URINARY INCONTINENCE
An Approach to Evaluation and Management
Kristen M. Nebel, D.O.September 29, 2010
Urinary Incontinence
Goals: Define urinary incontinence (UI) Epidemiology Types of UI Risk factors Brief pathophysiology Office based assessment and diagnosis UI in Long- term care Therapies
Urinary Incontinence
Definition:
Unintentional leakage of urine at inappropriate times (often leading to social embarrassment).
Types of Urinary Incontinence
Stress Urinary Incontinence Urge Urinary Incontinence Overflow Urinary Incontinence Mixed Urinary Incontinence Functional Urinary Incontinence Deformity of Urinary Tract
Prevalence 24 to 64 y/o
10-30% of women 1.5-5% of men
Community-dwelling over 60 y/o
25-35% of women 10-15% of men
Nursing home/ home-bound > 65 y/o
60-78% of women 45-72% of men
AFP 1998;57:11
What Percentage are Treated?
Less than 50% of those with urinary incontinence
Why? Under diagnosed
Patient - normal aging process, no help available, embarrassment
Physician
Impact of Urinary Incontinence
Psychosocial- perceived/ actual limitations on activities, caretaker strain, depression, low self-esteem
Financial- cost of management for those over 65 y/o:
2000: $20 billionUrology 1998; 51(3):355-61
Impact of Urinary Incontinence
Medical- decubitus ulcers, UTI’s, sepsis, renal failure, falls, dermatoses/ cellulitis
Care-giver: Hours per week of informal care in community- dwelling
Men: 7.4-> 11.3-> 16.6 Women: 5.9->7.6-> 10.7
Strain -> Institutionalization
Genito-urinary Age-Related Changes
Atrophic vaginitis/ urethritis BPH Inability to delay voiding Decreased detrusor contractility
Increased PVR Increased UOP later in day Detrusor overactivity Decreased bladder capacity
Stress Urinary Incontinence
Urethral sphincter opening without a bladder contraction during stress maneuvers Stress maneuvers: cough, laugh, running, bending
over, changing position Most common in young women and in men
s/p TURP 2nd most common form in ages >65 y/o
Etiologies of Stress UI
Urethral or bladder neck displacement Vaginal deliveries Pelvic surgeries
Nerve, muscle, connective tissue injury
Pelvic organ prolapsed- cystocele, rectocele, uterine prolapse
Etiologies of Stress UI
Menopause Decreased estrogen state atrophy of urethral
epithelium Atrophic urethritis Decreased urethral mucosal seal/ failure to close Loss of compliance Irritation Insufficient urethral support
ά-adrenergic blocking agents
Urge Urinary Incontinence
“Detrusor (Bladder) Overactivity”: uncontrolled bladder contractions or impaired contractility
Most common form >65y/o Abrupt sensation of need to void triggered by:
Running water, hand washing, cold weather, sights of home
Associated with moderate to severe leakage
Etiologies of Urge UI
90% idiopathic Advanced age Bladder irritation
Infection, calculi, tumors Fecal impaction CNS impairment of inhibitory pathways
CVA, cervical stenosis, dementia, drugs, MS, Parkinson’s disease
Risk Factors for UI
Most common Age Gender Parity- UI may occur 5 years after first vaginal
delivery
Mixed Urinary Incontinence
Loss of urine due to both urge and stress incontinence Treatment determined by predominant symptom
Overflow Urinary Incontinence
Over distension of the bladder due to: Lower urinary tract symptomatology
Bladder outlet obstruction BPH Prostate Cancer Urethral Stricture Fecal impaction
Overflow Urinary Incontinence
Lower urinary tract symptomatology Impaired detrusor contractility (5-10%)
Bladder fibrosis CNS damage Anticholinergic drugs
Neuropathic- poor autonomic nerve relay DM neuropathy
Overflow Urinary Incontinence
2nd most common type in men Accounts for 8% of UI in females Symptoms:
Continuous dribbling Loss of small amount of urine Weak stream Hesitancy Nocturia Frequency
Clinics in Geriatric Medicine 2004; 20:4
Evaluation of UI
Patient- initiated complaint or physician inquiry regarding incontinence
Focused H&P and simple office procedures can lead to initial working diagnosis
Evaluation of UI
History: Onset, frequency, timing, volume Bowel habits Sexual function Medications How the patient views quality of life
Evaluation of UI
History continued… Triggers
UI with stress maneuvers has moderate specificity and high sensitivity for SUI (although no formal studies)
Symptoms Obstructive- dribbling, hesitancy, intermittency,
impaired flow, incomplete void Irritating- nocturia, frequency, urgency, dysuria
J Am Geriatric Soc 1990 Mar;38(3):300-5
Questions to Guide you
Do you leak urine when you cough, laugh, lift something or sneeze? How often?
