indeed whether they were uniformly right-handed or mixed left- and right-handed). An early clinical study of patients with frontal brain tumors (Maurice-Williams, 1974) and a SPECT study of brain perfusion in the frail elderly (Griffiths, 1998) also suggested a right-sided preponderance. One limitation on our knowledge of the finer functional details of the mechanisms of conditions such as OAB, urgency incontinence, or chronic retention of urine (which occur idiopathically as well as a consequence of known brain lesions) is that the functional imaging studies performed to date have been based mainly on observations of activity in specific brain regions.