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ower urinary tract symptoms increase with age in both men and women and represent a major problem in the elderly due to the physical, psychological, and social consequences involved.¹ With over half of all residents in long-term care nursing facilities experiencing chronic, daily urinary incontinence, the problem is undoubtedly pervasive. Consequently, the challenges of understanding and managing incontinence in eldercare can be daunting, at best, for the professional caregiver.
       Although changes that occur throughout the normal aging process do not cause urinary incontinence, they may contribute to a situation that allows loss of bladder control or other voiding dysfunction to occur and are often multifaceted in nature. In both genders, general changes in bladder function include reduced bladder capacity, increased tendency for bladder spasms or unprovoked contractions, reduced strength of bladder contractions, decreased awareness of bladder filling, and increased nighttime urine production. In older men, enlarged prostate glands may cause bladder emptying to be difficult because of obstruction. In older women, reduced estrogen is believed to contribute to more lower urinary tract symptoms (LUTS). In addition, the risk of pelvic organ prolapse increases, especially following hysterectomy, in which case blockage and improper bladder emptying can occur.²
       As a result of such changes, older individuals are more likely to experience increased frequency of urination, increased urgency, an increased potential for incomplete emptying, increased frequency of urination during nighttime hours, an increased risk of leakage, and reduced response time between awareness of the need to urinate and the bladder’s contraction. In addition, there are general changes outside of the bladder that contribute to these effects, including decreased mobility and other health problems requiring medication that may adversely affect the bladder function.
       In an eldercare environment, several different diagnostic categories affecting the bladder’s holding capacity and loss of bladder control need to be considered.

In Older Men

       Benign prostatic hyperplasia (BPH). Low bladder contractility and low bladder capacity are significantly associated with LUTS in older men with noncancerous, enlarged prostate glands.³ In addition, in such individuals, bladder capacity has also been found to be significantly related to the maximum flow rate of urine as is retained urine following micturition or post-void residual volume (PVR).⁴ While it is speculated that there may be cellular changes in the bladder muscle itself or changes in nerve responses in and connecting to the bladder, the exact mechanism causing a loss of bladder control in men with BPH is largely unknown.⁵

In Older Women
       Pelvic organ prolapse (POP). Like BPH in men, a displaced, or “fallen,” pelvic organ, such as the bladder, can create an obstruction to the bladder outlet at its neck and influence urine flow rate, PVR, and voided volume.

In Older Men and Women
       Overactive bladder (OAB). OAB is today’s most common term used to describe LUTS, with or without incontinence. These symptoms have been previously described and usually include urgency, frequency, nocturia, troublesome or incomplete emptying, and occasionally pain. Since many researchers believe several different causes may produce similar or identical LUTS, it is also believed that effective treatment outcomes may not necessarily be improved significantly by diagnostic precision.⁶ This consideration may be especially true in the elderly.

The Role of Diagnostic Testing

       The term urodynamics represents a group of diagnostic tests that fully evaluate the function of the lower urinary tract. Specific problems related to the control of urine, poor bladder emptying, urinary frequency or urgency, weak or intermittent urine flow, and frequent urinary tract infections can be measured and precisely identified with urodynamics testing. This sophisticated equipment is typically housed in a clinical lab and may include biofeedback applications, computerized data storage and analysis, and video imaging.
       For the older, long-term care resident, such testing may not be easily accessible and, at best, is invasive and fatiguing. Oftentimes, a preferred route is use of portable, noninvasive ultrasound instruments that measure a single key variable, such as bladder volume, to aid in diagnosis, treatment, and management of LUTS. In fact, ultrasound-imaging devices have been used for many years as important tools in the management of dysfunctional and neuropathic bladders in children.

Equipment Selection Considerations

       Ultrasound bladder volume calculation, available as software embedded in the ultrasound scanner, is considered an easy method for estimation of bladder volume. While researchers have found no significant improvement in accuracy among different calculation methods, some recommend the prolate ellipsoid method as the standard calculation method, because it is fastest and easiest.⁷ At least one group of researchers in the United Kingdom has documented reasons for a preference of a low-cost, highly portable ultrasound imaging device over an automated scanner, i.e., Bladderscan™ (Diagnostic Ultrasound, Bothell, Washington) based on overall lower error rates.⁸ In other research, a portable three-dimensional (3-D) scanner and a multipurpose, stationary, two-dimensional (2-D), realtime scanner for determining bladder volumes have shown sufficient accuracy for clinical practice, both slightly overestimating actual bladder volume below 160mL and underestimating it at higher volumes.⁹

The Case for Urodynamics Testing

       As with pediatric experiences over the years, realtime ultrasound examination of the bladder in a patient-friendly environment can provide significant information regarding bladder function, often avoiding costly, invasive urodynamics. The test does not replace formal scanning for anomalies but may provide information that is masked by the more rigid environment of a hospital lab or radiology department. In particular, it may be a reliable tool in monitoring therapeutic effects on residents with BPH in terms of the relief of obstruction, for example. Still, urodynamics is recommended for individuals with mixed incontinence, those with neurological diseases, and especially for those being considered for surgery or for whom conservative treatments (i.e., behavioral and pharmacological measures) have failed. Videourodynamics can be especially helpful in complex cases. In fact, recent research documenting statistically significant differences in bladder volume at tested urge levels has demonstrated that sensory evaluation of urge and urgency, combined with noninvasive neuromodulation during urodynamics, may provide new criteria for improving patient selection for an implantable sacral nerve stimulator, i.e., InterStim® (Medtronic, Inc., Minneapolis, Minnesota), for intractable urge incontinence.¹⁰

       "…a portable means of easily capturing ultrasound measurements of bladder volume can offer a noninvasive alternative to catheterization in cases of suspected retention, thereby lowering the incidence of nosocomial urinary tract infection at your facility and reducing related costs of care…"

Comprehensive Incontinence Management in Long-Term Care

       Diagnostic ultrasound testing of bladder volume is intended as a tool in the clinical toolbox for delivering comprehensive incontinence management. Research supports the value of combining supplementary data from a somewhat subjective 48-hour bladder diary with more objective data obtained on bladder volume from either ultrasound or urodynamics testing in order to have a complete picture of the resident in diagnosing OAB.¹¹ Even body position can have an effect on bladder measurements and volume estimations.¹²
       Knowing bladder volume can assist with more easily differentiating between urological conditions, so that appropriate treatment can be recommended sooner. More importantly, a portable means of easily capturing ultrasound measurements of bladder volume can offer a noninvasive alternative to catheterization in cases of suspected retention, thereby lowering the incidence of nosocomial urinary tract infection at your facility and reducing related costs of care, such as ensuing hospitalizations and antibiotics. Such knowledge can be integrated into appropriate behavioral management intervention and pharmacological therapy, because there is less guesswork involved in selecting a protocol to pursue. Above all, bladder volume measurements can put you back in control of your facility and protect resident health, dignity, and well being. It’s another bladder basic.