Do you ever leak urine when you have a strong urge on the way to the bathroom? How often?
How frequently do you empty your bladder during the day?
How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
Do you ever leak urine during sex?
Questions continued…
Do you wear pads that protect you from leaking urine? How often do you have to change them?
Do you ever find urine on your pads or clothes and were unaware of when the leakage occurred?
Does it hurt when you urinate?
Do you ever feel that you are unable to completely empty your bladder?
Physical Examination
Assess memory impairment Functional status Dehydration – possible sign of immobility CV- volume overload? Abdomen- mass/ ascites/ organomegaly which
may increase intra-abdominal pressure
Physical Examination
Extremities- edema/ joint mobility/ function Rectal- mass/ prostate/ impaction Neuro- examination of lumbosacral nerve
roots: bulbocavernosus reflex
Physical Examination
Female GU- Atrophy/ vault stenosis/ inflammation/ cystocele/ rectocele/ bladder distention
Male GU- phimosis/ paraphimosis
Evaluation of UI
Transient (Acute) vs. Established (i.e. Urge, Stress, Overflow) Assess for reversible causes and treat
Delirium/ Drugs Retention/ Restricted mobility Infection/ Impaction Polyuria/ Prostatism
Up to 50% of UI in hospitalized patients and 33% of UI in community-dwelling patients may be due to reversible etiologies
Drug Effects on UrinationDrug Side Effect
Antidepressants, antipsychotics, sedatives/hypnotics
Sedation, retention (overflow)
Diuretics Frequency, urgency (OAB)
Caffeine Frequency, urgency (OAB)
Anticholinergics Retention (overflow)
Alcohol Sedation, frequency (OAB)
Narcotics Retention, constipation, sedation (OAB and overflow)
α-Adrenergic blockers Decreased urethral tone (stress incontinence)
α-Adrenergic agonists Increased urethral tone, retention (overflow)
α-Adrenergic agonists Inhibited detrusor function, retention (overflow)
Calcium channel blockers Retention (overflow)
ACE inhibitors Cough (stress incontinence)
Office Based Studies
Assess for reversible causes UA w/ C+S
PVR- via catheter or ultrasound Volume < 50 mL is normal Volume >200 mL is abnormal
Associated with OUI
Lab testing BMP B12 level
Office Based Studies
Clinical Stress Test Performed with full bladder Recumbent or standing position Response to stress maneuver If elevation of urethra prevents loss, most likely
SUI “Cough test”
Treatment options
Stress/ Urge Urinary Incontinence 1st line- Behavioral therapies/ devices 2nd line- Medications 3rd line- Surgery
Overflow Urinary Incontinence Catheterization-intermittent/ indwelling Medications
Behavioral Therapies for Urge and Stress
Bladder Training 2 principles:
Frequent voiding to keep urine volume low Retraining CNS and pelvic mechanisms to inhibit
detrusor contractions Conscious suppression/ resistance of urge to void
(often only helpful for 6 months)
Behavioral Therapies for Urge and Stress
Timed voiding Frequency of voids corresponds with shortest
interval between voids (bladder diary) After no leakage for 2 days, time is gradually increased
by 30-60 minutes to goal of 3-4 hours
Prompted voiding For use in cognitively impaired or Urge UI
Biofeedback
Other Therapies for SUI
Pelvic floor muscle exercise Kegel maneuvers
3 sets 8-12 CTX held for 6-8 s, 3-4 d/ wk x 15-20wks
Pessary
Weighted vaginal cones
Botulinum toxin Sacral neuromodulation
RCTs on SUI Therapies
Short term improvement in group with PFME + biofeedback compared to PFME only. However, no change in groups after 3 months.
