Presentation Prepared by Danielle Burgio and Ali Cunneen Brooklyn Bridge to Cambodia © 2012.
Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate...
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Transcript of Kathryn L. Burgio, PhD Associate Director for GRECC Research & Patricia S. Goode, MD Associate...
Kathryn L. Burgio, PhDKathryn L. Burgio, PhDAssociate Director for GRECC ResearchAssociate Director for GRECC Research
&&
Patricia S. Goode, MDPatricia S. Goode, MDAssociate Director for GRECC Clinical ProgramsAssociate Director for GRECC Clinical Programs
Birmingham/Atlanta Geriatric Research EducationBirmingham/Atlanta Geriatric Research Education and Clinical Center – July 27, 2006and Clinical Center – July 27, 2006
Assessment and Management of Assessment and Management of Urinary Incontinence in the ClinicUrinary Incontinence in the Clinic
05
10152025303540
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Age
Pre
vale
nce
(%
)
Severe Moderate
Slight Unknown
Hannestad et al., 2000
Prevalence of Prevalence of IncontinenceIncontinence
Severity
UI - Treatment Seeking UI - Treatment Seeking
Reported toProviderNot Reported
1,104 Community Dwelling Older Adults with Urinary Incontinence on interview
Burgio, et al: JAGS 42: 208, 1994Burgio, et al: JAGS 42: 208, 1994
38%38%62%62%
Reasons for Not Reporting Incontinence to Provider
Not aware that can be treatedNormal part of agingPersonal problem (not medical)EmbarrassedFear of nursing home placementAfraid treatment requires surgery
Patient Case
75 year old man Goes to the bathroom every 1-2 hours
daytime and 3 times at night. About once a week, on the way to the
bathroom, he can’t make it and wets his clothes.
Evaluation?Diagnosis?Appropriate treatment?
Incontinence History
Type Do you leak urine during physical activity
such as coughing, sneezing, lifting, or exercising?
Do you get the urge to go and can’t make it without leaking?
Onset
Severity Frequency of leakage Need for absorbent products
Incontinence History
Lower urinary tract symptoms Urgency, frequency, nocturia,
dysuria, weak stream, straining to void, etc.
Fluid intake – volume and type
Previous treatments and effects on incontinence
Medical History
Medical, neurological, history
Surgical history
Prostatectomy
Review medications including OTC
Habits (caffeine, tobacco, alcohol use)
Physical Exam
Brief Neurologic Exam Gait Lower extremity strength Cogwheel rigidity Sphincter tone and voluntary
contraction
Rectal (and Pelvic for women)
Post-Void Residual Volume
Measure amount of urine left in bladder after voiding.
Ultrasound or catheter
Normal: < 50 ml
Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up
Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation.
Physical: hard stool in vault UA: 2+ glucose (and Hgb A1C = 9.8 one month ago) PVR: 200 mL
Diagnosis? Treatment Options?
Contributors to UIto Treat First
Drugs and DietInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction
Contributors to UIto Treat First
DrugsSedatives including alcoholACE inhibitors (cough)Antipsychotics (pseudoparkinsonism)Diuretics (bad timing)Alpha Blockers – worsen stress UIAnticholinergics – incomplete emptying
Contributors to UIto Treat First
Drugs and Diet – Caffeine & FluidsInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction
Patient Case 75 year old man Frequent voiding and weekly urge incontinence Work up
Hx: Diabetes for 10 years, tries to adhere to diet – drinks about 4-5 diet sodas/day. Insomnia – takes Tylenol PM. Constipation.
Physical: hard stool in vault UA: 2+ glucose
(and Hgb A1C = 9.8 one month ago) PVR: 200 mL
Patient Case
75 year old man Frequent voiding and weekly urge
incontinence Work up
Hx: Otherwise negative Physical: unremarkable UA: normal PVR: 45 mL
Diagnosis? Treatment options?
First Line Treatments Medications
Anticholinergics Oxybutynin – generic, Ditropan XL, Oxytrol
patch Tolterodine - Detrol Solifenacin - VESIcare Trospium - Sanctura Darifenacin - Enablex
Alpha blocker for BPH
Other treatments Behavioral training – try BEFORE or with drug
PFM Training PFM Training and Exerciseand Exercise
PFM Training PFM Training and Exerciseand Exercise
Weight LossWeight LossWeight LossWeight Loss
Diet & Fluid Diet & Fluid ManagementManagement
Diet & Fluid Diet & Fluid ManagementManagement
Behavioral Behavioral ApproachesApproachesBehavioral Behavioral ApproachesApproaches
Behavioral Behavioral StrategiesStrategies
Behavioral Behavioral StrategiesStrategies
Bladder TrainingBladder TrainingBladder TrainingBladder Training BiofeedbackBiofeedbackBiofeedbackBiofeedback
Bladder Bladder DiariesDiaries
Bladder Bladder DiariesDiaries
Least Invasive – Use First !!