Am Jnl OB/GYN 1998;179(4):999-1007
PFME is better than electrical stimulation or vaginal cones in treating SUI.
BMJ 1999;318:487-93
RCTs on UUI Therapies
Biofeedback vs. Behavioral training for UUI: no significant difference
Evidence-based OB/ GYN 2003;5(2)
Biofeedback-assisted Behavioral Tx vs. drug therapy vs. placebo in Urge and Mixed UI: Behavioral 80.7% reduction of incont. episodes Drug therapy 68.5% reduction Placebo 39.4% reduction
JAMA 1998;280(23):1995-2000
UI in Long-term Care
Dementia patients: Success of prompted voids can be predicted if:
Patient can state name Transfer with </=1 assist Leaks < 4 x/ 12 hours Voids 75% of time when prompter during 3 day trial
JAGS: 190;38:356.
UI in Long-term Care
Functional Incidental Training: combination of prompted void with endurance and strength exercises Study of 107 VA pts found FIT reduced wet checks
episodes by ½. Practical limitations due to staffing, cost, limited
benefits after therapy endedJAGS 2005: 53(7); 1901-1100.
Pharmacological Therapy
Stress Incontinence Improve urethral sphincter contraction
ά-adrenergic agents: Imipramine Stimulate urethral smooth muscle contraction Better results if used with estrogen Not recommended if + orthostatics or at risk for
anticholinergic effects
Pharmacological Therapy
Stress Incontinence Estrogen: vaginal or oral forms
If used alone has limited effectiveness, some studies indicate worsening
Increases number /responsiveness of receptors to alpha-adrenergic agents
BJOG 1999;106(7):711-8
Serotonin-Norepinephrine reuptake inhibitor: Duloxetine
Approved for Stress UI in England
Am Jnl OB/GYN 2002;187(1):40-8
Pharmacological Therapy
Urge Incontinence Inhibit bladder contractions
Anticholinergics: Oxybutynin (Ditropan, Oxytrol): most common side effect is
dry mouth Controlled release form better tolerated
Solifenacin (Vesicare), Darifenacin (Enablex), (Fesoterodine) Toviaz
Muscarinic Receptor antagonist: Tolterodine (Detrol): slightly less efficacious than oxybutynin,
but with less side effects Trospium (Sanctura)
Pharmacological Therapy
Efficacy: 30% continence rate Reduces UI by ½ + episodes per day Results may take 4-6 weeks
Trials: Vesicare > tolterodine for reducing urgency/
frequency Oxybutynin > tolterodine for reducing
incontinence
Pharmacological Therapy
Dementia: Combination of cholinesterase inhibitors and
antimuscarinics can cause functional decline Oxybutynin 5mg ER daily x 4 weeks did not result
in cognitive declineJAGS 2008 May; 56(5):862-70.
Case reports of Tolterodine reported increased hallucinations
Pharmacological Therapy
Overflow Incontinence Relief of obstruction (BPH)
5-ά-reductase inhibitors: finasteride ά -1-adrenergic antagonists: flomax
Herbal Symptomatic relief Saw Palmetto
Significant improvement when compared to finasteride
Clinics in Geriatric Medicine 2004;20:3
Lifestyle Modifications for all Patients
Frequent toileting No fluids 3-4 hrs. before bed or leaving home Limit fluid to 1 L/ day Treat constipation with sorbitol D/C tobacco use (cut down on coughing) Protective garments
Clinics in Geriatric Medicine 2004;20(3)
Stay warm in cold weather Avoid ETOH and tobacco Elevate legs 2 hours before bed (re-circulate
extra-vascular fluid) Avoid caffeine Weight loss in morbidly obese
Urinary Incontinence
In Conclusion: Be aware and ask Follow algorithm and assess for reversible vs.
established causes Implement therapy Refer if warranted by history, exam, or refractory
incontinence
Case
70 y/o male with poor stream, straining to void, and incontinence. PMHx: TIA, HTN, DM II w/ neuropathy, OA Meds: Plavix, Notriptyline (dose doubled),
glipizide, naproxen, Ace-I UA: neg.
What is most likely diagnosis, what are contributing factors, what should be done next?
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