Behavioral Treatment: Multi-component Program
Pelvic floor muscle training
Home practice of exercisesIncrease duration of contraction/relaxation over time
Bladder Control Techniques
Self-Monitoring w/ bladder diaries
When the Urge Strikes –Freeze and Squeeze
Stop and stay still
Squeeze pelvic floor muscles
Relax rest of body
Concentrate on suppressing urge
Wait until the urge subsides
Walk to bathroom at normal pace
Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.
When to Void
WorstWorstTimeTime
WorstWorstTimeTime
BestBestTimeTime
CalmCalmPeriodPeriod
Burgio et al. Staying Dry: A Practical Guide to Bladder Control. 1989.
Other Behavioral Strategies
Stress Strategy
Squeeze before you sneeze (or cough or lift)
Post Void Dribbling Strategy
Squeeze after voiding
RCT Comparing Behavior and Drug Therapy
197 older women with urge incontinence Randomized to 8 weeks of:
Behavioral training (biofeedback) Drug therapy (oxybutynin) Placebo control
Burgio et al, JAMA, 1998
Patient Satisfaction with Treatment
78%
49%
28%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Completely satisfied
BehaviorDrugPlacebo
Burgio et al. JAMA. 1998; 280:1995-2000
Patient Case
85 year old woman Frequently leaks on the way to the bathroom Work up
Hx: Aricept for dementia Physical: Frail, walks slowly, uses a walker UA: normal PVR: 85 mL
Diagnosis? Treatment Options?
The Patient with The Patient with Functional LimitationsFunctional Limitations
Avoid anticholinergic drugs in pts with dementiaFacilitate functional status
Mobility devicesPhysical therapy
Bedside commodeUrinal for menPrompted voiding – VERY effective
Post-Prostatectomy Incontinence
65 yo had radical prostatectomy 1 year ago Leaks when he coughs, sneezes or lifts
something heavy Wears a pad in the daytime, dry at
night No problem making it to the bathroom Diagnosis? Treatment Options?
Behavioral Treatment of Post-Prostatectomy
Incontinence
20 men; 55-87 years oldAverage 2 ½ years since surgery8 weeks of biofeedback-assisted behavioral training 78.3% decrease in accidents
(range of -12 – 100%)
Burgio, et.al., J Urology, 1989
Behavioral Training for Post-Prostatectomy Incontinence
Case Series of 27 men with persistent post-prostatectomy UI
Taught pelvic floor muscle exercises without using biofeedback
56.6% reduction in leakage
Meaglia et al. J Urol. 1990;144:674
Post-Prostatectomy Incontinence
65 yo considering
radical prostatectomy Continent Read that 72% of patients reported
incontinence persisting 1 year after surgery
and 40% wearing pads What can he do to help prevent
incontinence?
Stanford, et.al. JAMA, 2000
Pre-Prostatectomy Muscle Pre-Prostatectomy Muscle TrainingTraining
00.10.20.30.40.50.60.70.80.9
1
0 50 100 150 200Time in Days until Continent
prevention
control
(p = .032)
N=125
Burgio, Goode, et al, J Urol, 175:196; 2006
Reduction of Incontinence
3252
73
54
0102030405060708090
100
Pad Use Proportion DryDays
Burgio, Goode, et.al., J Urology, 2006Burgio, Goode, et.al., J Urology, 2006
p=.045p=.090
%
Pre-Prostatectomy Muscle Pre-Prostatectomy Muscle TrainingTraining
Median Time to Continence: Intervention Group - 3.5 months Control Group - > 6 month
Number Needed to Treat to get 1 additional man out of pads at 6 months = 5
Burgio, Goode, et al, J Urol, 175:196; 2006
Summary: Contributors to Incontinence to Treat First
Drugs and DietInfectionAtrophic UrethritisPsychological - Depression, DeliriumEndocrine - Diabetes, HypercalcemiaRestricted MobilityStool Impaction
Urinary Incontinence Treatments
Behavioral Treatments Pelvic Floor Muscle
Exercises (Kegel)
Bladder training
Timed/Prompted voiding
Bladder Control Techniques
Biofeedback
Medications
Pessary
Pelvic Floor Electrical Stimulation
Magnetic Chair
Urethral Bulking Agents
Surgery
Current Studies at Bham/ATL GRECC
MOTIVE - Combined medication and behavioral therapy for overactive bladder in men (VA Rehab R&D)
ProsTech – Behavioral therapy with and without biofeedback and electrical stimulation for persistent incontinence in men after radical prostatectomy (NIH)
COMBO - Combined medication and behavioral therapy for urge incontinence in women (VA Rehab R&D)
ATLAS – Behavioral therapy or pessary or combined for stress incontinence in women (NIH)
RUBI - Botox injections for refractory urge incontinence in women (NIH)
Contact Information
Patricia Goode, MD [email protected] 205-934-3249 Kathryn Burgio, PhD [email protected] 205-558-7067 Ken Shay, DDS, MS [email protected] 734-222-4325 http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?
id=22318